Clinical outcomes after catheter ablation for atrial fibrillation in elderly patients: a meta-analysis with time-to-event data reconstruction

Background The effect of advanced age on outcomes after catheter ablation for atrial fibrillation (AF) remains uncertain. This systematic review and meta-analysis compared long-term efficacy and safety between elderly and non-elderly patients using time-to-event reconstruction. Methods A comprehensive search of PubMed, Scopus, Embase, and Web of Science was conducted for comparative studies up to January 2026. The primary outcome was AF recurrence. Secondary outcomes included mortality, stroke, and procedural complications. Pairwise meta-analysis estimated risk ratios (RR), and individual patient-level time-to-event data were reconstructed from Kaplan–Meier curves to calculate hazard ratios (HR). Results Twenty-eight studies involving 22,921 patients were included in the analysis. Elderly patients had a significantly higher risk of AF recurrence compared with non-elderly patients (RR 1.174, 95% CI 1.068–1.290; P < 0.001; I2 = 55%). This was consistent across age subgroups, including ≥ 80 years (RR 1.155, 95% CI 1.057–1.263; P = 0.001) and ≥ 75 years (RR 1.224, 95% CI 1.039–1.441; P = 0.015), with no significant subgroup difference (P = 0.54). Time-to-event analysis confirmed these findings (HR 1.138, 95% CI 1.055–1.227; P = 0.001), including ≥ 75 years (HR 1.147, 95% CI 1.037–1.268; P = 0.008) and ≥ 80 years (HR 1.127, 95% CI 1.005–1.264; P = 0.040). Elderly patients also had higher risks of all-cause mortality (RR 3.978, 95% CI 2.852–5.547; P < 0.001), stroke (RR 2.136, 95% CI 1.336–3.414; P = 0.002), hemopericardium/tamponade (RR 1.610, 95% CI 1.061–2.442; P = 0.025), atrioesophageal fistula (RR 4.398, 95% CI 1.638–11.811; P = 0.003), and pulmonary vein stenosis (RR 4.022, 95% CI 1.281–12.632; P = 0.017), with no significant differences in pericarditis (RR 1.830, 95% CI 0.653–5.129; P = 0.250), vascular complications (RR 1.183, 95% CI 0.854–1.637; P = 0.312), or phrenic nerve palsy (RR 1.449, 95% CI 0.985–2.130; P = 0.059). Conclusion Elderly patients have higher AF recurrence and increased risks of major complications, including mortality and stroke, after catheter ablation, underscoring the need for individualized risk assessment and shared decision-making.