Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Original Article

Volume 16, Number 1, February 2025, pages 33-43

Atrial Fibrillation Recurrence Post-Ablation Across Heart Failure Categories: A Systematic Review and Meta-analysis

↓ Figure 1. CONSORT diagram of literature search and identification of relevant studies all three heart failure categories based on left ventricular ejection fraction and atrial fibrillation.

↓ Figure 2. Pooled atrial fibrillation recurrence rate (95% CI) after ablation between the three heart failure categories. CI: confidence interval; AF: atrial fibrillation; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction.

↓ Figure 3. Pooled hazard ratio (95% CI) of all-cause mortality and heart failure hospitalization after ablation or other rhythm control compared to other conservative management between the heart failure categories. CI: confidence interval; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction.

↓ Figure 4. Funnel plot (a) and contour-enhanced funnel plot (b) of atrial fibrillation recurrence post-ablation studies included in meta-analysis. Egger’s test P value = 0.4175. CI: confidence interval; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction.

↓ **Table 1.** Baseline Characteristic of Studies Comparing Atrial Fibrillation Recurrence Post-Ablation Across the Three Standard Categories of Heart Failure
Study	Total sample size	Study design	HF class	Sub-sample size	Men, %	Age, years	HTN, %	AF duration	PAF, n	PerAF, n	Per AF, %	IHD, %	DM, %	LVEF, %	CKD, %	Stroke or TIA, %	C2V	NYHA III/IV, %	AAD, %
AAD: antiarrhythmic drug; AF: atrial fibrillation; CKD: chronic kidney disease; C2V: CHA2DS2-VASc; DM: diabetes mellitus, HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart failure with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; HTN: hypertension; IHD: ischemic heart disease; LVEF: left ventricular ejection fraction; N/A: not available; NYHA: New York Heart Association; PAF: paroxysmal atrial fibrillation; PerAF: persistent atrial fibrillation; RCT: randomized controlled trial; TIA: transient ischemic attack.
Chen et al, 2023 [21]	471	Cohort	HFrEF	37	62.2%	68	64.9%	13 months	28	9	24.3%	40.5%	35.1%	35%	29.7%	8.1%	3	N/A	37.8%
			HFmrEF	78	61.5%	69	59%	11 months	61	17	21.8%	35.9%	31.6%	45%	23.1%	7.7%	3	N/A	29.5%
			HFpEF	101	59.4%	67	66.3%	11 months	74	27	26.7%	29.7%	27.7%	57%	17.8%	3%	2	N/A	33.7%
Eitel et al, 2019 [22]	588	Cohort	HFrEF	99	77.7%	65	73%	N/A	26	40	40.1%	48.4%	21.3%	N/A	18.9%	5.4%	3.8	51.6%	36%
			HFmrEF	181	66.7%	66.1	70%	N/A	82	72	39.8%	48.8%	19.8%	N/A	4.8%	0%	2.2	9.7%	37.2%
			HFpEF	308	66.1%	65.4	76%	N/A	141	126	41.0%	45.3%	10.8%	N/A	4.7%	7.1%	2.5	8.7%	53.2%
Fujimoto et al, 2022 [23]	656	Cohort	HFrEF	98	83.7%	64.6	44.9%	14.3 months	39	39	39.8%	27.6%	24.5%	32%	N/A	N/A	3	26.5%	59.2%
			HFmrEF	107	73.8%	64.4	50.5%	23.3 months	35	48	44.9%	21.5%	23.4%	44.8%	N/A	N/A	3	13.1%	48.6%
			HFpEF	451	67.6%	67	59.4%	21.5 months	217	148	32.8%	10%	20.8%	62.9%	N/A	N/A	3	11.6%	49.9%
Mekhael et al, 2023 [24]	98	RCT	HFrEF	29	93.1%	60.8	62.1%	N/A	0	29	100%	24.1%	6.9%	31.8%	N/A	10.3%	N/A	N/A	N/A
			HFmrEF	23	78.3%	60.5	65.2%	N/A	0	23	100%	8.7%	0%	44.6%	N/A	0%	N/A	N/A	N/A
			HFpEF	46	82.6%	60.5	50%	N/A	0	46	100%	13%	17.4%	56.5%	N/A	15.2%	N/A	N/A	N/A
Rillig et al, 2021 [25]	798	RCT	HFrEF	132	78.8%	69.3	78%	2.6 months	22	52	39.4%	25.8%	31.1%	31.1%	18.9%	11.4%	4	18.2%	9.1%
			HFmrEF	211	75.4%	70.4	83.9%	2.7 months	52	69	32.7%	25.1%	28.4%	44.3%	15.2%	12.8%	4	6.2%	10.4%
			HFpEF	442	51.1%	70	91.9%	2.4 months	177	135	30.5%	20.1%	25.6%	60.8%	16.3%	10.4%	4	18.3%	5.9%
Von Olshausen et al, 2022 [18]	1,302	Cohort	HFrEF	858	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
			HFmrEF	221	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
			HFpEF	223	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Yazaki et al, 2020 [19]	150	Cohort	HFrEF	28	100%	61	N/A	28 months	12	N/A	N/A	11%	N/A	N/A	N/A	N/A	N/A	N/A	57%
			HFmrEF	49	80%	61	N/A	33 months	17	N/A	N/A	8%	N/A	N/A	N/A	N/A	N/A	N/A	25%
			HFpEF	73	86%	60	N/A	24 months	31	N/A	N/A	4%	N/A	N/A	N/A	N/A	N/A	N/A	18%

↓ Table 1. Baseline Characteristic of Studies Comparing Atrial Fibrillation Recurrence Post-Ablation Across the Three Standard Categories of Heart Failure

Study

Total sample size

Study design

HF class

Sub-sample size

Men, %

Age, years

HTN, %

AF duration

PAF, n

PerAF, n

Per AF, %

IHD, %

DM, %

LVEF, %

CKD, %

Stroke or TIA, %

C2V

NYHA III/IV, %

AAD, %

AAD: antiarrhythmic drug; AF: atrial fibrillation; CKD: chronic kidney disease; C2V: CHA2DS2-VASc; DM: diabetes mellitus, HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart failure with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; HTN: hypertension; IHD: ischemic heart disease; LVEF: left ventricular ejection fraction; N/A: not available; NYHA: New York Heart Association; PAF: paroxysmal atrial fibrillation; PerAF: persistent atrial fibrillation; RCT: randomized controlled trial; TIA: transient ischemic attack.

Chen et al, 2023 [21]

471

Cohort

HFrEF

62.2%

64.9%

13 months

24.3%

40.5%

35.1%

35%

29.7%

8.1%

N/A

37.8%

HFmrEF

61.5%

59%

11 months

21.8%

35.9%

31.6%

45%

23.1%

7.7%

N/A

29.5%

HFpEF

101

59.4%

66.3%

11 months

26.7%

29.7%

27.7%

57%

17.8%

N/A

33.7%

Eitel et al, 2019 [22]

588

Cohort

HFrEF

77.7%

73%

N/A

40.1%

48.4%

21.3%

N/A

18.9%

5.4%

3.8

51.6%

36%

HFmrEF

181

66.7%

66.1

70%

N/A

39.8%

48.8%

19.8%

N/A

4.8%

2.2

9.7%

37.2%

HFpEF

308

66.1%

65.4

76%

N/A

141

126

41.0%

45.3%

10.8%

N/A

4.7%

7.1%

2.5

8.7%

53.2%

Fujimoto et al, 2022 [23]

656

Cohort

HFrEF

83.7%

64.6

44.9%

14.3 months

39.8%

27.6%

24.5%

32%

N/A

26.5%

59.2%

HFmrEF

107

73.8%

64.4

50.5%

23.3 months

44.9%

21.5%

23.4%

44.8%

N/A

13.1%

48.6%

HFpEF

451

67.6%

59.4%

21.5 months

217

148

32.8%

10%

20.8%

62.9%

N/A

11.6%

49.9%

Mekhael et al, 2023 [24]

RCT

HFrEF

93.1%

60.8

62.1%

N/A

100%

24.1%

6.9%

31.8%

N/A

10.3%

N/A

HFmrEF

78.3%

60.5

65.2%

N/A

100%

8.7%

44.6%

N/A

HFpEF

82.6%

60.5

50%

N/A

100%

13%

17.4%

56.5%

N/A

15.2%

N/A

Rillig et al, 2021 [25]

798

RCT

HFrEF

132

78.8%

69.3

78%

2.6 months

39.4%

25.8%

31.1%

18.9%

11.4%

18.2%

9.1%

HFmrEF

211

75.4%

70.4

83.9%

2.7 months

32.7%

25.1%

28.4%

44.3%

15.2%

12.8%

6.2%

10.4%

HFpEF

442

51.1%

91.9%

2.4 months

177

135

30.5%

20.1%

25.6%

60.8%

16.3%

10.4%

18.3%

5.9%

Von Olshausen et al, 2022 [18]

1,302

Cohort

HFrEF

858

N/A

HFmrEF

221

N/A

HFpEF

223

N/A

Yazaki et al, 2020 [19]

150

Cohort

HFrEF

100%

N/A

28 months

N/A

11%

N/A

57%

HFmrEF

80%

N/A

33 months

N/A

25%

HFpEF

86%

N/A

24 months

N/A

18%

↓ **Table 2.** Atrial fibrillation Recurrence During Follow-Up
Study	Total sample size	HF class	Sub-sample size	Duration of follow-up	Ablation group (%)	Medical therapy group (%)	AF recurrence ablation group (%)	No AF recurrence ablation group (%)	AF recurrence, n	No AF recurrence, n	AF recurrence measurement	NOS
AF: atrial fibrillation; ECG: electrocardiogram; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart failure with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; N/A: not available; NOS: Newcastle-Ottawa Scale (for quality assessment with 0 - 3 = poor quality, 4 - 7 = fair quality, 8 - 9 = good quality).
Chen et al, 2023 [21]	471	HFrEF	37	23.1 months	100%	0%	35.1%	64.9%	13	24	ECG, 24-h monitor	9
		HFmrEF	78	23.1 months	100%	0%	28.2%	71.8%	22	56
		HFpEF	101	23.1 months	100%	0%	23.8%	76.2%	24	77
Eitel et al, 2019 [22]	588	HFrEF	99	12 months	100%	0%	39.8%	60.2%	35	64	ECG	8
		HFmrEF	181	12 months	100%	0%	36%	64%	62	119
		HFpEF	308	12 months	100%	0%	47.9%	52.1%	140	168
Fujimoto et al, 2022 [23]	656	HFrEF	98	34.8 months	100%	0%	48.2%	51.8%	47	51	ECG, 24-h monitor	9
		HFmrEF	107	34.8 months	100%	0%	42.8%	57.2%	46	61
		HFpEF	451	34.8 months	100%	0%	47.3%	52.7%	213	238
Mekhael et al, 2023 [24]	98	HFrEF	29	12 months	100%	0%	23.3%	76.9%	7	22	ECG	9
		HFmrEF	23	12 months	100%	0%	22.9%	77.1%	5	18
		HFpEF	46	12 months	100%	0%	20.9%	79.1%	10	39
Rillig et al, 2021 [25]	798	HFrEF	132	24 months	43.2%	56.8%	N/A	N/A	N/A	N/A	N/A	9
		HFmrEF	211	24 months	52.1%	47.9%	N/A	N/A	N/A	N/A
		HFpEF	442	24 months	50.7%	49.3%	N/A	N/A	N/A	N/A
Von Olshausen et al, 2022 [18]	1,302	HFrEF	858	31.2 months	N/A	N/A	N/A	N/A	N/A	N/A	N/A	8
		HFmrEF	221	31.2 months	N/A	N/A	N/A	N/A	N/A	N/A	N/A
		HFpEF	223	31.2 months	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Yazaki et al, 2020 [19]	150	HFrEF	28	31 months	100%	0%	57%	43%	16	12	ECG, 24-h monitor	7
		HFmrEF	49	31 months	100%	0%	47%	53%	23	26
		HFpEF	73	31 months	100%	0%	34%	66%	25	48

↓ Table 2. Atrial fibrillation Recurrence During Follow-Up

Study

Total sample size

HF class

Sub-sample size

Duration of follow-up

Ablation group (%)

Medical therapy group (%)

AF recurrence ablation group (%)

No AF recurrence ablation group (%)

AF recurrence, n

No AF recurrence, n

AF recurrence measurement

NOS

AF: atrial fibrillation; ECG: electrocardiogram; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart failure with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; N/A: not available; NOS: Newcastle-Ottawa Scale (for quality assessment with 0 - 3 = poor quality, 4 - 7 = fair quality, 8 - 9 = good quality).

Chen et al, 2023 [21]

471

HFrEF

23.1 months

100%

35.1%

64.9%

ECG, 24-h monitor

HFmrEF

23.1 months

100%

28.2%

71.8%

HFpEF

101

23.1 months

100%

23.8%

76.2%

Eitel et al, 2019 [22]

588

HFrEF

12 months

100%

39.8%

60.2%

ECG

HFmrEF

181

12 months

100%

36%

64%

119

HFpEF

308

12 months

100%

47.9%

52.1%

140

168

Fujimoto et al, 2022 [23]

656

HFrEF

34.8 months

100%

48.2%

51.8%

ECG, 24-h monitor

HFmrEF

107

34.8 months

100%

42.8%

57.2%

HFpEF

451

34.8 months

100%

47.3%

52.7%

213

238

Mekhael et al, 2023 [24]

HFrEF

12 months

100%

23.3%

76.9%

ECG

HFmrEF

12 months

100%

22.9%

77.1%

HFpEF

12 months

100%

20.9%

79.1%

Rillig et al, 2021 [25]

798

HFrEF

132

24 months

43.2%

56.8%

N/A

HFmrEF

211

24 months

52.1%

47.9%

N/A

HFpEF

442

24 months

50.7%

49.3%

N/A

Von Olshausen et al, 2022 [18]

1,302

HFrEF

858

31.2 months

N/A

HFmrEF

221

31.2 months

N/A

HFpEF

223

31.2 months

N/A

Yazaki et al, 2020 [19]

150

HFrEF

31 months

100%

57%

43%

ECG, 24-h monitor

HFmrEF

31 months

100%

47%

53%

HFpEF

31 months

100%

34%

66%