Outcomes and complications of catheter ablation for atrial fibrillation in females

doi:10.1016/j.hrthm.2009.10.025

Heart Rhythm

Volume 7, Issue 2, February 2010, Pages 167-172

Preliminary data were presented at the American College of Cardiology, which was held in Orlando, Florida, in March 29-31, 2009.

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https://doi.org/10.1016/j.hrthm.2009.10.025 Get rights and content

Background

Most atrial fibrillation (AF) ablation studies have consisted predominantly of males; accordingly, there is a paucity of information on the safety and efficacy of catheter ablation in a large cohort of female AF patients.

Objective

The purpose of this study was to evaluate catheter ablation for AF in female patients.

Methods

From January 2005 to May 2008, 3265 females underwent pulmonary vein antrum isolation. Success rates, patient profiles, and complications were collected.

Results

Approximately 16% of our population was female (P <.001). Females were older (59 ± 13 vs. 56 ± 19 years; P <.01) and had a lower prevalence of paroxysmal atrial fibrillation (PAF; 46% vs. 55%; P <.001). Females failed more antiarrhythmics (4 ± 1 vs. 2 ± 3; P = .04) and were referred later for catheter ablation (6.51 ± 7 vs. 4.85 ± 6.5 years; P = .02) than males. More females failed ablation (31.5% vs. 22.5%; P = .001) and had nonantral sites of firing than males (P <.001). Female patients had 11 (2.1%) hematomas versus 27 (0.9%) in males.

Conclusions

Five times as many males underwent catheter ablation than females. Females failed more ablations possibly because of a higher prevalence of nonantral firing, non-PAF, and longer history of AF. Females had more bleeding complications than males.

Section snippets

Patient population

We screened 3265 consecutive patients with highly symptomatic and drug-refractory AF who underwent ablation at Sutter Pacific Medical Center, San Francisco, California; Metro Health Case Western Reserve, Cleveland, Ohio; Stanford University, Palo Alto, California; Akron General Hospital, Akron, Ohio; and Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas from January 2005 to May 2008. All female patients were selected from each center's AF ablation registry. Male

Patient characteristics

Females made up 15.8% of the population (P <.001). The number of females who underwent catheter ablation during the observation period steadily increased from 105 in 2005 to 148 in 2008 (Figure 1). Females were older and had a higher incidence of prior stroke and LSPAF and a lower incidence of diabetes type II and coronary artery disease than males. Female had more non-PV sites of firing than males (261 [50.4%] vs. 449 [16.3%]; P <.001]. Females had failed more antiarrhythmic agents and were

Main findings

To the best of our knowledge, this is the largest multicenter study to date that has reported the safety and efficacy of catheter ablation for AF in female patients. The main findings of this study were that (1) significantly fewer females than males had undergone catheter ablation in our experience; (2) females who had undergone catheter ablation tended to be older, had a higher prevalence of non-PAF, had failed more antiarrhythmic agents, and were referred later than males; (3) females failed

Conclusion

Over 5 times more males than females had undergone AF ablation in our catheter ablation experience. Overall, females had lower procedural success rates and higher risk of bleeding complications than their male counterparts. Higher procedural failure rates in female patients can possibly be attributed to a higher prevalence of nonparoxysmal AF, extra non-PV triggers, and a longer history of AF before being considered for ablation, which may have resulted in increased electrical and structural

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Female sex has long been recognized to present a higher risk of stroke and atrial fibrillation (AF) recurrence after circumferential pulmonary vein isolation (CPVI) than in males. However, the underlying mechanisms and benefits of additional low-voltage area (LVA) modification in women remain unknown.
The purpose of this study was to investigate differences in atrial substrate and efficacy of additive LVA ablation between sex subgroups.
Patients with paroxysmal atrial fibrillation (PAF) aged 65–80 years were randomly assigned to either CPVI plus LVA modification (STABLE-SR) group or CPVI alone group. The primary outcome was freedom from atrial arrhythmias after a single ablation procedure.
Of 414 patients included in STABLE-SR-III, 204 (49.3%) were women (mean age 70.5 ± 4.7 years). Women demonstrated significantly higher LVA prevalence (51.5% vs 32.9%; P <.001) and LVA burden (6.5% vs 2.9%; P <.001) than men. In the STABLE-SR group, additional LVA ablation was associated with a 63% reduction in recurrence for women compared with the CPVI alone group (10.8% vs 29.4%; adjusted hazard ratio 0.37; 95% confidence interval 0.18–0.75; P for interaction = .040). However, this finding was not observed in men (18.7% vs 18.5%). In the female subgroup, both group 1 (CPVI + LVA modification) and group 3 (CPVI alone in females without LVA) had similar clinical outcomes, which were much better than in Group 2 (CPVI alone in women with LVA) (90% vs 83.8% vs 63.6%; P = .003).
In older patients with PAF, women demonstrated more advanced atrial substrate, including higher prevalence and burden of LVA compared with men. Women may receive greater benefit from additional LVA modification than men.
Sex-specific outcomes after catheter ablation for persistent AF
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Sex-specific outcomes after catheter ablation (CA) for atrial fibrillation (AF) have reported conflicting findings.
We examined the impact of female sex on outcomes in patients with persistent AF (PsAF) from the Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI with Posterior Left Atrial Wall Isolation (CAPLA) randomized trial.
A total of 338 patients with PsAF were randomized to pulmonary vein isolation (PVI) or PVI with posterior wall isolation (PWI). The primary outcome was arrhythmia recurrence at 12 months. Clinical and electroanatomical characteristics, arrhythmia recurrence, and quality of life were compared between women and men.
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Women undergoing CA for PsAF report more significant symptoms and poorer quality of life at baseline than men. Despite higher arrhythmia recurrence and repeat procedures in women, the AF burden was comparably low, resulting in significant improvements in quality of life and psychological well-being after CA in both sexes.
Including hemoglobin levels and female sex provide the additional predictive value of the APPLE score for atrial fibrillation recurrence post-catheter ablation
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We probed whether the addition of hemoglobin (HGB) or the female sex (SEX) as variables would provide additional prognostic value to the APPLE score.
An optimized APPLE score was used to evaluate the AF recurrence risk in the consecutive populations with AF post-catheter ablation including the development (n = 562) and validation (n = 239) cohorts.
In the populations of AF recurrence, most patients were female sex (103/164, 62.8%), and had the lower HGB levels. After adjusting for the APPLE score, HGB level (Odds Ratio [OR], 0.828; 95% Confidence Interval [CI], 0.749–0.915; P < 0.001) and female sex (OR, 1.596; 95% CI, 1.140-2.235; P = 0.006) independently predicted AF recurrence. Adjusting the APPLE score by HGB variable improved its predictive ability for AF recurrence (C-statistic value from 0.675 to 0.711, P = 0.010), which also increased the C-indexes in the external validation (from 0.653 to 0.725, p = 0.023). The female sex variable also enhanced the C-statistic value of the APPLE score for AF recurrence at both development and external validation (C-indices from 0.675 to 0.691, P = 0.004; C-indices from 0.653 to 0.704, p = 0.037, respectively). Decision curve analysis showed that the HGB plus APPLE score was better than the SEX plus APPLE score in predicting AF recurrence in two following AF populations.
The inclusion of HGB level and female sex variables improved the predictability and clinical usefulness of adjusted APPLE score. Adjustment of the APPLE score by HGB levels may provide better predictive value than inclusion of the female sex variable.
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This historical cohort study examined 453 consecutive patients with persistent AF who underwent a first-time AF ablation. We measured the PTFV1 at 3 months after the ablation. An abnormal PTF was defined as a ≥4 mVms depression. The 3-year incidence of AF recurrence and composite cardiovascular events, including strokes, heart failure hospitalizations, and cardiovascular death, were compared between the abnormal and normal PTF groups.
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Previous studies have shown that women with atrial fibrillation (AF) have a higher incidence of recurrence and non–pulmonary vein (non-PV) triggers. However, there remains an incomplete understanding of the impact of gender on AF ablation strategies and outcomes.
The purpose of this study was to evaluate the impact of gender on AF ablation outcomes.
We analyzed 1568 AF ablations in 1412 patients (34% female) performed at a single tertiary care center between January 2013 and July 2021. Patients were followed for at least 6 months (mean 34 months) for detection of AF recurrence, complications, and emergency department visits/hospitalizations. The effect was assessed by multivariate logistic regression analysis using propensity score matching (PSM).
Mean age was 64 years, and mean body mass index (BMI) was 31 kg/m². Seventy-seven percent of patients underwent de novo ablations. Twenty-seven percent of patients had persistent AF, with a recurrence rate of 37%. There was no difference in AF recurrence when stratified by gender (hazard ratio [HR] 1.15; 95% confidence interval [CI] 0.92–1.43; P >.05) and age. After PSM gender 1:1 (criteria: age, type of AF, hypertension, diabetes mellitus, and BMI; n = 888 patients), there was no difference in AF recurrence or procedure-related complications. Having a history of persistent AF (HR 1.54; 95% CI 1.18–1.99; P = .001) predisposed to recurrence of AF. Persistent AF (HR 2.99; 95% CI 1.94–4.78; P <.001) and age >70 years (HR 1.03; 95% CI 1.02–1.05; P <.001) were associated with the need for additional substrate modification with no difference based on gender.
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: J. David Burkhardt is a speaker for St. Jude Medical and Biosense Webster and Chief Medical Officer for Stereotaxis. Robert A. Schweikert is a consultant for Biosense Webster and a speaker for Medtronic, St. Jude Medical, Boston Scientific, Biosense Webster, and Reliant Pharmaceuticals. Andrea Natale is a speaker for St. Jude Medical, Boston Scientific, Medtronic, and Biosense Webster and a member of the Advisory Board for Stereotaxis and Biosense Webster. She also received a research grant from St. Jude Medical. Rodney Horton is on the Speakers' Bureau for Hansen Medical, St. Jude Medical, Medtronic, Boston Scientific, and Biosense Webster. Javier E. Sanchez receives speaker fees from Boston Scientific, St. Jude Medical, and Biosense Webster. G. Joseph Gallinghouse is a consultant for St. Jude Medical and Hansen Medical. All other authors have no conflicts of interest.

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ClinicalAblationOutcomes and complications of catheter ablation for atrial fibrillation in females

Background

Objective

Methods

Results

Conclusions

Section snippets

Patient population

Patient characteristics

Main findings

Conclusion

J Am Coll Cardiol

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Impact of atrial fibrillation on the risk of death: the Framingham Heart Study

Circulation

New-onset atrial fibrillation: sex differences in presentation, treatment and outcome

Circulation

Electrical isolation of the superior vena cava: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation

J Cardiovasc Electrophysiol

Clinical
Ablation
Outcomes and complications of catheter ablation for atrial fibrillation in females