Catheter Ablation Versus Medical Therapy in Atrial Fibrillation With Heart Failure With Reduced or Mildly Reduced Ejection Fraction: A GRADE-Assessed Systematic Review and Meta-Analysis

BACKGROUND: Catheter ablation is an established rhythm-control strategy for atrial fibrillation (AF), but its effectiveness in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF) remains incompletely defined. We performed a GRADE-assessed systematic review and meta-analysis comparing catheter ablation with conventional medical therapy in this population. METHODS: PubMed, Embase, and the Cochrane Library were searched from inception to February 2026. Randomized controlled trials and observational cohort studies enrolling adults with AF and left ventricular ejection fraction (LVEF) ≤ 50% were included. Primary outcomes were all-cause mortality, cardiovascular mortality, and change in LVEF. Secondary outcomes were change in B-type natriuretic peptide (BNP) and cardiovascular hospitalization. Random-effects models were used, and certainty of evidence was assessed using GRADE. RESULTS: Thirteen studies involving 131 492 participants were included. Catheter ablation significantly reduced all-cause mortality (RR 0.61, 95% CI 0.51-0.71) and cardiovascular mortality (RR 0.46, 95% CI 0.31-0.66), improved LVEF (MD 6.47%, 95% CI 4.47-8.47), and reduced BNP levels (MD -136.85 pg/mL, 95% CI -190.46 to -83.23). No significant reduction was observed in cardiovascular hospitalization (RR 0.78, 95% CI 0.53-1.13). Mortality benefits were consistent across subgroup analyses by study design and baseline LVEF. CONCLUSIONS: Catheter ablation was associated with lower mortality and improved cardiac function compared with medical therapy in patients with AF and HFrEF/HFmrEF. Further studies specifically evaluating HFmrEF populations are warranted.