Impact of atrial fibrillation catheter ablation on primary prevention ICD eligibility in heart failure with reduced ejection fraction: a systematic review and meta-analysis
F Landra, E Curti, G Falasconi, D Penela, M Bergonti, A Saglietto, K Benali, A C Latini, A Santoro, E Taravelli, A Rossi, J Marti-Almor, G Conte, M Anselmino, A BerruezoAbstract
Background and aims
Patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) may show positive remodeling after catheter ablation, yet rhythm control is not consistently prioritized alongside guideline-directed medical therapy (GDMT) before implantable cardioverter-defibrillator (ICD) implantation. This meta-analysis evaluated the effect of AF ablation on primary prevention ICD eligibility in patients with left ventricular ejection fraction (LVEF) ≤35%.
Methods
PubMed/MEDLINE, Scopus and Cochrane databases were searched until April 2025 for studies including patients with LVEF ≤35% undergoing AF catheter ablation and reporting outcomes regarding LVEF evolution during follow-up.
Results
Twenty-two studies, of which six randomized controlled trials and 16 observation studies, comprising 913 patients, were included. At a median follow-up of 11.4 months (IQR: 6.0 – 15.0) the pooled proportion of patients with LVEF >35% was 72.1% (95% CI, 63.0–80.3; I2 = 84.8%). Subgroup analysis including only patients on GDMT for >3 months with known HF etiology showed that 52.8% (95% CI, 43.2–66.6; I2 = 78.2%) of them exceeded the LVEF threshold at follow-up. Ischemic etiology was negatively associated with LVEF improvement beyond 35% (β = -40.4%, 95% CI -86.2 – -3.4; p = 0.007). Longitudinal meta-analysis revealed an estimated 5.3 months needed to surpass the 35% threshold.
Conclusions
AF ablation leads to LVEF recovery >35% in the majority of HFrEF patients during follow-up, particularly in non-ischemic etiologies. A 6-months waiting period could be more appropriate before taking a decision on prophylactic ICD implantation.Graphical Abstract