Metabolic Dysfunction-Associated Steatotic Liver Disease and Atrial Fibrillation Recurrence After Catheter Ablation: A Systematic Review and Meta-Analysis

Background: Catheter ablation (CA) is an established rhythm-control strategy for atrial fibrillation (AF); however, AF recurrence remains common and is influenced by the underlying cardiometabolic substrate, including metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to evaluate the association of MASLD and MASLD-related fibrosis risk with AF recurrence following CA. Methods: We conducted a systematic review and random-effects meta-analysis of observational studies reporting AF recurrence after CA, stratified by MASLD status and liver fibrosis risk, as assessed using the fibrosis-4 (FIB-4) index and the non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS). Eligible studies included adults undergoing CA for AF with recurrence outcomes reported and stratified by MASLD or fibrosis risk categories. Results: A total of 160 records were identified, and seven studies were included in the qualitative synthesis. Six studies, including 2921 patients, contributed to the primary meta-analysis comparing MASLD versus no MASLD. An additional fibrosis-only study contributed to fibrosis-stratified analyses. The meta-analysis of six studies (MASLD: 894; non-MASLD: 2027) demonstrated that MASLD was associated with a significantly higher risk of AF recurrence after CA (risk ratio (RR) 1.77, 95% confidence interval (CI) 1.43–2.18; p < 0.001; I2 = 64.1%). In a separate meta-analysis of five studies reporting adjusted estimates, MASLD remained significantly associated with recurrence (hazard ratio (HR) 2.13, 95% CI 1.49–3.04; p < 0.001; I2 = 70.5%). In fibrosis-stratified analyses, Intermediate/High FIB-4 (RR 2.03, 95% CI 1.27–3.26; p = 0.003; I2 = 71.3%) and Intermediate/High NFS (RR 1.65, 95% CI 1.12–2.43; p = 0.01; I2 = 49.9%) were associated with a higher risk of AF recurrence compared with low scores. Conclusion: MASLD is associated with a significantly higher risk of AF recurrence after CA. Fibrosis risk stratification using FIB-4 and NFS also shows a significant association between Intermediate/High fibrosis and increased recurrence rates. PROSPERO Registration: CRD420261335405, https://www.crd.york.ac.uk/PROSPERO/view/CRD420261335405.