Catheter Ablation Versus Medical Therapy in Persistent Atrial Fibrillation Across the Spectrum from Pre–Heart Failure to Symptomatic Heart Failure: A Systematic Review and Meta-Analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Persistent or long-standing persistent atrial fibrillation with concomitant heart failure (n=2853). Intervention: Catheter ablation (pulmonary vein isolation with or without additional substrate modification) vs. Medical therapy (rate control, pharmacological rhythm control, or both). Primary outcome: Change in left ventricular ejection fraction (LVEF) from baseline to study end (MD 6.28%, 95% CI 2.45-10.11, p=0.001).

Q: What does this research mean for the field?

Catheter ablation improves left ventricular ejection fraction by 6.28% and reduces unplanned rehospitalization compared to medical therapy in patients with persistent atrial fibrillation and heart failure. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Dya Andryan; Cynthia Parameswari; Muhammad Rizky Felani; Robert Fitryno; Andrew Jonathan; Drian Danya Hardi; Khariz Fahrurrozi; Mochamad Faisal Adam

doi:10.21203/rs.3.rs-10949006/v1

September 29, 2026Open Access

Catheter Ablation Versus Medical Therapy in Persistent Atrial Fibrillation Across the Spectrum from Pre–Heart Failure to Symptomatic Heart Failure: A Systematic Review and Meta-Analysis

View Full Paper

Ask AI

Bookmark

Share

Key result

Catheter ablation improves LVEF by ~6 percentage points vs. medical therapy in persistent AF and HF.

MD 6.28%
95% CI 2.45-10.11
P=0.001
n=2,853

Why the study?

Although catheter ablation is increasingly used for rhythm control in AF with HF, its effects on ventricular function, functional status, and clinical outcomes remain incompletely defined specifically for persistent and long-standing persistent AF.

Does catheter ablation improve left ventricular ejection fraction, functional status, and clinical outcomes compared with medical therapy in adults with persistent or long-standing persistent atrial fibrillation and concomitant heart failure?

Key Points

To quantify the clinical and functional effects of catheter ablation compared with medical therapy in patients with persistent or long-standing persistent atrial fibrillation and concomitant heart failure.
Systematic search of PubMed, Scopus, ScienceDirect, EBSCO, and the Cochrane Library through May 2026 for randomized controlled trials and peer-reviewed subgroup analyses.
Eligible studies enrolled adults with non-paroxysmal atrial fibrillation and at least Stage B heart failure.
Included 10 randomized controlled trials and two extended follow-up studies totaling 2853 participants, pooling outcomes using random-effects meta-analysis.
Catheter ablation improved left ventricular ejection fraction (MD 6.28%, 95% CI 2.45 to 10.11; P = 0.001 across 7 trials), disease-specific quality of life (MD -6.97, 95% CI -12.11 to -1.83; P = 0.008), and NYHA functional class (MD -0.70, 95% CI -0.85 to -0.56; P < 0.00001).
Ablation increased freedom from atrial fibrillation (RR 1.84, 95% CI 1.55 to 2.19; P < 0.00001) and reduced unplanned rehospitalization (68/804 vs 126/712; RR 0.54, 95% CI 0.42 to 0.69; P < 0.00001).
All-cause mortality showed no significant difference in the primary analysis (RR 0.72; P = 0.13), and no significant differences were observed for stroke or transient ischemic attack (22/658 vs 25/485; RR 0.69, 95% CI 0.38 to 1.24; P = 0.22) or six-minute walk distance (MD 2.63 m; P = 0.84).

Study Design

Type

Meta-Analysis (n=2,853)

Blinding

Open-label

Randomization

Randomised controlled trials and peer-reviewed subgroup analyses

Multicenter

Yes

Structured PICO

Does catheter ablation improve left ventricular ejection fraction, functional status, and clinical outcomes compared with medical therapy in adults with persistent or long-standing persistent atrial fibrillation and concomitant heart failure?

P

Population

2,853 adults (mean age 65.4 years, 28.4% female) with persistent or long-standing persistent atrial fibrillation and at least ACC/AHA Stage B heart failure across 10 RCTs and 2 extended follow-up studies, followed primarily for 6 to 24 months (up to 3.2 years in extended cohorts).

I

Intervention

Catheter ablation (n=1,492), primarily radiofrequency ablation (9 trials) or pulsed field ablation (1 trial, AVANT GUARD), with pulmonary vein isolation (PVI) with or without additional substrate modification.

C

Comparator

Medical therapy (n=1,361), consisting of rate control alone, pharmacological rhythm control (including amiodarone in AATAC), or both.

O

Outcome

Change in left ventricular ejection fraction (LVEF) from baseline to study end (primary follow-up ranging from 6 to 24 months).surrogate

Main Result

Mean Difference: 6.28 (95% CI 2.45–10.11)

p-value: p=0.001

In patients with persistent or long-standing persistent atrial fibrillation and heart failure (Stage B or higher), catheter ablation significantly improves LVEF, quality of life, NYHA class, and arrhythmia-free survival while reducing unplanned rehospitalizations compared to medical therapy.

Limitations

High between-study heterogeneity in the primary LVEF analysis (I²=88%)
Several included trials had small sample sizes and open-label designs by necessity
Formal quantitative publication bias assessment (funnel plot or Egger's test) was not performed because fewer than ten studies contributed to each outcome
Long-term mortality and LVEF analyses combined randomized trial data with extended observational follow-up cohorts in which randomization no longer held
Eligibility criteria permitted inclusion of patients at the ACC/AHA Stage B heart failure threshold, which is broader than conventional symptomatic heart failure populations
Conceptual heterogeneity in unplanned rehospitalization event definitions across trials
Open-label design across all included trials leading to risk of bias and downgrading of GRADE certainty
High risk of bias in five trials due to protocol deviations including treatment crossover from medical therapy to ablation
Substantial statistical heterogeneity in the primary LVEF analysis (I²=88%)
Conceptual heterogeneity in the definition of unplanned rehospitalization across trials
Extended follow-up cohorts were observational and susceptible to crossover, uncontrolled subsequent management, and confounding

Implication

Supports catheter ablation for LVEF recovery in persistent AF with HF; reinforces Level 1 evidence for rhythm control.

Abstract

Background Catheter ablation is increasingly used for rhythm control in atrial fibrillation (AF) with heart failure (HF), but its effects on ventricular function, functional status, and clinical outcomes remain incompletely defined for non-paroxysmal AF specifically. We aimed to quantify the effects of catheter ablation versus medical therapy in patients with persistent or long-standing persistent AF and concomitant HF. We searched PubMed, Scopus, ScienceDirect, EBSCO, and the Cochrane Library through May 2026 for randomised controlled trials and peer-reviewed subgroup analyses enrolling adults with non-paroxysmal AF and HF at least Stage B ACC/AHA. Outcomes were pooled as mean differences (MDs) or risk ratios (RRs) using random-effects meta-analysis. Risk of bias was assessed with RoB 2 and certainty of evidence with GRADE. Results Ten randomised controlled trials and two extended follow-up studies, comprising 2853 participants, were included. Catheter ablation improved left ventricular ejection fraction (MD 6.28%, 95% CI 2.45 to 10.11), disease-specific quality of life (MD -6.97), and New York Heart Association functional class (MD -0.70), increased freedom from AF (RR 1.84), and reduced unplanned rehospitalisation (RR 0.54). All-cause mortality did not differ significantly in the primary analysis (RR 0.72; P = 0.13) but showed a directional reduction approaching significance on long-term follow-up (P = 0.05). Six-minute walk distance and stroke or transient ischaemic attack did not differ between groups. An exploratory subgroup analysis suggested that the magnitude of structural benefit may vary by medical comparator strategy. Conclusions In persistent and long-standing persistent AF spanning pre-heart failure to symptomatic HF, catheter ablation improves ventricular function, quality of life, functional class, and arrhythmia-free survival, and reduces rehospitalisation, with a directional but not definitive reduction in long-term mortality. These findings support catheter ablation as a disease-modifying rather than purely symptomatic strategy in this population.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Andryan et al. (2026) conducted a meta-analysis in Persistent or long-standing persistent atrial fibrillation with concomitant heart failure (n=2,853). Catheter ablation (pulmonary vein isolation with or without additional substrate modification) vs. Medical therapy (rate control, pharmacological rhythm control, or both) was evaluated on Change in left ventricular ejection fraction (LVEF) from baseline to study end (MD 6.28%, 95% CI 2.45-10.11, p=0.001). Catheter ablation improved left ventricular ejection fraction by a mean difference of 6.28% (95% CI 2.45-10.11; P=0.001) compared to medical therapy in persistent AF with heart failure.

synapsesocial.com/papers/6ae28f53cbadf70daf6c44f3 https://doi.org/10.21203/rs.3.rs-10949006/v1

View Full Paper

Ask AI

Bookmark

Share

Catheter Ablation Versus Medical Therapy in Persistent Atrial Fibrillation Across the Spectrum from Pre–Heart Failure to Symptomatic Heart Failure: A Systematic Review and Meta-Analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Catheter Ablation Versus Medical Therapy in Persistent Atrial Fibrillation Across the Spectrum from Pre–Heart Failure to Symptomatic Heart Failure: A Systematic Review and Meta-Analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading