Catheter Ablation Versus Medical Therapy in Atrial Fibrillation With Heart Failure With Reduced or Mildly Reduced Ejection Fraction: A GRADE-Assessed Systematic Review and Meta-Analysis

Abstract

Background

Catheter ablation is an established rhythm-control strategy for atrial fibrillation (AF), but its effectiveness in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF) remains incompletely defined. We performed a GRADE-assessed systematic review and meta-analysis comparing catheter ablation with conventional medical therapy in this population.

Methods

PubMed, Embase, and the Cochrane Library were searched from inception to February 2026. Randomized controlled trials and observational cohort studies enrolling adults with AF and left ventricular ejection fraction (LVEF) ≤ 50% were included. Primary outcomes were all-cause mortality, cardiovascular mortality, and change in LVEF. Secondary outcomes were change in B-type natriuretic peptide (BNP) and cardiovascular hospitalization. Random-effects models were used, and certainty of evidence was assessed using GRADE.

Results

Thirteen studies involving 131 492 participants were included. Catheter ablation significantly reduced all-cause mortality (RR 0.61, 95% CI 0.51–0.71) and cardiovascular mortality (RR 0.46, 95% CI 0.31–0.66), improved LVEF (MD 6.47%, 95% CI 4.47–8.47), and reduced BNP levels (MD −136.85 pg/mL, 95% CI −190.46 to −83.23). No significant reduction was observed in cardiovascular hospitalization (RR 0.78, 95% CI 0.53–1.13). Mortality benefits were consistent across subgroup analyses by study design and baseline LVEF.

Conclusions

Catheter ablation was associated with lower mortality and improved cardiac function compared with medical therapy in patients with AF and HFrEF/HFmrEF. Further studies specifically evaluating HFmrEF populations are warranted.