Abstract 4369582: Ablation for Atrial Fibrillation: A Comprehensive Meta-Analysis of Randomized Controlled Trials with Reconstructed Time-to-Event Data

Abstract

Introduction: Catheter ablation is widely used for rhythm control in atrial fibrillation (AF), yet outcomes vary across trials and patient populations. No prior study has combined time-to-event data from all randomized controlled trials (RCTs) to provide a unified, long-term view of recurrence. We conducted the first meta-analysis to reconstruct and pool Kaplan-Meier (KM) curves, offering a more realistic framework for clinical decision-making. Research Question: To characterize time-stratified AF recurrence and antiarrhythmic drug (AAD) use by reconstructing and aggregating KM curves from RCTs to better inform long-term rhythm management. Methods: We systematically reviewed 210 RCTs comparing catheter ablation to medical therapy or different ablation strategies. Time-to-event data were extracted by digitizing published KM curves using WebPlotDigitizer v5.2, enabling reconstruction of pooled survival estimates for arrhythmia recurrence. Subgroup analyses included AF type (paroxysmal vs. persistent), comparator (AAD vs. rate control), and lesion set (PVI-only vs. adjunctive ablation). Results: Ninety-four RCTs comprising 36,691 patients with a median follow-up of 12 months were included. Pooled KM analysis showed reduced arrhythmia recurrence with ablation compared to medical therapy. In paroxysmal AF, 12-month recurrence-free survival was 72.1% with ablation vs. 64.3% with AAD. In persistent AF, rates were lower (61.3%) but still favored ablation. At 3 years, recurrence-free survival declined to 63.3% in paroxysmal and 59.6% in persistent AF. Substantial heterogeneity was observed across studies in terms of ablation modality (radiofrequency, cryoballoon, pulsed field), intensity of follow-up (implantable monitor vs. intermittent Holter), and patient characteristics (heart failure status, AF duration). This variability complicates direct application of aggregate outcomes to individual patients. Conclusion: This is the first meta-analysis to reconstruct and pool KM curves from AF ablation RCTs, providing a unified, time-based perspective on recurrence. While ablation provides substantial short-term benefit, recurrence increases over time. These pooled KM curves may support shared decision-making and help set realistic expectations for long-term rhythm management.