Mortality benefit of catheter ablation versus medical therapy in atrial fibrillation: An RCT only meta‐analysis

Abstract

Introduction Catheter ablation for atrial fibrillation (AF) in comparison to medical therapy alone is known to improve freedom from arrhythmia and quality of life, but the benefit regarding mortality is unclear. The publication of several recent large randomized controlled trials (RCT) comparing ablation with medical therapy has warranted an updated meta‐analysis. Methods We sought to compare the effectiveness of catheter ablation versus medical therapy only in patients with AF. MEDLINE, Cochrane, and http://ClinicalTrials.gov databases were searched from inception until 04/30/2021. Relevant RCTs comparing catheter ablation versus medical therapy in patients with AF were selected. Results A total of 24 RCTs involving 5730 adult patients were included (2992 in catheter ablation and 2738 in medical therapy). There was a reduction in all‐cause mortality with catheter ablation compared with medical therapy only (risk ratio (RR) 0.70 [95% confidence interval (CI) 0.55–0.89]; p = .003). Catheter ablation also demonstrated a reduction in hospitalizations (RR 0.50 [95% CI 0.36–0.70]; p < .001), improvement in left ventricular ejection fraction (LVEF) (mean difference [MD] + 5.94% [95% CI 0.40–11.48] p = .04), greater freedom from atrial arrhythmia (RR 2.23 [95% CI 1.79–2.76]; p < .001), and AF (RR 1.95 [95% CI 1.44–2.66]; p < .001). In subgroup analysis, catheter ablation demonstrated a significant reduction in mortality and hospitalizations among patients with reduced LVEF, and when ablation was compared with antiarrhythmic drug use. Conclusions In comparison to medical therapy only, catheter ablation for atrial fibrillation reduces mortality, hospitalizations, and increases freedom from arrhythmia.

Atrial fibrillation and risk of adverse outcomes in heart failure with reduced, mildly reduced, and preserved ejection fraction: A systematic review and meta‐analysis

“…Findings from aggregate data in meta‐analyses in the general population have shown that AF ablation as compared to conservative management is associated with significantly reduced risk of all‐cause mortality, HF hospitalization, stroke, and greater freedom from atrial arrhythmias 62,63 . Catheter ablation for AF in HFrEF patients has been shown to reduce AF recurrence, mortality, and HF hospitalization 49,50 .…”

“…11 Findings from aggregate data in meta-analyses in the general population have shown that AF ablation as compared to conservative management is associated with significantly reduced risk of all-cause mortality, HF hospitalization, stroke, and greater freedom from atrial arrhythmias. 62,63 Catheter ablation for AF in HFrEF patients has been shown to reduce AF recurrence, mortality, and HF hospitalization. 49,50 In HFpEF patients, catheter ablation compared to medical therapy is significantly associated with reduction in AF recurrence, 64,65 and may be associated with significant benefit in mortality or HF hospitalization.…”

Effect of Catheter Ablation for Atrial Fibrillation in Heart Failure With Mid-Range or Preserved Ejection Fraction ― Pooled Analysis of the AF Frontier Ablation Registry and Hokuriku-Plus AF Registry ―

“…8 A recent report showed that catheter ablation for AF resulted in a significant reduction in all-cause mortality and hospitalization, and a greater improvement in left ventricular systolic function than medical therapy. 9 In addition, the Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation (CASTLE-AF) trial reported that catheter ablation for AF with heart failure and severe systolic dysfunction (left ventricular ejection fraction [LVEF] ≤35%) was associated with a reduction in mortality or heart failure. 10 However, the clinical outcomes of catheter ablation for AF in heart failure with mid-range ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) have not been fully evaluated.…”

Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials

“…For example, the CABANA (Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial reported that CA did not significantly reduce the primary end point of death, disabling stroke, severe bleeding, or cardiac arrest compared with MT [ 9 ]. Several meta-analyses comparing CA vs. MT reported outcomes such as a reduction in all-cause mortality and hospitalizations, improvement in left ventricular ejection fraction (LVEF), and greater freedom from atrial arrhythmia and AF [ 10 ]. However, contrasting evidence on the effectiveness of CAs for these outcomes is available from meta-analyses, and the determination of the credibility of these findings remains to be assessed.…”