Impact of atrial fibrillation catheter ablation on primary prevention ICD eligibility in heart failure with reduced ejection fraction: a systematic review and meta-analysis

Patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) may show positive remodeling after catheter ablation, yet rhythm control is not consistently prioritized alongside guideline-directed medical therapy (GDMT) before implantable cardioverter-defibrillator (ICD) implantation. This meta-analysis evaluated the effect of AF ablation on primary prevention ICD eligibility in patients with left ventricular ejection fraction (LVEF) ≤35%.

PubMed/MEDLINE, Scopus and Cochrane databases were searched until April 2025 for studies including patients with LVEF ≤35% undergoing AF catheter ablation and reporting outcomes regarding LVEF evolution during follow-up.

Twenty-two studies, of which six randomized controlled trials and 16 observation studies, comprising 913 patients, were included. At a median follow-up of 11.4 months (IQR: 6.0 – 15.0) the pooled proportion of patients with LVEF >35% was 72.1% (95% CI, 63.0–80.3; I2 = 84.8%). Subgroup analysis including only patients on GDMT for >3 months with known HF etiology showed that 52.8% (95% CI, 43.2–66.6; I2 = 78.2%) of them exceeded the LVEF threshold at follow-up. Ischemic etiology was negatively associated with LVEF improvement beyond 35% (β = -40.4%, 95% CI -86.2 – -3.4; p = 0.007). Longitudinal meta-analysis revealed an estimated 5.3 months needed to surpass the 35% threshold.

AF ablation leads to LVEF recovery >35% in the majority of HFrEF patients during follow-up, particularly in non-ischemic etiologies. A 6-months waiting period could be more appropriate before taking a decision on prophylactic ICD implantation.

Graphical Abstract