OBJECTIVES: Catheter ablation, an expensive procedure with high Atrial Fibrillation (AF) recurrence rate, is indicated in patients refractory to drug therapy or in patients with drug tolerability issues. The study examines the CE of MRI-guided ablation vs. current standard of care (SoC) of ablating all eligible patients in preventing AF. METHODS: A decision tree model was developed with a payer perspective over a 1-year time horizon. Participants of the DECAAF trial (n=260), prospective multicenter-blinded study, were categorized to Utah Stage I (19%), II (41%), III (31%), and Stage IV (9%) based on degree of atrial structural remodeling quantified using delayed enhancement MRI. Proportion of patients with post ablation AF recurrence for Utah Stage I-IV was 16.33%, 30.84%, 45.68%, and 58.33% respectively. Survival from outcomes was considered as effectiveness. Selective ablation was defined as ablating Stage I and II AF patients and medically managing Stage III and IV patients. Recurrence rates from the DECAAF trial and other costs and probabilities from the literature were used in the model. Probabilistic sensitivity analysis was conducted on all variables in the model. RESULTS: The mean total per patient annual cost in the MRI-guided selective ablation cohort was $23,238 compared to $28,659 for the SoC ablates all cohorts. However, no significant – clinical or statistical, difference in effectiveness was observed. The higher cost of the ablate all cohort was associated with higher AF recurrence and costs of AF treatment. Probabilistic sensitivity analysis demonstrated the similar substantial difference between two procedures. The probability associated with AF recurrence in SoC was most sensitive variable. CONCLUSIONS: MRI-guided selective ablation is economically beneficial with annual savings of $5,421 per person with same effectiveness compared to current SoC. Future research taking QoL and age into account is warranted to help payers assess the CE of ablation procedure in AF patients.