Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure A Meta-analysis of Randomized Controlled Trials

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with increased morbidity and mortality risk. Purpose: To compare benefits and harms between catheter ablation and drug therapy in adult patients with AF and HF. Data Sources: ClinicalTrials.gov, PubMed, Web of Science (Clarivate Analytics), EBSCO Information Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from 1 January 2005 to 1 October 2018. Study Selection: Randomized controlled trials (RCTs) published in English that had at least 6 months of follow-up and compared clinical outcomes of catheter ablation versus drug therapy in adults with AF and HF. Data Extraction: 2 investigators independently extracted data and assessed study quality. Data Synthesis: 6 RCTs involving 775 patients met inclusion criteria. Compared with drug therapy, AF ablation reduced all cause mortality (9.0% vs. 17.6%; risk ratio [RR], 0.52 [95% Cl, 0.33 to 0.81]) and HF hospitalizations (16.4% vs. 27.6%; RR, 0.60 [Cl, 0.39 to 0.93]). Ablation improved left ventricular ejection fraction (LVEF) (mean difference, 6.95% [Cl, 3.0% to 10.9%]), 6-minute walk test distance (mean difference, 20.93 m [Cl, 5.91 to 35.95 m]), peak oxygen consumption (VO(2)max) (mean difference, 3.17 mL/kg per minute [Cl, 1.26 to 5.07 mL/kg per minute]), and quality of life (mean difference in Minnesota Living with Heart Failure Questionnaire score, -9.02 points [Cl, -19.75 to 1.71 points]). Serious adverse events were more common in the ablation groups, although differences between the ablation and drug therapy groups were not statistically significant (7.2% vs. 3.8%; RR, 1.68 [Cl, 0.58 to 4.85]). Limitation: Results driven primarily by 1 clinical trial, possible patient selection bias in the ablation group, lack of patient-level data, open-label trial designs, and heterogeneous follow-up length among trials. Conclusion: Catheter ablation was superior to conventional drug therapy in improving all-cause mortality, HF hospitalizations, LVEF, 6-minute walk test distance, VO(2)max, and quality of life, with no statistically significant increase in serious adverse events.