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

Background 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. Objective This meta-analysis evaluated the effect of AF ablation on primary prevention ICD eligibility in patients with left ventricular ejection fraction (LVEF) <= 35%. Methods 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 (PROSPERO CRD420251028456). Results 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; I-2 = 84.8%). Subgroup analysis of studies including only patients with structural heart disease on contemporary GDMT showed a pooled proportion of 62.7% (95% CI 52.0 - 72.8, p < 0.001, I-2 = 16.9%). Ischemic etiology was negatively associated with LVEF improvement beyond 35% (beta = -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. Conclusion AF ablation leads to LVEF recovery > 35% in the majority of HFrEF patients within 6 months, particularly in non-ischemic etiologies, potentially impacting prophylactic ICD decision-making.