Skip to main content
SpringerLink
Log in

The impact of catheter ablation in patient’s heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Recent trial data suggest a benefit to catheter ablation (CA) compared to medical therapy for atrial fibrillation (AF) in patients with heart failure (HF). Nevertheless, because of mixed trial evidence, contemporary guidelines give it a class 2 recommendation. Accordingly, we sought to assess the currently available evidence for CA in HF with AF.

Methods

Electronic databases were searched to identify randomized clinical trials (RCTs) comparing CA to medical therapy in patients with AF and HF. Study data was pooled using fixed and random effects, and the number needed to treat (NNT) was calculated to gauge absolute risk differences. Heterogeneity was quantified using I2. Our primary outcome was all-cause mortality.

Results

Nine trials (CA 1075 patients; medical therapy 1083 patients) were included. Ablation reduced the relative risk of all-cause mortality by 31.5% (95% CI 13.7 to 45.6%; NNT = 23), cardiovascular mortality by 39.3% (95% CI 10.9 to 58.7%; NNT = 31), cardiovascular hospitalization by 29.1% (95% CI 9.4 to 44.6%; NNT = 9), and heart failure hospitalization by 28.5% (95% CI 6.5 to 45.4%; NNT = 22). Improvements in quality of life were observed with CA using the Minnesota Living with Heart Failure Questionnaire (mean difference – 5.26; 95% CI − 2.73 to − 7.78) and the Atrial Fibrillation Effect on Quality of Life (mean difference 5.36; 95% CI 2.72 to 8.00).

Conclusion

Compared to medical therapy, CA for AF in patients with HF reduces all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, and heart failure hospitalizations, and may improve quality of life.

Graphical Abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

All of the data and code for statistical analysis used for this manuscript will be made available upon request by emailing the first author.

Abbreviations

HF:

Heart failure

AF:

Atrial fibrillation

CA:

Catheter ablation

RCT:

Randomized clinical trial

HFrEF:

Heart failure with reduced ejection fraction

HFpEF:

Heart failure with preserved ejection fraction

NNT:

Number needed to treat

RR:

Risk ratio

References

  1. Roth GA, et al. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020;76(25):2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chiang CE, et al. Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice: insight from the real-life global survey evaluating patients with atrial fibrillation international registry. Circ Arrhythm Electrophysiol. 2012;5(4):632–9. https://doi.org/10.1161/CIRCEP.112.970749.

    Article  PubMed  Google Scholar 

  3. Avitall B, Bi J, Mykytsey A, Chicos A. Atrial and ventricular fibrosis induced by atrial fibrillation: evidence to support early rhythm control. Heart Rhythm. 2008;5(6):839–45. https://doi.org/10.1016/j.hrthm.2008.02.042.

    Article  PubMed  Google Scholar 

  4. Li D, Fareh S, Leung TK, Nattel S. Promotion of atrial fibrillation by heart failure in dogs: atrial remodeling of a different sort, (in eng). Circulation. 1999;100(1):87–95. https://doi.org/10.1161/01.cir.100.1.87.

    Article  CAS  PubMed  Google Scholar 

  5. Mamas MA, Caldwell JC, Chacko S, Garratt CJ, Fath-Ordoubadi F, Neyses L. A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure. Eur J Heart Fail. 2009;11(7):676–83. https://doi.org/10.1093/eurjhf/hfp085.

    Article  PubMed  Google Scholar 

  6. Kirchhof P, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305–16. https://doi.org/10.1056/NEJMoa2019422.

    Article  PubMed  Google Scholar 

  7. Ruzieh M, et al. Meta-analysis comparing the relative risk of adverse events for amiodarone versus placebo. Am J Cardiol. 2019;124(12):1889–93. https://doi.org/10.1016/j.amjcard.2019.09.008.

    Article  CAS  PubMed  Google Scholar 

  8. Torp-Pedersen C, et al. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. New England J Med. 1999;341(12):857–65. https://doi.org/10.1056/NEJM199909163411201.

    Article  CAS  Google Scholar 

  9. Lehmann MH, Hardy S, Archibald D, Quart B, MacNeil DJ. Sex difference in risk of Torsade de Pointes With d, l-Sotalol. Circulation. 1996;94(10):2535–41. https://doi.org/10.1161/01.CIR.94.10.2535.

    Article  CAS  PubMed  Google Scholar 

  10. Køber L, et al. Increased mortality after dronedarone therapy for severe heart failure. New England J Med. 2008;358(25):2678–87. https://doi.org/10.1056/NEJMoa0800456.

    Article  Google Scholar 

  11. Marrouche NF, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417–27. https://doi.org/10.1056/NEJMoa1707855.

    Article  PubMed  Google Scholar 

  12. Packer DL, et al. Ablation versus drug therapy for atrial fibrillation in heart failure: results from the CABANA trial. Circulation. 2021;143(14):1377–90. https://doi.org/10.1161/CIRCULATIONAHA.120.050991.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895–1032. https://doi.org/10.1161/CIR.0000000000001063.

    Article  PubMed  Google Scholar 

  14. McDonagh TA, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–726. https://doi.org/10.1093/eurheartj/ehab368.

    Article  CAS  PubMed  Google Scholar 

  15. January CT, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140(2):e125–51. https://doi.org/10.1161/CIR.0000000000000665.

    Article  PubMed  Google Scholar 

  16. Jones DG, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. J Am Coll Cardiol. 2013;61(18):1894–903. https://doi.org/10.1016/j.jacc.2013.01.069.

    Article  PubMed  Google Scholar 

  17. Kuck KH, et al. Catheter ablation versus best medical therapy in patients with persistent atrial fibrillation and congestive heart failure: the randomized AMICA trial. Circ Arrhythm Electrophysiol. 2019;12(12):e007731. https://doi.org/10.1161/CIRCEP.119.007731.

    Article  PubMed  Google Scholar 

  18. MacDonald MR, et al. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial. Heart. 2011;97(9):678–8. https://doi.org/10.1136/hrt.2010.207340.

  19. Di Biase L, et al. Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: results from the AATAC multicenter randomized trial. Circulation. 2016;133(17):1637–44. https://doi.org/10.1161/CIRCULATIONAHA.115.019406.

    Article  CAS  PubMed  Google Scholar 

  20. Hunter RJ, et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol. 2014;7(1):31–8. https://doi.org/10.1161/CIRCEP.113.000806.

    Article  CAS  PubMed  Google Scholar 

  21. Parkash R, et al. Randomized ablation-based rhythm-control versus rate-control trial in patients with heart failure and atrial fibrillation: results from the RAFT-AF trial. Circulation. 2022;145(23):1693–704. https://doi.org/10.1161/CIRCULATIONAHA.121.057095.

    Article  CAS  PubMed  Google Scholar 

  22. Prabhu S, et al. Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: the CAMERA-MRI study. J Am Coll Cardiol. 2017;70(16):1949–61. https://doi.org/10.1016/j.jacc.2017.08.041.

    Article  PubMed  Google Scholar 

  23. Sugumar H, et al. Catheter ablation versus medication in atrial fibrillation and systolic dysfunction: late outcomes of CAMERA-MRI study. JACC Clin Electrophysiol. 2020;6(13):1721–31. https://doi.org/10.1016/j.jacep.2020.08.019.

    Article  PubMed  Google Scholar 

  24. Wong C, et al. Abstract 15101: long-term outcomes following catheter ablation in patients with atrial fibrillation and heart failure: 7-year follow-up of the ARC-HF trial. Circulation. 2018;138(Suppl_1):A15101–A15101. https://doi.org/10.1161/circ.138.suppl_1.15101.

    Article  Google Scholar 

  25. S-po05–108 catheter ablation of atrial fibrillation on heart failure symptoms and quality of life, Heart Rhythm 16(5):S426-S521 2019, https://doi.org/10.1016/j.hrthm.2019.04.018.

  26. He X, et al. Atrial fibrillation induces myocardial fibrosis through angiotensin II type 1 receptor-specific Arkadia-mediated downregulation of Smad7. Circ Res. 2011;108(2):164–75. https://doi.org/10.1161/CIRCRESAHA.110.234369.

    Article  CAS  PubMed  Google Scholar 

  27. Roy D, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. New England J Med. 2008;358(25):2667–77. https://doi.org/10.1056/NEJMoa0708789.

    Article  CAS  Google Scholar 

  28. Hagens VE, et al. Rate control versus rhythm control for patients with persistent atrial fibrillation with mild to moderate heart failure: results from the RAte Control versus Electrical cardioversion (RACE) study. Am Heart J. 2005;149(6):1106–11. https://doi.org/10.1016/j.ahj.2004.11.030.

    Article  PubMed  Google Scholar 

  29. McMurray JJV, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381(21):1995–2008. https://doi.org/10.1056/NEJMoa1911303.

    Article  CAS  PubMed  Google Scholar 

  30. McMurray JJ, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371(11):993–1004. https://doi.org/10.1056/NEJMoa1409077.

    Article  CAS  PubMed  Google Scholar 

  31. Packer M, et al. Effect of carvedilol on survival in severe chronic heart failure, (in eng). N Engl J Med. 2001;344(22):1651–8. https://doi.org/10.1056/nejm200105313442201.

    Article  CAS  PubMed  Google Scholar 

  32. Effect of metoprolol CR/XL in chronic heart failure. Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF), (in eng). Lancet. 1999;353(9169):2001–7.

    Article  Google Scholar 

  33. Betts TR, et al. Absolute risk reduction in total mortality with implantable cardioverter defibrillators: analysis of primary and secondary prevention trial data to aid risk/benefit analysis. Europace. 2013;15(6):813–9. https://doi.org/10.1093/europace/eus427.

    Article  PubMed  Google Scholar 

  34. Turagam MK, et al. Catheter ablation of atrial fibrillation in patients with heart failure: a meta-analysis of randomized controlled trials. Ann Intern Med. 2019;170(1):41–50. https://doi.org/10.7326/M18-0992.

    Article  PubMed  Google Scholar 

  35. Bahnson TD, et al. Association Between age and outcomes of catheter ablation versus medical therapy for atrial fibrillation: results from the CABANA trial. Circulation. 2022;145(11):796–804. https://doi.org/10.1161/CIRCULATIONAHA.121.055297.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Faculty of Medicine, Ain Shams University, Cairo, Egypt

    Ahmed Sayed & Ahmed K. Awad

  2. Internal Medicine Department, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA

    Omar M. Abdelfattah

  3. Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA

    Omar M. Abdelfattah

  4. Section of Cardiac Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Mahmoud Elsayed & Rod Passman

  5. Department of Cardiology, Tufts Medical Center, Boston, MA, USA

    Khader Herzallah

  6. Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Joseph E. Marine

  7. Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT, 84132, USA

    Jared T. Bunch

Authors
  1. Ahmed Sayed
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed K. Awad
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Omar M. Abdelfattah
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mahmoud Elsayed
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Khader Herzallah
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Joseph E. Marine
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rod Passman
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jared T. Bunch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jared T. Bunch.

Ethics declarations

Ethical approval

This study was exempted from the institutional review board’s approval because it used anonymized data that is publicly available.

Informed consent

Because this study used publicly available data, there was no patient involvement, and thus, no consent process was required.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 1814 KB)

Supplementary file2 (DOCX 23 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sayed, A., Awad, A.K., Abdelfattah, O.M. et al. The impact of catheter ablation in patient’s heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials. J Interv Card Electrophysiol 66, 1487–1497 (2023). https://doi.org/10.1007/s10840-022-01451-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-022-01451-2

Keywords

Search

Navigation