The aim is to evaluate the impact of catheter ablation (CA) versus medical therapy for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF), focusing on mortality, heart failure (HF) hospitalizations, and left ventricular ejection fraction (LVEF). We conducted a systematic review and meta-analysis of 11 randomized controlled trials and randomized controlled trial-derived studies comparing CA with medical therapy for AF patients with HFrEF. Databases including PubMed, Embase, and Cochrane Library were searched up to December 2025. Outcomes included all-cause mortality, HF hospitalizations, change in LVEF, AF recurrence, and quality of life. Risk of bias was assessed using the Cochrane RoB 2.0 tool, and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate certainty. A total of 11 studies comprising over 2100 patients were included. CA significantly reduced all-cause mortality [risk ratio = 0.61, 95% confidence interval (CI): 0.45-0.83] and HF hospitalizations (risk ratio = 0.68, 95% CI: 0.50-0.91). LVEF improved by a mean of 6.4% (95% CI: 4.2-8.7) in the ablation group. AF recurrence and quality of life also favored CA. Sensitivity analyses confirmed the robustness of findings. In patients with HFrEF and AF, CA significantly improves survival, reduces HF hospitalizations, and enhances cardiac function, supporting its role as a disease-modifying therapy.