Early Versus Delayed Catheter Ablation in Atrial Fibrillation and Heart Failure: A Systematic Review and Meta-Analysis.

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist, worsening outcomes. Catheter ablation (CA) is an established therapy, but the optimal timing remains unclear.

Objective: To evaluate the impact of early versus delayed CA on clinical outcomes in patients with AF and HF.

Methods: This PROSPERO-registered systematic review (CRD42025643686) adhered to PRISMA guidelines. Comparative studies enrolling adults with AF and HF were included. Early CA was defined as ablation performed within varying timeframes (often ≤12 months) after AF diagnosis or HF decompensation versus delayed CA beyond that period. Primary outcomes were AF recurrence, all-cause mortality, and HF hospitalizations. Random-effects meta-analyses were performed.

Results: Ten studies (n=15,822) contributed to the meta-analyses. Early CA was associated with significantly reduced AF recurrence (k=8; HR 0.63, 95% CI: 0.52-0.78, p<0.0001) and HF hospitalization (k=5; HR 0.63, 95% CI: 0.51-0.77, p<0.0001). A non-significant trend towards reduced all-cause mortality was observed (k=4; HR 0.71, 95% CI: 0.41-1.24, p=0.23). Statistical heterogeneity was absent for HF hospitalization (I²=0%), moderate for AF recurrence (I²=67.6%), and high for mortality (I²=75.3%). Narrative synthesis included two additional RCTs comparing treatment strategies.

Conclusion: Evidence from pooled observational studies suggests early CA is associated with reduced AF recurrence and HF hospitalization in patients with AF and HF; a mortality benefit was not statistically confirmed. Interpretation warrants caution due to reliance on observational data and methodological heterogeneity across studies.