Metabolic Dysfunction-Associated Steatotic Liver Disease and Atrial Fibrillation Recurrence After Catheter Ablation: A Systematic Review and Meta-Analysis
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Key result
MASLD is linked to a ~77% higher risk of AF recurrence after catheter ablation.
- RR 1.77
- 95% CI 1.43-2.18
- P<0.001
- n=2,921
Why the study?
AF recurrence after catheter ablation remains common and may be influenced by metabolic dysfunction-associated steatotic liver disease and related fibrosis risk.
Does the presence of metabolic dysfunction-associated steatotic liver disease (MASLD) or related liver fibrosis increase the risk of atrial fibrillation recurrence in adults undergoing catheter ablation?
Population
2921 adults undergoing catheter ablation for atrial fibrillation
Comparison
MASLD or intermediate/high fibrosis risk vs no MASLD or low fibrosis risk
Design
Systematic review and random-effects meta-analysis of observational studies
Authors
Discussion
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Implication
Supports closer post-ablation surveillance in MASLD; hypothesis-generating pending randomized trials of liver-directed interventions.
Key Points
- To evaluate the association of metabolic dysfunction-associated steatotic liver disease (MASLD) and MASLD-related liver fibrosis risk with atrial fibrillation recurrence following catheter ablation.
- Conducted a systematic review and random-effects meta-analysis of observational studies in adults undergoing catheter ablation for atrial fibrillation, with PROSPERO registration CRD420261335405.
- Identified 160 records, including seven studies in qualitative synthesis and six studies (N=2,921 total; 894 with MASLD and 2,027 non-MASLD) in the primary meta-analysis.
- Stratified liver fibrosis risk using the fibrosis-4 (FIB-4) index and the non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS).
- In the primary meta-analysis of six studies, MASLD was associated with a significantly higher risk of atrial fibrillation recurrence after catheter ablation (RR 1.77, 95% CI 1.43–2.18; p < 0.001; I2 = 64.1%), persisting across five studies reporting adjusted estimates (HR 2.13, 95% CI 1.49–3.04; p < 0.001; I2 = 70.5%).
- Patients with intermediate or high FIB-4 scores exhibited a significantly increased risk of recurrence compared with those with low scores (RR 2.03, 95% CI 1.27–3.26; p = 0.003; I2 = 71.3%).
- Intermediate or high NFS categories were also significantly associated with higher recurrence rates relative to low scores (RR 1.65, 95% CI 1.12–2.43; p = 0.01; I2 = 49.9%).
Study Design
Type
Meta-Analysis (n=2,921)
Structured PICO
Does the presence of metabolic dysfunction-associated steatotic liver disease (MASLD) or related liver fibrosis increase the risk of atrial fibrillation recurrence in adults undergoing catheter ablation?
P
Population
2,921 adults with atrial fibrillation undergoing catheter ablation, stratified by MASLD status, followed for 12 to 29 months.
E
Exposure
Presence of metabolic dysfunction-associated steatotic liver disease (MASLD) or intermediate/high MASLD-related liver fibrosis risk (assessed by FIB-4 index or NAFLD fibrosis score [NFS]).
C
Comparator
Absence of MASLD or low liver fibrosis risk.
O
Outcome
Atrial fibrillation recurrence (documented AF, atrial flutter, or atrial tachyarrhythmia lasting more than 30 seconds) after a standard 3-month blanking period.hard clinical
Main Result
Relative Risk: 1.77 (95% CI 1.43–2.18)
p-value: p=<0.001
MASLD and its associated intermediate-to-high liver fibrosis risk are significant independent predictors of atrial fibrillation recurrence following catheter ablation.
Limitations
- Embase was not searched separately, potentially missing eligible records.
- All included studies were observational, meaning residual confounding cannot be excluded.
- The small number of available studies precluded formal evaluation of publication bias.
- Exposure definitions varied across studies and did not uniformly use contemporary MASLD nomenclature.
- Rhythm monitoring protocols differed between studies, potentially introducing detection bias.
- Peri-procedural and post-ablation antiarrhythmic drug protocols were not consistently reported.
- Data on newer energy sources, such as pulsed field ablation, were not available.
- Embase was not searched separately, potentially missing eligible records
- All included studies were observational, so residual confounding cannot be excluded
- Small number of available studies precluded formal evaluation of publication bias
- Exposure definitions varied across studies and did not uniformly use contemporary MASLD nomenclature
- Rhythm monitoring and peri-procedural antiarrhythmic drug protocols differed between studies
Cite This Study
Theofilis et al. (2026) conducted a meta-analysis in Atrial Fibrillation (n=2,921). Metabolic dysfunction-associated steatotic liver disease (MASLD) vs. No MASLD was evaluated on Atrial fibrillation recurrence after catheter ablation (RR 1.77, 95% CI 1.43-2.18, p=<0.001). Metabolic dysfunction-associated steatotic liver disease was associated with a significantly higher risk of atrial fibrillation recurrence after catheter ablation compared to patients without the condition (RR 1.77).
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