Early catheter ablation for atrial fibrillation after acute decompensated heart failure: a systematic review and meta-analysis with reconstructed Kaplan–Meier individual patient data

OBJECTIVE: Catheter ablation (CA) for atrial fibrillation (AF) reduces mortality and heart failure (HF) hospitalizations in stable chronic HF, but optimal timing following acute decompensated heart failure (ADHF) remains uncertain. This meta-analysis aimed to evaluate whether early CA reduces mortality, rehospitalization, and improves cardiac function compared with delayed or no ablation. METHODS: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines. PubMed and SCOPUS databases were searched through December 16, 2025. Studies reporting outcomes of CA performed during ADHF hospitalization or within 90 days post-discharge were included. RESULTS: Four studies (n = 396 patients, 221 early ablation) were included. Qualitatively, early CA was consistently associated with improved clinical outcomes across included studies. Early CA improved left ventricular ejection fraction and reduced left atrial dimensions. Procedural complication rates were low with no significant difference between groups. Quantitatively, early CA significantly reduced the composite outcomes of cardiovascular mortality or HF rehospitalization (RR 0.35, 95% CI 0.17-0.70; p = 0.003). Reconstructed survival analysis demonstrated an association between early CA and higher event-free survival for the composite of cardiovascular death and HF rehospitalization (HR 0.24, 95% CI 0.12-0.50; p < 0.0001) and all-cause mortality (HR 0.51, 95% CI 0.27-0.94; p = 0.033). CONCLUSION: Early CA following ADHF was associated with substantial reductions in mortality or HF rehospitalization with acceptable safety. These findings suggest a potential role of early CA during or shortly after ADHF in hemodynamically stable patients, though randomized trials are needed to confirm efficacy and optimize patient selection.