Catheter ablation for atrial fibrillation and impact on clinical outcomes

Abstract Aims Catheter ablation is the most effective rhythm-control option in patients with atrial fibrillation (AF) and is currently considered an option mainly for improving symptoms. We aimed to assess the impact of catheter ablation on hard clinical outcomes. Methods and results We performed a systematic review of randomized controlled trials (RCTs) comparing catheter ablation vs. optimized medical treatment. We searched MEDLINE, EMBASE, and CENTRAL on 8 January 2024, for trials published ≤10 years. We pooled data through risk ratio (RR) and mean differences (MDs), with 95% confidence interval (CI), and calculated the number needed to treat (NNT). Sub-group and sensitivity analyses were performed for the presence/absence of heart failure (HF), paroxysmal/persistent AF, early ablation, higher/lower quality, and published ≤5 vs. 5 years. Twenty-two RCTs were identified, including 6400 patients followed for 6–52 months. All primary endpoints were significantly reduced by catheter ablation vs. medical management: all-cause hospitalization (RR = 0.57, 95% CI 0.39–0.85, P = 0.006), AF relapse (RR = 0.48, 95% CI 0.39–0.58, P 0.00001), and all-cause mortality (RR = 0.69, 95% CI 0.56–0.86, P = 0.0007, NNT = 44.7, driven by trials with HF patients). A benefit was also demonstrated for all secondary endpoints: cardiovascular mortality (RR = 0.55, 95% CI 0.34–0.87), cardiovascular (RR = 0.83, 95% CI 0.71–0.96), and HF hospitalizations (RR = 0.71, 95% CI 0.56–0.89), AF burden (MD = 20.6%, 95% CI 5.6–35.5), left ventricular ejection fraction (LVEF) recovery (MD = 5.7%, 95% CI 3.5–7.9), and quality of life (MLHFQ, AFEQT, and SF-36 scales). Conclusion Catheter ablation significantly reduced hospitalizations, AF burden, and relapse, and improved quality of life. An impact on hard clinical outcomes, with an important mortality reduction and improvement in LVEF, was seen for patients with AF and HF.