Catheter ablation vs. drug therapy in the treatment of atrial fibrillation patients with heart failure: An update meta-analysis for randomized controlled trials

Background: Atrial fibrillation (AF) and heart failure (HF) often coexist. The treatment of AF in patients with HF has been challenging because of the ongoing debate about the merits of catheter ablation vs. drug therapy.Methods: The Cochrane Library, PubMed, and www.clinicaltrials.gov were searched until June 14, 2022. Inclusion criteria were catheter ablation compared with drug therapy in adults with AF and HF in randomized controlled trials (RCTs). Primary outcomes consisted of all-cause mortality, re-hospitalization, change in left ventricular ejection fraction (LVEF), and AF recurrence. Secondary outcomes referred to quality of life [QoL; measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ)], six-minute walk distance (6MWD), and adverse events. The PROSPERO registration ID was CRD42022344208. Findings: In total, nine RCTs with 2,100 patients met the inclusion criteria, with 1,062 for catheter ablation and 1,038 for medication. According to the meta-analysis, catheter ablation significantly reduced all-cause mortality compared with drug therapy [9.2% vs. 14.1%, OR: 0.62, (95% CI: 0.47-0.82), P = 0.0007, I2 = 0%], improved LVEF [MD: 5.65%, (95% CI: 3.32-7.98), P < 0.00001, I2 = 86%], reduced AF recurrence [41.6% vs. 61.9%, OR: 0.23, (95% CI: 0.11-0.48), P < 0. 0001, I2 = 82%], decreased the MLHFQ score [MD: -6.38, (95% CI: -11.09 to -1. 67), P = 0.008, I2= 64%] and increased 6MWD [MD: 17.55, (95% CI: 15.77-19.33), P < 0.0001, I2 = 37%]. Catheter ablation did not increase the re-hospitalization [30.4% vs. 35.5%, OR: 0.68, (95% CI: 0.42-1.10), P = 0.12, I2 = 73%] and adverse events [31.5% vs. 30.9%, OR: 1.06, (95% CI: 0.83-1.35), P = 0.66, I2 = 48%].Interpretation: In AF patients with HF, catheter ablation improves exercise tolerance, QoL, and LVEF and significantly reduced all-cause mortality and AF recurrence. Although the differences were not statistically significant, the study found lower re-hospitalization and approximate adverse events with improved catheter ablation tendency.