'Ablate and pace' reduces mortality in heart failure patients with atrial fibrillation: an updated meta-analysis

We compared the effects of 'ablate and pace' to pharmacological therapy on mortality and left ventricular ejection fraction (LVEF) in patients with atrial fibrillation (AF), with or without heart failure (HF).

Articles were identified by searching PubMed, Central, and Embase until 30 June 2024. Inclusion criteria encompassed observational and randomized controlled trials (RCTs) comparing 'ablate and pace' with pharmacological therapy and investigating outcomes of mortality and LVEF in patients with AF. An exclusion criterion was lack of a parallel study design. The primary outcomes were all-cause mortality and the mean difference (MD) in LVEF. Endpoints were assessed through meta-analyses computing relative risks (RRs) and MDs. The clinical diagnosis of HF was used to distinguish between patients with and without HF. Initially, 3837 studies were identified, of which 24 (n = 4292 patients) fulfilled the inclusion criteria, including 17 (n = 3261 patients) that focused on HF. Follow-up time varied from 3 to 96 months. Only in HF patients, 'ablate and pace' reduced mortality significantly with a risk reduction of 36% [RR, 0.64; 95% confidence interval (CI), 0.49-0.85; P < 0.01; n = 10] as compared with pharmacological therapy. Except for two studies, cardiac resynchronization therapy (CRT) was the chosen pace mode. The mortality reduction was independent of study design: RCTs (RR, 0.41; 95% CI, 0.18-0.94; P = 0.04; n = 2) and observational studies (RR, 0.70; 95% CI, 0.55-0.90; P = 0.01; n = 8). 'Ablate and pace' and pharmacological therapy were similar for the LVEF outcome (MD, 1.1; 95% CI, -1.6-3.8; P = 0.39; n = 16), which was independent of both HF and study designs (results not shown).

'Ablate and CRT' reduced mortality in HF patients as compared with pharmacological therapy, which was supported by statistical associations in observational studies. A single RCT corroborated the finding.