Cardiology ยท Medical Literature
Impact of Catheter Ablation on LVEF in Patients with Atrial Fibrillation and Heart Failure with Reduced Ejection Fraction: A Systematic Review.
Abstract
Atrial fibrillation (AF) is a condition that frequently affects patients with heart failure with reduced ejection fraction (HFrEF) and is associated with worsening left ventricular ejection fraction (LVEF) and unfavorable clinical outcomes. Catheter ablation has been proposed as a strategy to restore sinus rhythm; however, its effects on LVEF remain heterogeneous in the literature. To evaluate the impact of catheter ablation, compared with medical therapy, on LVEF in patients with AF and HFrEF. A systematic review of randomized clinical trials was conducted in accordance with the PRISMA guidelines. The primary outcome was improvement in LVEF, while secondary outcomes included cardiovascular mortality, all-cause mortality, and hospitalizations due to heart failure. Other exploratory outcomes were also considered. The included randomized clinical trials demonstrated improvement in LVEF among patients undergoing catheter ablation compared with those receiving medical therapy. In the CAMERA-MRI study, an absolute increase of 18.3% in LVEF was observed after six months. In the CASTLE-AF trial, catheter ablation was also associated with a lower incidence of cardiovascular mortality and heart failure hospitalizations. In the absence of a meta-analysis, no quantitative synthesis of the effects was performed. The available evidence from individual randomized trials suggests that catheter ablation may be associated with improvement in LVEF and more favorable clinical outcomes in patients with AF and HFrEF. However, given the lack of quantitative synthesis, these findings should be interpreted with caution.
Clinical relevance
AF coexisting with HFrEF represents a high-risk phenotype associated with progressive ventricular dysfunction and adverse outcomes, yet optimal rhythm-control strategy remains debated. This systematic review addresses the critical clinical question of whether catheter ablation offers measurable benefits over medical therapy in LVEF recovery in this vulnerable population. Given the growing prevalence of both conditions and the limitations of pharmacological rate/rhythm control, these findings are directly relevant to electrophysiologists, heart failure specialists, and general cardiologists managing this complex comorbidity.
Key findings
1. Catheter ablation was consistently associated with improvement in LVEF compared with medical therapy across the included randomized clinical trials, though effect sizes varied across studies. 2. In the CAMERA-MRI trial, catheter ablation produced an absolute increase of 18.3% in LVEF at six months compared with the medical therapy arm. 3. The CASTLE-AF trial demonstrated that catheter ablation was associated with a lower incidence of cardiovascular mortality compared with medical therapy in patients with AF and HFrEF. 4. Catheter ablation was also associated with a reduced rate of heart failure hospitalizations in the CASTLE-AF trial. 5. Secondary outcomes including all-cause mortality and HF hospitalizations were incorporated as endpoints across trials, supporting a broader clinical benefit signal beyond LVEF alone. 6. No quantitative pooled synthesis (meta-analysis) was performed due to heterogeneity across trials, limiting the ability to derive a single summary effect estimate; findings must therefore be interpreted at the individual trial level.
Practice implications
In patients with concurrent AF and HFrEF who remain symptomatic or demonstrate progressive ventricular dysfunction despite optimized guideline-directed medical therapy, referral for catheter ablation should be strongly considered as a rhythm-control strategy with potential for meaningful LVEF recovery, as suggested by an absolute LVEF gain of up to 18.3% in the CAMERA-MRI cohort. The association between ablation and reductions in cardiovascular mortality and HF hospitalizations observed in CASTLE-AF supports incorporating catheter ablation earlier in the treatment algorithm for eligible patients, particularly those with AF presumed to be a contributor to cardiomyopathy. Clinicians should individualize patient selection based on AF burden, HF etiology, procedural candidacy, and institutional expertise, while awaiting larger pooled analyses to more precisely define the magnitude of benefit across subgroups.