Prognostic impact of catheter ablation in atrial fibrillation with heart failure with preserved ejection fraction: an updated systematic review and reconstructed individual patient data meta-analysis

Abstract

Background Catheter ablation improves outcomes in atrial fibrillation (AF) with heart failure with reduced ejection fraction, but its efficacy in heart failure with preserved ejection fraction (HFpEF) remains uncertain. We performed a systematic review and reconstructed individual patient data meta-analysis to evaluate catheter ablation compared with medical therapy in this population. Methods Electronic databases were searched from inception through December 8, 2025, for randomized and observational studies comparing catheter ablation with medical therapy in adults with AF and HFpEF (LVEF ≥50% or guideline-consistent definitions). Primary outcomes were all-cause mortality and heart failure (HF) hospitalizations. Results Across 13 studies (45,642 patients), catheter ablation was associated with significantly lower all-cause mortality (HR 0.55, 95% CI 0.42–0.73; p < 0.0001), reduced HF hospitalizations (HR 0.67, 95% CI 0.52–0.86; p = 0.001), lower stroke/TIA risk (RR 0.89, 95% CI 0.79–0.99; p = 0.04) and reduced AF/atrial arrhythmia recurrence (HR 0.59, 95% CI 0.51–0.69; p < 0.00001). Reconstructed Kaplan–Meier curves demonstrated consistent time-to-event separation favouring catheter ablation across these outcomes. All-cause hospitalizations were lower (HR 0.90, 95% CI 0.81–1.00; p = 0.05), but not significant. Exploratory analyses demonstrated directionally favourable reductions in NT-proBNP and small changes in LVEF following ablation. Conclusion Catheter ablation may confer prognostic benefit in selected AF and HFpEF populations, though large, randomized trials are needed to confirm these findings. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261278738, PROSPERO, CRD420261278738.