Sex differences in recurrence after linear ablation for persistent atrial fibrillation

Women with atrial fibrillation (AF) often experience worse outcomes after catheter ablation, but prior evidence is confounded by heterogeneity in AF types and ablation strategies.

The purpose of this study was to determine whether sex remains an independent determinant of recurrence in patients with persistent AF (PeAF) undergoing standardized ablation.

We retrospectively analyzed 2864 patients undergoing first-time "2C3L" ablation (pulmonary vein isolation plus left atrial roof, mitral isthmus, and cavotricuspid isthmus lines) for PeAF between December 2020 and August 2023. The primary end point was atrial arrhythmia recurrence beyond the 3-month blanking period. We performed Kaplan-Meier analyses, restricted mean survival time (truncation at 1095 days), multivariable Cox regression, inverse probability of treatment weighting, prespecified subgroup analyses, and 1:1 nearest-neighbor propensity score matching.

Women comprised 826 patients (28.8%). During a median follow-up of 357 days (interquartile range 171-724 days), recurrence was higher in women than in men (40.0% vs 34.4%; log-rank, P = .002). The restricted mean survival time was 698.2 days in women and 759.4 days in men (difference -61.2 days; 95% confidence interval [CI] -100.0 to -22.4 days; P = .002). Female sex was independently associated with recurrence in the fully adjusted Cox model (hazard ratio [HR] 1.24; 95% CI 1.07-1.43; P = .003) and in the inverse probability of treatment weighting analysis (HR 1.32; 95% CI 1.12-1.54; P = .001). Findings were consistent after 1:1 nearest-neighbor propensity score matching (826 pairs; HR 1.32; 95% CI 1.12-1.54; P = .001).

In this large PeAF cohort treated with the 2C3L strategy, female sex was independently associated with earlier and more frequent postablation atrial arrhythmia recurrence.