Highlights
Introduction
Atrial fibrillation (AF) and heart failure (HF) frequently coexist in patients, with a complicated yet incompletely understood link [1]. Specifically, despite their common roots, both illnesses appear to promote and exacerbate one another. According to recent projections, more than 12 million people in the United States will have AF, while approximately 8 million will have HF by 2030. It is essential to highlight that the occurrence of AF increases with the severity of heart failure, with prevalence ranging from 5% in functional class I patients to nearly 50% in functional class IV [2]. Both are common among our aging population, and the death rate associated with their co-occurrence is significantly higher than for either disease alone [3]. Furthermore, they share common risk factors, such as aging, hypertension, diabetes, obesity, sleep apnea, and coronary disease [4]. Moreover, it has been proposed that AF might cause severe HF by tachycardia-induced cardiomyopathy [5]. In contrast, HF can be caused by high filling pressures and atrial stretch associated with AF [3].
Rate and rhythm control drugs as medical therapy (MT) have traditionally been the foundation of therapy for attaining rate and rhythm control in individuals with AF. Nevertheless, the principal limitations of this approach are the poor selection of MT options for patients with HF, their moderate efficacy in preserving sinus rhythm, and the incidence of serious adverse events [6]. The guidelines also support a limited number of pharmacologic alternatives for rhythm control in HF patients, including dofetilide and amiodarone, both of which have recognized concerns such as arrhythmia and multi-organ toxicity. However, many randomized controlled trials (RCTs) have shown that catheter ablation (CA) of AF is not only safe but also more effective than MT in maintaining sinus rhythm and preventing AF recurrence [7]. Similarly, several RCTs consistently show that CA improves left ventricular ejection fraction and quality of life and reduces cardiovascular hospitalizations compared to medical therapy [8].
Due to inconsistent findings in earlier meta-analyses on the effects of MT against CA in patients with AF and HF, we conducted the first umbrella review of the systematic reviews and meta-analyses accessible. To guarantee consistency in our findings when utilizing this evidence-based approach, we included studies that covered all patients with AF and HF while omitting those with a small number of cases.
Methodology
This comprehensive review followed the guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and the Cochrane Collaboration Handbook [9, 10].
Search Approach
The search was conducted across multiple databases, including PubMed, Cochrane Library, and Google Scholar, to ensure a comprehensive exploration of the scientific literature. A wide range of keywords and Medical Subject Headings (MeSH) were thoughtfully selected to ensure inclusivity. These keywords covered aspects such as "catheter ablation," "CA," "medical therapy," "MT," "atrial fibrillation," "heart failure," "patients," "comparison," "treatment outcomes," "intervention," "cardiovascular," and "meta-analysis."  A detailed summary of the search strategy, including specific combinations of keywords and operators, can be found in Supplementary Table S1.
To maintain the integrity of the process and minimize potential selection bias, two independent researchers searched, resolving any discrepancies through consensus. In cases of persistent discrepancies, a third researcher was involved to ensure resolution and reliability.
Study Inclusion and Exclusion Criteria
Inclusion Criteria:
The umbrella review on "Catheter Ablation versus Medical Therapy of Atrial Fibrillation in Patients with Heart Failure" incorporated studies that met rigorous inclusion criteria. These criteria comprised meta-analyses that synthesized data from primary studies comparing catheter ablation (CA) and medical therapy (MT) specifically for atrial fibrillation (AF) in patients diagnosed with heart failure (HF). Only meta-analyses directly addressing this comparative intervention within the context of concurrent atrial fibrillation and heart failure were considered eligible. Studies involving human participants across all age groups and demographic backgrounds were included. The review focused on meta-analyses reporting relevant clinical outcomes such as mortality rates, arrhythmia recurrence, quality of life enhancements, and adverse events. Furthermore, only peer-reviewed meta-analyses published in reputable scientific journals were deemed suitable for inclusion. To ensure broad accessibility, studies published in English or with available translations were considered.
Exclusion Criteria:
 Meta-analyses that did not directly compare CA with MT in patients diagnosed winth both AF and HF were excluded. Additionally, studies comparing interventions other than CA and MT for atrial fibrillation in HF patients were not considered. Meta-analyses based solely on animal models or laboratory experiments were also excluded from the review. Furthermore, abstracts presented at conferences without subsequent full-text publication were omitted due to limited data availability and lack of peer review. Systematic reviews without meta-analysis or quantitative synthesis of data were excluded to ensure the inclusion of only studies offering comprehensive data analysis.
Data Extraction
Relevant information encompassing publication details, study attributes, participant features, and clinical outcomes was extracted. The outcomes were divided into efficacy and safety outcomes. The efficacy outcomes were further divided into primary and secondary outcomes. Primary efficacy outcomes included all-cause mortality, HF hospitalization, and AF recurrence. Secondary efficacy outcomes included a change in Left ventricular ejection fraction (LVEF), change in the 6-minute walk test (6MWT), change in maximal oxygen consumption (VO2 max), change in Minnesota Living with Heart Failure Questionnaire (MLHFQ), and change in Brain natriuretic peptide (BNP).
The safety endpoints included were pericardial effusion/tamponade and major adverse cardiovascular events (MACEs).
Assessment of Risk of Bias
The methodological robustness of the included reviews and meta-analyses underwent a thorough examination by two independent researchers utilizing the AMSTAR 2 tool. This tool offers a comprehensive evaluation across 16 critical methodological domains, providing a detailed assessment. The overall quality of the studies was then categorized as high, moderate, low, or critically low, guided by established criteria [11].
To gauge the inherent risk of bias in randomized controlled trials (RCTs) included in individual meta-analyses, we employed the Cochrane Collaboration risk of bias tool [12]. This tool systematically evaluates eight potential sources of bias, including random sequence generation, allocation concealment, blinding of participants and assessors, outcome assessments, and management of incomplete outcome data.
The certainty of evidence and the strength of recommendations drawn from meta-analyses underwent rigorous scrutiny using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method [13]. This method categorizes evidence into four tiers: 'high,' 'moderate,' 'low,' and 'very low.' Initially set at the 'high' level, the GRADE assessment was adjusted based on identified risks of bias, inconsistencies in results, indirect evidence, imprecision, or publication bias. Two researchers independently conducted the GRADE assessment for each study's primary efficacy outcomes, engaging in discussions and reaching agreements to resolve any discrepancies.
Statistical Analysis
All statistical analyses were conducted utilizing STATA 16 and Review Manager version 5.4. Categorical outcomes were evaluated by computing Risk Ratios (RR) along with 95% Confidence Intervals (CIs), employing the random-effects model. Mean differences were calculated for continuous data, with statistical significance determined by P < 0.05. The I2 statistic was employed to assess heterogeneity among study associations [14]. Sensitivity analyses were performed to assess the robustness of summary estimates and identify any individual studies significantly contributing to heterogeneity, notably when it exceeded 75%. Egger's regression asymmetry test was utilized to examine evidence of small-study effects for primary efficacy outcomes [15], with a p-value below 0.05 indicating such effects. 'P-hacking' [16] and assessment of publication bias were conducted through funnel plots of primary outcomes.
In terms of ethical considerations and conflicts of interest, this umbrella review relies solely on previously published systematic reviews and meta-analyses, eliminating the necessity to gather or analyze primary data from human participants. Consequently, ethical review board approval and patient consent are not applicable to this study. The authors affirm that there are no conflicts of interest, whether financial or non-financial, that could influence the impartiality or interpretation of the findings in this umbrella review. The entire research process and outcomes remain independent of external affiliations or funding sources, ensuring a commitment to unbiased reporting.
Results
Study Selection
Initially, a total of 25 systematic reviews and meta-analyses were identified, and subsequent removal of duplicate entries was carried out. Upon thorough examination of the full texts, a final selection of 6 systematic reviews and meta-analyses [17-22] was made. These chosen studies collectively compiled data from 10 randomized controlled trials (RCTs). Among the 6 meta-analyses, 4 focused solely on pulmonary vein isolation (PVI) [18, 19, 21, 22] as the ablation strategy, while the remaining 2 [17, 20] examined PVI in combination with additional ablation strategies. Only one study [22] assessed rate control drugs as medical therapy, whereas the remaining 5 studies evaluated both rate and rhythm control drugs. Patients with both paroxysmal and persistent atrial fibrillation (AF) were investigated, with the exception of one study by Zhu et al. [22], which exclusively included patients with persistent AF. Table 1 provides a brief overview of the characteristics of the included meta-analyses.
Risk of Bias of Included Studies
The methodological quality evaluations of the six systematic reviews and meta-analyses were assessed using the AMSTAR 2 tool, as outlined in Supplementary Table S2. Each of these six studies received a moderate quality rating. The GRADE assessment, provided in Supplementary Table S3, demonstrated high levels of certainty in the reviews included in our study. Individual randomized controlled trials (RCTs) underwent a thorough quality assessment using the Cochrane risk of bias tool, revealing trials with a moderate to low risk of bias, as depicted in Supplementary Figure S1.
Primary Efficacy Outcomes
The primary efficacy outcomes included all-cause mortality, HF hospitalization, and AF recurrence.
Data on all-cause mortality was provided by 5 out of 6 studies. The pooled analysis indicated that CA treatment was associated with a significantly reduced risk of all-cause mortality compared to MT (RR [95% CI]: 0.55 [0.44, 0.68], I2: 60%, p-value: <0.00001), as illustrated in Figure 1.
Information on HF hospitalization was available from 4 out of 6 studies. The pooled analysis showed that CA treatment was associated with a significant decrease in the risk of HF hospitalization compared to MT (RR [95% CI]: 0.61 [0.54, 0.70], I2: 0%, p-value: <0.00001), as depicted in Figure 2.
Data on AF recurrence was reported by 2 out of 6 studies. The pooled analysis revealed a significant reduction in the risk of AF recurrence with CA treatment compared to MT (RR [95% CI]: 0.36 [0.27, 0.47], I2: 0%, p-value: <0.00001), as shown in Figure 3.
 
Secondary Efficacy Outcomes
The secondary efficacy outcomes included changes in LVEF, 6MWT, VO2 max, MLFHQ, and BNP. All six studies provided data on LVEF, 6MWT, and MLFHQ. The pooled analysis indicated that CA treatment was linked to a significant increase in LVEF and 6MWT and a significant decrease in MLFHQ compared to MT. However, due to significant in-study heterogeneity in 6MWT and MLFHQ, a sensitivity analysis was conducted. Excluding the study by Elgendy et al. [18] reduced the high in-study heterogeneity in both 6MWT and MLFHQ from 85% to 0%.
Three out of six studies reported data on VO2 max, showing a significant increase with CA treatment compared to MT. Two out of six studies reported BNP data, indicating a non-significant decrease with CA treatment compared to MT. Despite the high heterogeneity, a sensitivity analysis could not be performed as fewer than three studies reported the outcome.
Safety Outcomes
The safety outcomes included pericardial effusion/tamponade and MACEs. Only one meta-analysis by Magnocavallo et al. [17] reported data on safety outcomes. It indicated that CA was linked to a non-significant decrease in the risk of pericardial effusion/tamponade compared to MT. However, the same study revealed a non-significant increase in the risk of MACEs with CA compared to MT.
P-hacking, Publication Bias and small study effect
The absence of evidence suggesting P-hacking in our research indicates that the outcomes were not manipulated to fit a preconceived conclusion. Our analysis of primary efficacy outcomes was thorough, involving an ample number of studies, which allowed for a detailed examination through funnel plot analysis. The symmetry observed in the funnel plots for each primary outcome suggests the absence of publication bias, as illustrated in Supplementary Figure S2. Additionally, Egger's regression asymmetry test was employed to evaluate small study effects, with all values exceeding 0.05, indicating a lack of significant evidence supporting such effects. Details of Egger's regression asymmetry test results can be found in Table 3.
Discussion
Although MT is widely utilized in the management of AF, its efficacy has been limited in controlled trials. It is essential to note that significant adverse effects are also a possibility [22]. Considerable research efforts have demonstrated that the implementation of a rhythm control strategy for the management of atrial fibrillation may offer few benefits in comparison to rate control [23]. However, comprehensive subgroup analyses conducted during these trials have revealed that patients who attain sinus rhythm have higher survival rates, highlighting the inadequate effectiveness of MT in maintaining sinus rhythm [24]. CA with pulmonary vein isolation (PVI) is an innovative and increasingly popular approach for treating AF, providing an alternative to maintaining sinus rhythm. Some researchers have advocated for catheter ablation as the primary treatment option for AF [25]. However, the argument around this proposition still needs to be solved. Given the lack of solid data and the fact that catheter ablation is associated with a complication rate as high as 6%, according to a global survey, caution is exercised when prescribing it as the first treatment option [26].
Our umbrella review of 6 different meta-analysis aimed to compare and produce firm evidence on the safety and efficacy profile of CA with MT in patients with AF. Considering safety outcomes, CA has shown to decrease the risk of all-cause mortality, HF hospitalization and AF recurrence clinically significant over MT. Shantha et al. [27] conducted a study which revealed that the utilization of MT subsequent to catheter ablation (CA) was associated with a reduced likelihood of all-cause mortality (hazard ratio [HR] = 0.62, p = 0.02) in an unadjusted propensity-matched analysis. After implementing comprehensive adjustment, while the statistical significance of the mortality difference between the two groups decreased, a noticeable pattern emerged that indicated a possible benefit in mortality from MT (HR: 0.66, p = 0.05). In 2019, Guo et al. [28] conducted a thorough investigation, which revealed a significant decline of approximately 38% (p < 0.001) in all-cause hospitalizations subsequent to AF ablation. The reduction in hospitalizations was characterized by a substantial decline in arrhythmic hospitalizations, with a notable 56% decrease in hospitalizations associated with atrial fibrillation and AF (p < 0.001). Furthermore, the effectiveness of AF ablation in reducing nonarrhythmic cardiovascular hospitalizations was predominantly demonstrated by a significant 43% reduction in HF hospitalizations (p = 0.019). AF ablation had no noticeable impact on hospitalizations relating to non-cardiovascular disease. Additionally, a significant reduction in the use of Class I and III AADs was observed in the year following ablation, falling from 64% to 40% (p < 0.001).
Considering other functional improvement, MT was shown to have more improvement in LVEF, 6MWT and VO2 max than CA group. Improvement in these parameters depend on severity and duration of the condition of patient as per observations. As an illustration, MacDonald et al. [29] observed reduced rates of success in conjunction with no improvements in exercise tolerance or LVEF. However, it is crucial to acknowledge that the individuals who were enrolled in this study had more advanced chronic heart failure (CHF), had a longer duration of AF, and had a lower functional status [approximately 90% of subjects were categorized as NYHA Functional Class III]. Moreover, the research carried out by Chang et al. [30] demonstrated that the CA group exhibited no observable improvement in comparison to the MT group. Prior meta-analyses hypothesized that CA could increase the 6MWT distance and VO2 max, two parameters that are considered independent predictors of survival in patients with heart failure (HF). Nevertheless, the inclusion of data obtained from the AMICA trial included by Chang et al. [30] in the analysis failed to reveal any noticeable discrepancy in the 6MWT distance.
Our study had some strengths as well as some limitations. In terms of strengths, our study exhibited minimal publication bias and heterogeneity due to the fact that all the studies incorporated in this umbrella review encompassed the entire patient population with AF and HF, thereby minimizing variations in patient baseline demographics. Secondly, this review produces new evidence-based results which vary from previous meta-analysis hence eliminating all discrepancies in previously published meta-analysis. Firstly, as with all comprehensive review articles, despite careful efforts to reduce confounding variables, there is the possibility of unmeasured covariates influencing treatment outcomes among AF patients with HF, such as socioeconomic status, healthcare accessibility, treatment adherence, and lifestyle factors. Second, the heterogeneity in the quality of evidence obtained from constituent studies may jeopardize the overall reliability of the umbrella review's conclusions. Disparities in research quality might result from differences in sample numbers, study durations, outcome assessments, and confounding variable control.
Conclusion
Patients with AF and HF who receive CA as opposed to MT experience improved functional outcomes and safety. Improvement in change in LVEF, 6MWT, and VO2 max, all-cause mortality, hospitalization for HF, and AF recurrence rates are substantially reduced in the CA group compared to the MT group. In order to ensure a comprehensive analysis, future research endeavors should encompass all participants who experience HF and AF simultaneously.
References
1.      Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB; CABANA Investigators. Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results from the CABANA Trial. Circulation. 2021 Apr 6;143(14):1377-1390. doi: 10.1161/CIRCULATIONAHA.120.050991. Epub 2021 Feb 8. PMID: 33554614; PMCID: PMC8030730.
2.      Briceño DF, Markman TM, Lupercio F, Romero J, Liang JJ, Villablanca PA, Birati EY, Garcia FC, Di Biase L, Natale A, Marchlinski FE, Santangeli P. Catheter ablation versus conventional treatment of atrial fibrillation in patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol. 2018 Oct;53(1):19-29. doi: 10.1007/s10840-018-0425-0. Epub 2018 Jul 31. PMID: 30066291.
3.      Skanes AC, Tang ASL. Atrial Fibrillation and Heart Failure: Untangling a Modern Gordian Knot. Can J Cardiol. 2018 Nov;34(11):1437-1448. doi: 10.1016/j.cjca.2018.07.483. Epub 2018 Aug 20. PMID: 30404749.
4.      Prabhu S, Voskoboinik A, Kaye DM, Kistler PM. Atrial Fibrillation and Heart Failure - Cause or Effect? Heart Lung Circ. 2017 Sep;26(9):967-974. doi: 10.1016/j.hlc.2017.05.117. Epub 2017 May 22. PMID: 28684095.
5.      Gopinathannair R, Etheridge SP, Marchlinski FE, Spinale FG, Lakkireddy D, Olshansky B. Arrhythmia-Induced Cardiomyopathies: Mechanisms, Recognition, and Management. J Am Coll Cardiol. 2015 Oct 13;66(15):1714-28. doi: 10.1016/j.jacc.2015.08.038. PMID: 26449143; PMCID: PMC4733572.
6.      Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. doi: 10.1056/NEJMoa021328. PMID: 12466506.
7.      Black-Maier E, Ren X, Steinberg BA, Green CL, Barnett AS, Rosa NS, Al-Khatib SM, Atwater BD, Daubert JP, Frazier-Mills C, Grant AO, Hegland DD, Jackson KP, Jackson LR, Koontz JI, Lewis RK, Sun AY, Thomas KL, Bahnson TD, Piccini JP. Catheter ablation of atrial fibrillation in patients with heart failure and preserved ejection fraction. Heart Rhythm. 2018 May;15(5):651-657. doi: 10.1016/j.hrthm.2017.12.001. Epub 2017 Dec 6. PMID: 29222043.
8.      Asad ZUA, Yousif A, Khan MS, Al-Khatib SM, Stavrakis S. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circ Arrhythm Electrophysiol. 2019 Sep;12(9):e007414. doi: 10.1161/CIRCEP.119.007414. Epub 2019 Aug 21. PMID: 31431051.
9.      Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372: n71. doi: 10.1136/bmj. n71. PMID: 33782057; PMCID: PMC8005924.
10.  Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, Thomas J. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019 Oct 3;10(10): ED000142. doi: 10.1002/14651858.ED000142. PMID: 31643080; PMCID: PMC10284251.
11.  Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017 Sep 21;358: j4008. doi: 10.1136/bmj. j4008. PMID: 28935701; PMCID: PMC5833365.
12.  Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343: d5928. doi: 10.1136/bmj. d5928. PMID: 22008217; PMCID: PMC3196245.
13.  Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6. doi: 10.1136/bmj.39489.470347.AD. PMID: 18436948; PMCID: PMC2335261.
14.  Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557-60. doi: 10.1136/bmj.327.7414.557. PMID: 12958120; PMCID: PMC192859.
15.  Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997 Sep 13;315(7109):629-34. doi: 10.1136/bmj.315.7109.629. PMID: 9310563; PMCID: PMC2127453.
16.  Simonsohn U, Nelson LD, Simmons JP. P-curve: a key to the file-drawer. J Exp Psychol Gen. 2014 Apr;143(2):534-47. doi: 10.1037/a0033242. Epub 2013 Jul 15. PMID: 23855496.
17.  Magnocavallo M, Parlavecchio A, Vetta G, Gianni C, Polselli M, De Vuono F, Pannone L, Mohanty S, Cauti FM, Caminiti R, Miraglia V, Monaco C, Chierchia GB, Rossi P, Di Biase L, Bianchi S, de Asmundis C, Natale A, Della Rocca DG. Catheter Ablation versus Medical Therapy of Atrial Fibrillation in Patients with Heart Failure: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2022 Sep 21;11(19):5530. doi: 10.3390/jcm11195530. PMID: 36233407; PMCID: PMC9572511.
18.  Elgendy AY, Mahmoud AN, Khan MS, Sheikh MR, Mojadidi MK, Omer M, Elgendy IY, Bavry AA, Ellenbogen KA, Miles WM, McKillop M. Meta-Analysis Comparing Catheter-Guided Ablation Versus Conventional Medical Therapy for Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction. Am J Cardiol. 2018 Sep 1;122(5):806-813. doi: 10.1016/j.amjcard.2018.05.009. Epub 2018 Jun 5. PMID: 30037427.
19.  Şaylık F, Çınar T, Akbulut T, Hayıroğlu Mİ. Comparison of catheter ablation and medical therapy for atrial fibrillation in heart failure patients: A meta-analysis of randomized controlled trials. Heart Lung. 2023 Jan-Feb;57:69-74. doi: 10.1016/j.hrtlng.2022.08.012. Epub 2022 Sep 7. PMID: 36084398.
20.  Yu Z, Xing Y, Peng J, Xu B, Qi Y, Zheng Z, Qiu Y, Qiu F, Peng F. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation in Patients with Heart failure: A Meta-Analysis of Randomized Controlled Trials. Anatol J Cardiol. 2022 Sep;26(9):685-695. doi: 10.5152/AnatolJCardiol.2022.1826. PMID: 35949135; PMCID: PMC9524201.
21.  Pan KL, Wu YL, Lee M, Ovbiagele B. Catheter Ablation Compared with Medical Therapy for Atrial Fibrillation with Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Int J Med Sci. 2021 Jan 21;18(6):1325-1331. doi: 10.7150/ijms.52257. PMID: 33628087; PMCID: PMC7893556.
22.  Zhu M, Zhou X, Cai H, Wang Z, Xu H, Chen S, Chen J, Xu X, Xu H, Mao W. Catheter ablation versus medical rate control for persistent atrial fibrillation in patients with heart failure: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2016 Jul;95(30):e4377. doi: 10.1097/MD.0000000000004377. PMID: 27472728; PMCID: PMC5265865.
23.  Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1834-40. doi: 10.1056/NEJMoa021375. PMID: 12466507.
24.  Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD Jr, Raisch DW, Ezekowitz MD; Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) Investigators. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med. 2005 May 5;352(18):1861-72. doi: 10.1056/NEJMoa041705. PMID: 15872201.
25.  Padanilam BJ, Prystowsky EN. Should atrial fibrillation ablation be considered first-line therapy for some patients? Should ablation be first-line therapy and for whom? the antagonist position. Circulation. 2005 Aug 23;112(8):1223-9; discussion 1230. PMID: 16118843.
26.  Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005 Mar 8;111(9):1100-5. doi: 10.1161/01.CIR.0000157153.30978.67. Epub 2005 Feb 21. PMID: 15723973.
27.  Shantha G, Alyesh D, Ghanbari H, Yokokawa M, Saeed M, Cunnane R, Latchamsetty R, Crawford T, Jongnarangsin K, Bogun F, Pelosi F Jr, Chugh A, Morady F, Oral H. Antiarrhythmic drug therapy and all-cause mortality after catheter ablation of atrial fibrillation: A propensity-matched analysis. Heart Rhythm. 2019 Sep;16(9):1368-1373. doi: 10.1016/j.hrthm.2019.06.007. Epub 2019 Jun 12. PMID: 31201962.
28.  Guo J, Nayak HM, Besser SA, Beaser A, Aziz Z, Broman M, Ozcan C, Tung R, Upadhyay GA. Impact of Atrial Fibrillation Ablation on Recurrent Hospitalization: A Nationwide Cohort Study. JACC Clin Electrophysiol. 2019 Mar;5(3):330-339. doi: 10.1016/j.jacep.2018.10.015. Epub 2018 Dec 26. PMID: 30898236.
29.  MacDonald MR, Connelly DT, Hawkins NM, Steedman T, Payne J, Shaw M, Denvir M, Bhagra S, Small S, Martin W, McMurray JJ, Petrie MC. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial. Heart. 2011 May;97(9):740-7. doi: 10.1136/hrt.2010.207340. Epub 2010 Nov 4. PMID: 21051458.
30.  Chang TY, Chao TF, Lin CY, Lin YJ, Chang SL, Lo LW, Hu YF, Chung FP, Chen SA. Catheter ablation of atrial fibrillation in heart failure with impaired systolic function: An updated meta-analysis of randomized controlled trials. J Chin Med Assoc. 2023 Jan 1;86(1):11-18. doi: 10.1097/JCMA.0000000000000823. Epub 2022 Oct 13. PMID: 36227015.