Early versus delayed catheter ablation in atrial fibrillation and heart failure: A systematic review and meta-analysis

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist, worsening outcomes. Catheter ablation (CA) is an established therapy, but the optimal timing remains unclear.

Objective: This study aimed to evaluate the impact of early vs delayed CA on clinical outcomes in patients with AF and HF.

Methods: This International Prospective Register of Systematic Reviews-registered systematic review (CRD42025643686) adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies enrolling adults with AF and HF were included. Early CA was defined as ablation performed within varying timeframes (often ≤12 months) after AF diagnosis or HF decompensation vs delayed CA beyond that period. Primary outcomes were AF recurrence, all-cause mortality, and HF hospitalizations. Random-effects meta-analyses were performed.

Results: Ten studies (n = 15,822) contributed to the meta-analyses. Early CA was associated with significantly reduced AF recurrence (k = 8, hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.52-0.78, P < .0001) and HF hospitalization (k = 5, HR 0.63, 95% CI 0.51-0.77, P < .0001). A nonsignificant trend toward reduced all-cause mortality was observed (k = 4, HR 0.71, 95% CI 0.41-1.24, P = .23). Statistical heterogeneity was absent for HF hospitalization (I² = 0%), moderate for AF recurrence (I² = 67.6%), and high for mortality (I² = 75.3%). Narrative synthesis included 2 additional randomized controlled trials comparing treatment strategies.

Conclusion: Evidence from pooled observational studies suggests early CA is associated with reduced AF recurrence and HF hospitalization in patients with AF and HF; a mortality benefit was not statistically confirmed. Interpretation warrants caution owing to reliance on observational data and methodological heterogeneity across studies.

Keywords: Atrial fibrillation; Catheter ablation; Diagnosis-to-ablation time; Heart failure; Meta-analysis; Timing.