Timing of Atrial Fibrillation Ablation and Outcomes in Elderly Patients with HFrEF: A Propensity-Matched Study

<b>Background:</b> Catheter ablation is an established rhythm-control strategy for atrial fibrillation, yet the optimal timing of ablation in older patients with heart failure with reduced ejection fraction remains uncertain. <b>Methods:</b> We conducted a retrospective study using the TriNetX research network, including adults aged ≥ 60 years with atrial fibrillation and systolic heart failure who underwent catheter ablation between 2010 and 2022. Patients were classified by the timing of catheter ablation relative to cardiac diagnosis, with early ablation defined as occurring within 1 year and delayed ablation defined as occurring after 1 year. Propensity score matching (1:1) across 24 covariates was performed to balance demographics, comorbidities, medications, and baseline clinical characteristics. Outcomes assessed from 90 days blanking period to 3 years post-ablation included atrial fibrillation recurrence, heart failure exacerbation events, and all-cause hospitalization using risk, survival, and incidence analyses. <b>Results:</b> After matching, 678 patients were included in each cohort with well-balanced baseline characteristics. Atrial fibrillation recurrence did not differ significantly between early and delayed ablation groups (hazard ratio [HR] 0.71, 95% CI 0.39-1.28). In contrast, delayed ablation (>1 year) was associated with a significantly higher risk of heart failure events (HR 0.62, 95% CI 0.54-0.70) and shorter median heart failure-free survival compared with early ablation. All-cause hospitalization risk was similar between groups, although time-to-event analyses favored ablation within 1 year (HR 0.71, 95% CI 0.59-0.85). <b>Conclusions:</b> In this large, real-world cohort of older patients with atrial fibrillation and systolic heart failure, late ablation was associated with worse 3-years heart failure outcomes and delayed hospitalization-free survival, despite similar atrial fibrillation recurrence rates. These findings suggest that ablation timing may differentially influence heart failure progression independent of rhythm recurrence and highlight the need for prospective studies to define patient-specific timing strategies in elderly populations.