Differential impact of catheter ablation across heart failure phenotypes in atrial fibrillation: a grade assessed systematic review and meta-analysis

Introduction Atrial fibrillation (AF) is highly prevalent in heart failure (HF) and is linked to increased mortality and hospitalization in both preserved (HFpEF) and reduced ejection fraction (HFrEF). Catheter ablation (CA) has emerged as an effective rhythm-control strategy beyond medical therapy (MT), but phenotype-specific differences remain unclear. We compared the efficacy and safety of CA versus MT in AF with HFpEF or HFrEF. Methods PubMed, Embase, Scopus, and Cochrane databases were searched through December 2025. Random-effects meta-analyses were conducted in R (version 4.5.3), reporting risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). Results Fifteen studies involving 27,130 patients (CA: 13,579; MT: 13,551) were included. Catheter ablation significantly reduced overall all-cause mortality (RR 0.44), with a significant benefit in HFpEF (RR 0.44), whereas the reduction in HFrEF did not reach statistical significance (RR 0.53, 95% CI 0.21–1.38). Cardiovascular mortality and cardiovascular hospitalization were also reduced overall, without significant differences between HF phenotypes. Stroke and atrial arrhythmia recurrence were not significantly reduced in the primary analyses, and favorable findings observed in sensitivity analyses were considered exploratory . Catheter ablation significantly improved LVEF in HFrEF but not in HFpEF, while effects on exercise capacity and biomarkers varied across outcomes and phenotypes. Adverse events were comparable between treatment strategies. Conclusion Catheter ablation was associated with favorable clinical outcomes compared with medical therapy in AF with HF; however, the magnitude and statistical certainty of benefit varied across heart failure phenotypes and outcomes.