Prognostic impact of catheter ablation in atrial fibrillation with heart failure with preserved ejection fraction: an updated systematic review and reconstructed individual patient data meta-analysis.

BACKGROUND: Catheter ablation improves outcomes in atrial fibrillation (AF) with heart failure with reduced ejection fraction, but its efficacy in heart failure with preserved ejection fraction (HFpEF) remains uncertain. We performed a systematic review and reconstructed individual patient data meta-analysis to evaluate catheter ablation compared with medical therapy in this population. METHODS: Electronic databases were searched from inception through December 8, 2025, for randomized and observational studies comparing catheter ablation with medical therapy in adults with AF and HFpEF (LVEF ≥50% or guideline-consistent definitions). Primary outcomes were all-cause mortality and heart failure (HF) hospitalizations. RESULTS: Across 13 studies (45,642 patients), catheter ablation was associated with significantly lower all-cause mortality (HR 0.55, 95% CI 0.42-0.73; p < 0.0001), reduced HF hospitalizations (HR 0.67, 95% CI 0.52-0.86; p = 0.001), lower stroke/TIA risk (RR 0.89, 95% CI 0.79-0.99; p = 0.04) and reduced AF/atrial arrhythmia recurrence (HR 0.59, 95% CI 0.51-0.69; p < 0.00001). Reconstructed Kaplan-Meier curves demonstrated consistent time-to-event separation favouring catheter ablation across these outcomes. All-cause hospitalizations were lower (HR 0.90, 95% CI 0.81-1.00; p = 0.05), but not significant. Exploratory analyses demonstrated directionally favourable reductions in NT-proBNP and small changes in LVEF following ablation. CONCLUSION: Catheter ablation may confer prognostic benefit in selected AF and HFpEF populations, though large, randomized trials are needed to confirm these findings. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261278738, PROSPERO, CRD420261278738.