ImportanceCatheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain.ObjectiveTo investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype.Data SourceA systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023.Study SelectionParallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria.Data Extraction and SynthesisData were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences.Main Outcomes and MeasuresThe primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality.ResultsA total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39).Conclusions and RelevanceThis study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.

中文翻译：

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减少射血分数与保留射血分数的心力衰竭的心房颤动消融

重要性导管消融与某些心房颤动 (AF) 和射血分数降低的心力衰竭 (HFrEF) 患者的心力衰竭 (HF) 住院率和死亡减少相关。然而，射血分数保留 (HFpEF) 的心力衰竭患者的获益尚不确定。目的根据心力衰竭表型，研究房颤导管消融是否与心力衰竭相关结局的减少相关。数据来源 MEDLINE、Embase 和 Cochrane Central 的系统搜索是在从开始到 2023 年 9 月发表的研究中进行的。研究选择平行组随机临床试验 (RCT)，在患有心力衰竭、纽约心脏协会功能分级为 II 级或以上且有以下病史的患者中比较导管消融与常规心率或节律控制治疗阵发性或持续性房颤均包括在内。成对的独立评审员筛选了 7531 篇标题和摘要，其中 12 项随机对照试验和 4 项子研究符合选择标准。 数据提取和综合 根据系统评价和荟萃分析的首选报告项目（棱镜) 报告指南。使用随机效应 Mantel-Haenszel 模型计算汇总效应估计值。相互作用磷值用于测试亚组差异。主要结果和测量主要结果是心力衰竭事件，定义为心力衰竭住院、心力衰竭临床显着恶化或不定期就诊临床医生以加强治疗。次要结局包括心血管死亡率和全因死亡率。结果共纳入 12 项随机对照试验，涉及 2465 名参与者（平均 [SD] 年龄，65.3 [9.7] 岁；658 名女性 [26.7%]）；有 1552 名 HFrEF 参与者和 913 名 HFpEF 参与者。与传统的心率或节律控制相比，导管消融可降低 HFrEF 中心力衰竭事件的风险（风险比 [RR]，0.59；95% CI，0.48-0.72），而对 HFpEF 患者没有益处（RR，95% CI，0.48-0.72）。 0.93；95% CI，0.65-1.32）（磷交互作用 = .03)。与 HFrEF 的常规治疗相比，导管消融可降低心血管死亡风险（RR，0.49；95% CI，0.34-0.70），但在 HFpEF 中未检测到差异相关性（RR，0.91；95% CI，0.46-1.79） ) (磷交互作用 = .12)。同样，HFrEF（RR 与传统疗法，0.63；95% CI，0.47-0.86）和 HFpEF（RR 与传统疗法，0.95；95% CI，0.39）之间没有发现导管消融与全因死亡率之间的差异。 -2.30) 组 (磷交互作用 = .39）。结论和相关性本研究发现，房颤导管消融与 HFrEF 患者发生心力衰竭事件的风险降低相关，但对 HFpEF 的益处有限或没有益处。正在进行的试验结果可能会进一步阐明导管消融治疗 HFpEF 中 AF 的作用。