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%