Temporal trends and sex differences in pulmonary vein isolation for patients with atrial fibrillation

Sex differences in overweight and obese patients undergoing high-power short-duration pulmonary vein isolation for atrial fibrillation: an observational cohort study

Atrial fibrillation (AF) is the most common heart rhythm disorder worldwide. As treatment methods evolve, optimizing personalized therapy based on patient characteristics, such as sex, becomes crucial. This study investigates sex differences in high-power short-duration (HPSD) pulmonary vein isolation (PVI) in overweight and obese patients. We analyzed data from 189 overweight and obese patients who underwent HPSD PVI for AF, comparing demographic information, procedural details, outcomes, and complications between male and female patients. Our analysis revealed fewer women underwent PVI compared to men, with women typically older and showing more pronounced changes in the left atrial substrate. Despite these differences, the safety and efficacy of PVI were comparable between sexes, including in the BMI ≥ 30 kg/m2 subgroup and after age adjustment. The findings emphasize the need for early AF screening in women to prevent treatment delays and show that considering sex-specific differences in fat distribution can improve procedural outcomes. These insights support the need for tailored management strategies for AF in overweight and obese populations, addressing sex-specific risks and anatomical variations.

Pulsed-field- vs. cryoballoon-based pulmonary vein isolation: lessons from repeat procedures

AIMS

Pulsed-field ablation (PFA) is an emerging technology to perform pulmonary vein isolation (PVI). Initial data demonstrated high safety and efficacy. Data on long-term PVI durability and reconduction patterns in comparison to established energy sources for PVI are scarce. We compare findings in repeat ablation procedures after a first PFA to findings in repeat ablation procedures after a first cryoballoon ablation (CBA) based PVI.

METHODS AND RESULT

A total of 550 consecutively enrolled patients underwent PFA or CBA index PVI. Repeat ablations in patients with symptomatic atrial arrhythmia recurrences were analysed. A total of 22/191 (12%) patients after index PFA-PVI and 44/359 (12%) after CBA-PVI underwent repeat ablation. Reconduction of any pulmonary vein (PV) was detected by multipolar spiral mapping catheter at each PV with careful evaluation of PV potentials and by 3D-mapping in 16/22 patients (73%) after PFA-PVI and in 33/44 (75%) after CBA-PVI (P = 1.000). Of 82 initially isolated PVs after PFA-PVI, 31 (38%) were reconducting; of 169 isolated PVs after CBA-PVI, 63 (37%) were reconducting (P = 0.936). Clinical atrial tachycardia occurred similarly in patients after PFA (5/22; 23%) and CBA (7/44; 16%; P = 0.515). Roof lines were set more often after PFA- (8/22; 36%) compared with CBA-PVI (5/44; 11%; P = 0.023). Repeat procedure duration [PFA: 87 (76, 123) min; CBA: 93 (75, 128) min; P = 0.446] was similar and fluoroscopy time [PFA: 11 (9, 14) min; CBA: 11 (8, 14) min; P = 0.739] equal between groups at repeat ablation.

CONCLUSION

During repeat ablation after previous PFA- or CBA-based PVI, electrical PV-reconduction rates and patterns were similar.

Sex differences in clinical features, utilization of oral anticoagulant agents, and 1-year outcome in Middle Eastern patients with atrial fibrillation

OBJECTIVE

Studies have revealed that sex can predict differences in multiple aspects of atrial fibrillation (AF). These differences are underreported in the Middle East. This study aims to describe sex-specific differences in risk factors, symptomatology, management, and outcomes in Middle Eastern patients with AF.

METHODS

The JoFib (Jordan-Atrial-Fibrillation) study is an observational, prospective, multicenter, nationwide registry in AF. Comparisons were made between female and male patients using Pearson chi-square and Mann-Whitney U tests. Multivariable regression models were constructed to investigate whether the female sex was predictive of any AF-related outcomes (all-cause death, cardiovascular death, ischemic stroke or systemic embolism [IS/SE], major bleeding, and clinically relevant non-major bleeding).

RESULTS

Of 2,020 patients with AF, 54% (n = 1091) were females. Females with AF were older (median age 71 vs. 69, p <.001), but had less heart failure (20.9% vs. 27.2%, p = .001) and coronary artery disease (7.5% vs. 14.7%, p <.001). Females with AF were more symptomatic (74.7% vs. 66.5%, p <.001) and frequently received anticoagulant therapy (84.4% vs. 78.9%, p = .001). Rhythm control was pursued less frequently in females (23.4% vs. 27.3%, p = .04). All studied outcomes occurred with similar frequencies in females and males, and sex was not significantly predictive of any outcome.

CONCLUSION

Females with AF are more symptomatic, yet they are treated less with rhythm control. Despite higher risk, females have similar risk-adjusted all-cause cardiovascular death and stroke rates compared to males. Future studies should explore how treatments and interventions can influence quality-of-life and cardiovascular outcomes in females with AF.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

The impact of sex on stroke care: From epidemiology to outcome

BACKGROUND

Carotid stenosis and atrial fibrillation are key risk factors for development of hemispheric strokes. In this review we aim to identify sex-specific differences in the pathophysiology and treatment of these risk factors and areas for future study.

KEY FINDINGS

Women are underrepresented in research studies of stroke in patients with carotid disease and atrial fibrillation. However, key differences have been found between men and women that suggest that the development of carotid disease and atrial fibrillation occur at later stages of life and are associated with higher severity of stroke. Some treatments, including surgical treatment, seem to have different rates of efficacy and women and women are at higher risk of surgical complications. This suggests that treatment recommendations may need to be sex specific.

CONCLUSION

Efforts should be made to address research and treatment gaps in women with stroke risk factors. This may lead to the development of sex-specific recommendations for stroke prevention and treatment.

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Gender-Related Differences in Atrial Substrate in Patients with Atrial Fibrillation

Gender-related differences have been reported in patients who underwent pulmonary vein isolation (PVI). Atrial substrate plays a role in the outcomes after ablation but gender-related differences in atrial substrate have never been described in detail. We sought to analyze gender-related differences in atrial remodeling (spontaneous low-voltage zones [LVZs]) and their clinical relevance after PVI. We conducted a prospective multicenter study, including consecutive patients who underwent first PVI-only atrial fibrillation (AF) ablation. LVZs were analyzed on high-density electroanatomical maps collected with multipolar catheter, before PVI. In total, 262 patients (61 ± 11 years, 31% female, 50% persistent AF) were followed for 28 months. In women, LVZs were larger (10% vs 4% of left atrial surface [p <0.001]) and female gender was independently associated with fourfold higher risk of having advanced (LVZ > 15%) atrial remodeling (odds ratio 4.56, p <0.001). AF recurrence-free survival was not different between men and women (log-rank p = 0.2). Although LVZs were independently associated higher AF recurrences at multivariate analysis (hazard ratio [HR] 1.2, p = 0.038), female gender was not (HR 1.4, p = 0.211). Specifically, the LVZ cutoff to predict outcomes was different in men and women: >5% in men (HR 3.0, p <0.001), >15% in women (HR 2.7, p = 0.02). In conclusion, women have more widespread LVZ in all left atrial regions. Despite more extensive atrial remodeling, the AF recurrence rate is similar in men and women, and LVZs become prognostic in women only at high burden (>15%). LVZs seem to have a different prognostic role in men and women.

Sex-based differences in safety and efficacy of catheter ablation for atrial fibrillation

BACKGROUND

Studies have identified significant sex-based differences and disparities in the clinical presentation and treatment of atrial fibrillation (AF). Studies have shown women are less likely to be referred for catheter ablation, are older at the time of ablation, and are more likely to have recurrence after ablation. However, in most studies investigating AF ablation outcomes, the female cohorts were relatively small. The impact of sex on the outcome and safety of ablation procedures is still unclear.

OBJECTIVE

To investigate sex-based differences in outcomes and complications after AF catheter ablation, with a significant female cohort METHOD: In this retrospective study, patients undergoing AF ablation from January 1, 2014, to March 31, 2021, were included. We investigated clinical characteristics, duration and progression of AF, number of EP appointments from diagnosis to ablation, procedural data, and procedure complications.

RESULTS

Total of 1346 patients underwent first catheter ablation for AF during this period, including 896 (66.5%) male and 450 (33.4%) female patients. Female patients were older at the time of ablation (66.2 vs. 62.4 years; p < .001). Women had higher CHA2 DS2 -VASc (congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, sex category) scores (3 vs. 2; p < .001) than men, expectedly, as the female sex warrants an additional point. 25.3% female patients had PersAF at the time of diagnosis versus 35.3% male patients (p < .001). At the time of ablation, 31.8% female patients had PersAF as compared to 43.1% male patients (p < .001), indicating progression of PAF to PersAF in both sexes. Women tried more AADs than men before ablation (1.13 vs. 0.98; p = .002). Male and female patients had no statistically significant difference in (a) arrhythmia recurrence at 1-year post ablation (27.7% vs. 30%; p = .38) or (b) procedural complication rate (1.8% vs. 3.1%; p = .56).

CONCLUSION

Female patients were older and had higher CHA2 DS2 -VASc scores compared to males at the time of AF ablation. Women tried more AADs than men before ablation. One-year arrhythmia recurrence rates and procedural complications were similar in both sexes. No sex-based differences were observed in safety and efficacy of ablation.

Race and Ethnic and Sex Differences in Rhythm Control Treatment of Incident Atrial Fibrillation

Background

Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment is critical in alleviating AF disease burden. Variation in treatment by race and ethnic and sex could lead to inequities in health outcomes.

Objective

To identify racial and ethnic and sex differences in rhythm treatment for patients with incident AF.

Methods

Using 2010-2019 Optum Clinformatics database, an administrative claims data for commercially insured patients in the United States (US), incident AF patients ≥20 years old who were continuously enrolled 12-months pre- and post-index diagnosis were identified. Rhythm control treatment (ablation, antiarrhythmic drugs [AAD], and cardioversion) for AF were compared by patient race and ethnicity (Asian, Hispanic, Black vs White) and sex (female vs male). Multivariable regression analysis was used to examine the relationship of race and ethnicity and sex with rhythm control AF treatment.

Results

A total of 77,932 patients were identified with incident AF. Black and Hispanic female patients had the highest CHA2DS2VASc scores (4.3 ± 1.8) and Elixhauser scores (4.1 ± 2.8 and 4.0 ± 6.7), respectively. Black males were less likely to receive AAD treatment (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI], 0.79-0.96) or ablation (aOR, 0.72; 95% CI, 0.58-0.90). Compared to White males, all groups had lower likelihood of receiving cardioversion with Asian females having the lowest [aOR, 0.48; 95% CI, (0.37-0.63)].

Conclusion

Black patients were less likely to receive pharmacologic and procedural rhythm control therapies. Further research is needed to understand the drivers of undertreatment among racial and ethnic groups and females with AF.

Racial/ethnic and sex differences in safety outcomes and atrial fibrillation/atrial flutter-related acute healthcare utilization after catheter ablation of atrial fibrillation

Background

Catheter ablation is recommended for the treatment of symptomatic atrial fibrillation (AF) refractory to medical therapy.

Objective

The study sought to examine racial/ethnic and sex differences in complications and AF/atrial flutter (AFL)-related acute healthcare utilization following catheter ablation for AF.

Methods

We performed a retrospective analysis using data from the Centers for Medicare and Medicaid Services Medicare Standard Analytical Files (October 1, 2014, to September 30, 2019) among patients ≥65 years of age with AF who underwent catheter ablation for rhythm control. The risk of any complication within 30 days and AF/AFL-related acute healthcare utilization within 1 year of ablation by race, ethnicity, and sex were assessed using multivariable Cox regression modeling.

Results

We identified 95,394 patients for analysis of postablation complications and 68,408 patients for analysis of AF/AFL-related acute healthcare utilization. Both cohorts were ∼95% White and 52% male. Female patients had a slightly elevated risk of complications compared with male patients (adjusted hazard ratio [aHR] 1.07, 95% confidence interval [CI] 1.03-1.12). Black (aHR 0.78, 95% CI 0.77-1.00) and Asian (aHR 0.67, 95% CI 0.50-0.89) patients had lower utilization compared with White patients. Specifically, Asian men (aHR 0.58, 95% CI 0.38-0.91) had lower utilization compared with White men.

Conclusion

Differences in safety and healthcare utilization after catheter ablation for AF were observed by race/ethnicity and sex groups. Underrepresented racial and ethnic groups with AF had a lower risk of AF/AFL-related acute healthcare utilization postablation.

Women and Ischemic Stroke

Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.

Catheter ablation of symptomatic atrial fibrillation: Sex, ethnicity, and socioeconomic disparities

Catheter ablation for treatment of atrial fibrillation (AF), AF ablation, is more effective than antiarrhythmic drugs in reducing AF burden, reducing symptoms and increasing health-related quality of life. Although females more often experience AF-related symptoms, and have more severe symptoms, have lower quality of life, and experience more serious adverse effects of antiarrhythmic drugs than males, they are less likely to undergo AF ablation. Potential explanations for the disparity include older age at diagnosis, longer AF duration, a greater number of comorbidities, more extensive atrial fibrosis, and presumed lower success rate and more complications after AF ablation in women. Studies have failed to show sex-related differences in AF recurrence or serious complications following AF ablation but show more nuisance bleeds in women. Ethnic minorities, such as African Americans and Latin Americans, and individuals of low socioeconomic status are also less likely to undergo AF ablation, possibly associated with greater numbers of comorbidities, lack of patient advocacy, healthcare costs, and inadequate insurance coverage. Inclusion of marginalized patient groups in clinical trials of AF treatment and a personalized, patient-centered approach may expand equality in utilization of AF ablation.

Sex differences in clinical profile, management, and outcomes of patients hospitalized for atrial fibrillation in the United States

AIMS

This study aimed to investigate the impact of sex on the clinical profile, utilization of rhythm control therapies, cost of hospitalization, length of stay, and in-hospital mortality in patients admitted for atrial fibrillation (AF) in the United States.

METHODS AND RESULTS

We used data from the Nationwide Inpatient Sample for the year 2018. Regression analysis was performed to investigate differences between men and women. A P-value ≤ 0.05 was considered significant. We included 82592 patients with a primary diagnosis of of AF 50.8% women. Women were significantly older (mean age 74 vs. 67 years, P < 0.001) and had a higher CHA2DS2-VASc score (median 4 vs. 2, P < 0.001) than men. Women had relatively higher in-hospital mortality (0.9% vs. 0.8%, P = 0.070); however, after adjustment for known risk factors female sex was no longer a predictor of mortality (P = 0.199). In sex-specific regression analyses, increased age, chronic obstructive pulmonary disease, previous stroke, heart failure, and chronic kidney disease were risk factors for in-hospital mortality in both sexes, vascular disease only in women, and race and alcohol abuse only in men. After adjusting for potential confounders, female sex was associated with lower likelihood of receiving catheter ablation [adjusted odds ratio (aOR) 0.69, 95% confidence interval (CI) 0.64-0.74] and electrical cardioversion (aOR 0.69, 95% CI 0.67-0.72), and with longer hospitalization (aOR 1.33, 95% CI 1.28-1.37), whereas sex had no influence on hospitalization costs (P = 0.339).

CONCLUSION

There were differences in the risk profile, management, and outcomes between men and women hospitalized for AF. Further studies are needed to explore why women are treated differently regarding rhythm control procedures.

Sex differences in presentation of atrial fibrillation: Findings from 30-day ambulatory monitoring in real-world practice

Background

Women are less likely to receive oral anticoagulation or ablation for treatment of atrial fibrillation (AF). Identification of sex differences in arrhythmia characteristics and symptoms may lead to a better understanding of potential reasons for these differences.

Objectives

To determine sex differences in AF with respect to heart rate, duration, burden, and symptoms in patients undergoing mobile cardiac telemetry (MCT) monitoring.

Methods

All patients who registered for ≤30-day MCT using PocketECG (MediLynx) in the USA in 2017 were included (n = 27,512, 58 % women). PocketECG records and transmits a three-lead ambulatory electrocardiogram (ECG) with real-time beat-to-beat analysis. Sex-related differences were analyzed with Chi2 and Spearmans rho.

Results

Fewer women than men were diagnosed with AF lasting ≥30s (13.7 % versus [vs] 19.0 %, p < 0.001). AF burden was lower in women in all age groups <90 years (all p < 0.01). Women were older at the time of AF diagnosis (median 76 vs 73 years, p < 0.001), had faster heart rate during AF (mean: 104.7 ± 26.0 vs 96.7 ± 26.7 bpm, p < 0.001), and shorter AF duration (mean: 96.2 ± 176.0 vs 121.6 ± 189.9 min, p < 0.001). There was a non-significant trend toward more symptoms (such as dizziness, racing heart, fatigue, or palpitations) during AF in women compared to men (46.5 % vs 43.7 %, p = 0.062).

Conclusions

AF was less prevalent and occurred at lower burdens in women than men in each age strata. Despite faster heart rates in AF in women, there were no significant sex differences in reported symptoms during AF. Sex differences in therapy cannot be explained by differences in symptoms or rates in AF.

Condensed abstract

Real-world data on sex differences in AF using a 30-day MCT monitoring device remain scarce. We aim to determine the sex differences in AF with respect to prevalence, burden, heart rate, and symptom in patients undergoing ≤30-day MCT monitoring. Our data analysis suggests that fewer women than men had AF, women were older at diagnosis of AF, and women with AF had higher mean heart rate, shorter mean AF duration, and lower mean AF burden than men. Further studies are needed to examine reasons for sex differences, specifically in relation to AF therapy and its impact on clinical outcomes.

Influence of Sex-Based Differences in Cardiac Phenotype on Atrial Fibrillation Recurrence in Patients Undergoing Pulmonary Vein Isolation

Background

Pulmonary vein isolation (PVI) is a commonly engaged therapy for symptomatic atrial fibrillation (AF). Prior studies have documented elevated AF recurrence rates among females vs. males. Sex-specific mechanisms underlying this phenomenon are poorly understood. This prospective cohort study aimed to evaluate the sex-based differences in cardiac phenotype and their influence on (AF) recurrence following first-time PVI.

Methods

A total of 204 consecutive patients referred for first-time PVI and 101 healthy subjects were prospectively studied by cardiovascular magnetic resonance (CMR) imaging. Multi-chamber volumetric and functional measures were assessed by sex-corrected Z-score analyses vs. healthy subjects. Patients were followed for a median of 2.6 years for the primary outcome of clinical AF recurrence. Multivariable analyses adjusting for age and comorbidities were performed to identify independent predictors of AF recurrence.

Results

AF recurrence following first PVI occurred in 41% of males and 59% of females (p = 0.03). Females were older with higher prevalence of hypertension and thyroid disorders. Z-score-based analyses revealed significantly reduced ventricular volumes, greater left atrial (LA) volumes, and reduced LA contractility in females vs. males. Multivariable analysis revealed each of LA minimum and pre-systolic volumes and booster EF Z-scores to be independently associated with AF recurrence, providing respective hazard ratios of 1.10, 1.19, and 0.89 (p = 0.001, 0.03, and 0.01).

Conclusion

Among patients referred for first time PVI, females were older and demonstrated significantly poorer LA contractile health vs. males, the latter independently associated with AF recurrence. Assessment of LA contractile health may therefore be of value to identify female patients at elevated risk of AF recurrence. Factors influencing female patient referral for PVI at more advanced stages of atrial disease warrant focused investigation.

Sex Differences and Temporal Trends in Hospitalization for Catheter Ablation of Nonvalvular Atrial Fibrillation: A Single-Center Experience for 15 Years

Background

There exist sex differences in the clinical profile, management, and outcome of atrial fibrillation (AF). Catheter ablation of AF has become a first-line therapy and has markedly made headway over the recent decades. Little is known about sex differences and temporal trends in hospitalization for catheter ablation of AF in the real-world setting.

Methods

We retrospectively retrieved medical records of patients at Beijing Anzhen Hospital between January 2005 and December 2019. The patients undergoing catheter ablation of AF were enrolled. Demographical and clinical data were compared between sexes. The temporal trends of sex differences were evaluated.

Results

We identified 13502 male patients (66.8%) and 6713 female patients (33.2%). The number of patients undergoing AF ablation had remarkably increased over time, but no sex differences were observed (p=0.17). The median age of women was five years older than that of men (p < 0.001). The median time of in-hospital stay for the women decreased from 11 days to 4 days and for the men from 9 to 4 days. In-hospital mortality was 0.03% and 0.01% for women and men, respectively, with no significant difference between sexes. The women were more likely to have a comorbid diagnosis of hypertension and heart failure than men (p < 0.001). The CHA2DS2-VA score was higher in women than in men (1.64 vs. 1.28, p < 0.001). The temporal trend in the score increased in women from 1.17 to 1.81 (p < 0.001) and in men from 0.91 to 1.41 (p < 0.001). The percentage of patients with CHA2DS2-VA score ≥2 was higher in women than in men (49.8% vs. 35.8%, p < 0.001), and the temporal trend of this sex gap was nearly doubled (8.0% in 2005-2007 vs. 15.5% in 2017-2019, p=0.03).

Conclusions

Safety of catheter ablation for AF was comparable in both sexes. In contrast, the women showed a higher CHA2DS2-VA score than men. The percentage of patients with CHA2DS2-VA score ≥2 increased more quickly in women than in men. Furthermore, sex-specific research is warranted to reduce this sex disparity.

Sex Differences in the Outcomes of Cryoablation for Atrial Fibrillation

Background

The literature data on the outcomes of radiofrequency catheter ablation for atrial fibrillation (AF) in women are contradictory.

Aim

To determine and compare the outcomes and complications of cryoballoon pulmonary vein isolation (cryo-PVI) in men vs. women, and to identify predictors of atrial tachyarrhythmia (ATa) recurrence.

Methods

We included all consecutive patients having undergone cryo-PVI for the treatment of symptomatic AF in our center since 2012. Peri-operative complications were documented. All patients were prospectively monitored for the recurrence of ATa, and predictors were assessed.

Results

A total of 733 patients were included (550 men (75%) and 183 (25%) women). Paroxysmal AF was recorded in 112 (61%) female patients and 252 male patients (46%; p < 0.001). Female patients were older (p < 0.001) and had a greater symptom burden (p = 0.04). Female patients were more likely to experience complications (p = 0.02). After cryo-PVI for paroxysmal AF, 66% of the female patients and 79% of the male patients were free of ATa at 24 months (p = 0.001). Female sex was the only independent predictive factor for ATa recurrence (hazard ratio [95% confidence interval] = 1.87 [1.28; 2.73]; p = 0.001). After cryo-PVI for non-paroxysmal AF, 37% of the male patients and 39% of the female patients were free of ATa at 36 months (p = 0.73). Female patients were less likely than male patients to undergo repeat ablation after an index cryo-PVI for non-paroxysmal AF (p = 0.019).

Conclusion

A single cryo-PVI procedure for paroxysmal AF was significantly less successful in female patients than in male patients. Overall, the complication rate was higher in women than in men.

Treatment success and its predictors as well as the complications of catheter ablation for atrial fibrillation in a high-volume centre

PURPOSE

Catheter ablation for atrial fibrillation (AF) is a standard procedure for maintaining sinus rhythm. The aim of this study was to evaluate treatment success and its predictors and to provide quality control data on complications and redo operations in a centre with an initially a low but currently high annual volume.

METHODS

Data on patients (n = 1,253) treated with catheter ablation for AF in Tays Heart Hospital between January 2010 and May 2018 was evaluated (n = 1178 ablation-naïve patients and n = 1514 AF ablations). Comprehensive data on patient characteristics, treatment results, redo operations and complications were collected. Treatment success (maintenance of sinus rhythm at 1 year) was evaluated among patients residing within the hospital district (45% of the entire study population).

RESULTS

Treatment success was observed in approximately 62.9% of the ablation-naïve patients. Preoperative predictors of treatment success were paroxysmal AF type, previous use of antiarrhythmic drugs, left atrium diameter and age. The experience at the centre did not associate with the 1-year outcome. A relapse during the first 3-month blanking period was associated with a nine-fold risk of failure at 1 year (unadjusted OR 9.1, 95% CI 5.5-15.1, p < 0.001). The major complication rate was 4.5% (68/1514) with no deaths. Ten percent of the patients needed a redo procedure within the first year.

CONCLUSIONS

Patient-related factors are the most significant predictors of treatment success. A relapse during a 3-month blanking period is associated with a very high risk of failure at 1 year.

The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database

AIMS

The effectiveness and safety of same-day discharge (SDD) for catheter ablation (CA) for atrial fibrillation (AF) has not been fully elucidated using a large nationwide database. This study aimed to evaluate the all-cause readmission rates within 30-days among patients receiving CA for AF with an SDD protocol compared with a conventional overnight stay (ONS).

METHODS AND RESULTS

We performed a retrospective cohort study using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission following discharge in patients receiving CA and a secondary outcome was requiring total healthcare cost. A 1 : 3 propensity score matching was conducted to compare the safety and efficacy within both SDD and ONS group. Among 30 776 patients [mean 67.2 ± 11.4 years, 12 590 female (41.5%)] who received CA from 2016 through 2018, 440 (1.42%) patients were discharged on the same-day following CA (SDD group), and the remaining 30 336 patients stayed at least one night in the hospital (ONS group). A propensity score analysis generated 1751 matched pairs (440 in the SDD group; 1311 in the ONS group). The 30-day readmission following discharge was not significantly higher in the SDD group than the ONS group (SDD vs. ONS: 12.7% vs. 9.7%; hazard ratio: 1.17, 95% confidence interval: 0.76-1.81, P = 0.47). Healthcare cost was significantly higher in the ONS group ($25 237 ± 14 036 vs. $30 749 ± 16 383; P < 0.01).

CONCLUSION

In this nationwide database study, there was no significant difference in the all-cause 30-day readmission following SDD for CA compared with ONS.

Long-term effectiveness of catheter ablation in patients with atrial fibrillation and heart failure

AIMS

Randomized trials suggest reductions in all-cause mortality and heart failure (HF) rehospitalizations with catheter ablation (CA) in patients with atrial fibrillation (AF) and HF. Whether these results can be replicated in a real-world population with long-term follow-up or varies over time is unknown. We sought to evaluate the long-term effectiveness of CA in reducing the incidence of all-cause mortality, HF hospitalizations, stroke, and major bleeding in AF-HF patients.

METHODS AND RESULTS

In a cohort of patients newly diagnosed with AF-HF in Quebec, Canada (2000-2017), CA patients were matched 1:2 to controls on time and frequency of hospitalizations. Confounders were controlled for using inverse probability of treatment weighting. Multivariable Cox models adjusted for the presence of cardiac electronic implantable devices and medication use during follow-up, and the effect of time since CA was modelled with B-splines. For non-fatal outcomes, the Lunn-McNeil approach was used to account for the competing risk of death. Among 101 933 AF-HF patients, 451 underwent CA and were matched to 899 controls. Over a median follow-up of 3.8 years, CA was associated with a statistically significant reduction in all-cause mortality [hazard ratio 0.4 (95% confidence interval 0.2-0.7)], but no difference in stroke or major bleeding. The hazard of HF rehospitalization for CA patients, relative to non-CA patients, varied with time since CA (P = 0.01), with a reduction in HF rehospitalizations until approximately 3 years post-CA.

CONCLUSION

Compared with matched non-CA patients, CA was associated with a long-term reduction in all-cause mortality and a reduction in HF rehospitalizations until 3 years post-CA.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation

OBJECTIVE

The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures.

METHODS

Among 3282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5±10.3 years old, 61.5% with paroxysmal atrial fibrillation) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications and long-term clinical recurrences after propensity score matching.

RESULTS

LA volume index (43.1±18.6 vs 35.8±11.6 mL/m², p<0.001) was higher, but LA dimension (40.0±6.8 vs 41.6±6.3 mm, p=0.018), LA voltage (0.94±0.55 vs 1.20±0.68 mV, p=0.002) and pericardial fat volume (89.5±43.1 vs 122.1±53.9 cm³, p<0.001) were lower in women with repeat ablation than in their male counterparts. Pulmonary vein (PV) reconnections were lower (58.7% vs 74.9%, p=0.001), but the proportion of extra-PV triggers (27.5% vs 17.0%, p=0.026) and elevated LA pulse pressures (79.7% vs 63.7%, p=0.019) was significantly higher in women than in men. There was no significant sex difference in the rate of procedure-related complications (4.6% vs 4.2%, p=0.791). During a 31-month (8-60) median follow-up, clinical recurrences were significantly higher in women after both the de novo procedure (log-rank p=0.039, antiarrhythmic drug (AAD)-free log-rank p<0.001) and the second procedure (log-rank p=0.006, AAD-free log-rank p=0.093). Female sex (HR 1.51, 95% CI 1.06 to 2.15, p=0.023), non-paroxysmal atrial fibrillation (HR 1.78, 95% CI 1.30 to 2.34, p<0.010) and extra-PV triggers (HR 1.88, 95% CI 1.28 to 2.75, p=0.001) were independently associated with clinical recurrences after repeat procedures.

CONCLUSIONS

During repeat AFCA procedures, PV reconnections were lower in women than in men, and the existence of extra-PV triggers and an LA pressure elevation were more significant, which resulted in poor rhythm outcomes.

TRIAL REGISTRATION NUMBER

NCT02138695.

Sex-Related Differences in Catheter Ablation for Patients With Atrial Fibrillation and Heart Failure

The coexistence of atrial fibrillation and heart failure significantly increases the risk of all-cause mortality and heart failure hospitalizations. Sex-related differences in all patients undergoing atrial fibrillation catheter ablation include the referral of fewer women for catheter ablation (15–25%), older age of women at ablation, and higher risk of post-ablation recurrence of atrial fibrillation. We searched the existing literature for sex-related differences in patients undergoing atrial fibrillation catheter ablation with a focus on heart failure. Randomized controlled trials assessing atrial fibrillation catheter ablation in patients with heart failure have demonstrated a significant reduction in all-cause mortality and heart failure hospitalizations. Within the eight existing randomized controlled trials on heart failure with reduced ejection fraction, women composed a small proportion of the study population. Only two studies (CASTLE-AF and AATAC-HF) specifically assessed the effect of gender on outcome and showed no difference in post-ablation outcomes. Registry data-based studies assessing sex-related differences in atrial fibrillation catheter ablation in heart failure reveal that women are half as likely as men to undergo ablation. Conflicting data exist on the interaction of gender and heart failure as they may affect peri-ablation and post-ablation long-term outcomes such as atrial fibrillation recurrence or heart failure hospitalizations. In conclusion, existing studies provide insight into the gender-based differences in patients undergoing catheter ablation for atrial fibrillation as it pertains to heart failure. Further prospective studies with higher proportions of female participants are required to accurately determine gender-based differences in this population.

Women and atrial fibrillation

Atrial fibrillation (AF) remains a growing problem in the United States and worldwide, imposing a high individual and health system burden, including increased resource consumption due to repeated hospitalizations, stroke, dementia, heart failure, and death. This comprehensive review summarizes the most recent data on sex-related differences in risks associated with AF. Women with AF have increased risk of stroke and death compared to men, and possible reasons for this disparity are explored. Women also continue to have worse symptoms and quality of life, and poorer outcomes with stroke prevention, as well as with rate and rhythm control management strategies. Many current rhythm control treatment strategies for AF, including cardioversion and ablation, are used less frequently in women as compared to men, whereas women are more likely to be treated with rate control strategies or antiarrhythmic drugs. Sex differences should be considered in treating women with AF to improve outcomes and women and men should be offered the same interventions for AF. We need to improve the evidence base to understand if variation in utilization of rate and rhythm control management between men and women represents health inequities or appropriate clinical judgement.

Symptom Under-Recognition of Atrial Fibrillation Patients in Consideration for Catheter Ablation: A Report From the KiCS-AF Registry

OBJECTIVES

This study sought to investigate whether symptom under-recognition is associated with the application of catheter ablation.

BACKGROUND

Atrial fibrillation (AF) symptom burden is frequently under-recognized and may affect the choice of treatment strategies.

METHODS

A total of 3,276 patients with AF consecutively registered in a Japanese multicenter database from 2012 to 2017 were analyzed. All patients underwent AF symptom burden assessment via the symptom and daily activities domain within the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire. For the present analysis, 1,173 symptomatic patients (AFEQT score ≤80) with a clinical indication for catheter ablation were included. Under-recognition of symptom burden was defined as no subjective complaints checked by physicians despite self-reported AFEQT scores ≤80. Logistic regression analysis identified the predictors associated with receiving catheter ablation.

RESULTS

Of the 1,173 patients (age: 68 ± 12 years, men: 61%) analyzed, 459 underwent catheter ablation (ablation group); they had lower overall AFEQT scores (p < 0.01 for all domains) compared with the nonablation group. At the 1-year follow-up, greater improvement in the AFEQT scores was noted in the ablation group, even after adjusting for clinically relevant factors (+20.0 ± 1.2, +14.2 ± 0.9, respectively; p < 0.001). Notably, 306 (28%) patients met the criteria for symptom under-recognition, which was associated with the nonuse of catheter ablation during follow-up (odds ratio: 0.41; 95% confidence interval: 0.28 to 0.60; p < 0.001).

CONCLUSIONS

Under-recognition of AF symptom burden was frequently noted and was associated with less use of catheter ablation. Standardized recognition of symptoms using the application of validated questionnaires may facilitate outcome improvement.

Sex differences in catheter ablation of atrial fibrillation: results from AXAFA-AFNET 5

AIMS

Study sex-differences in efficacy and safety of atrial fibrillation (AF) ablation.

METHODS AND RESULTS

We assessed first AF ablation outcomes on continuous anticoagulation in 633 patients [209 (33%) women and 424 (67%) men] in a pre-specified subgroup analysis of the AXAFA-AFNET 5 trial. We compared the primary outcome (death, stroke or transient ischaemic attack, or major bleeding) and secondary outcomes [change in quality of life (QoL) and cognitive function] 3 months after ablation. Women were older (66 vs. 63 years, P < 0.001), more often symptomatic, had lower QoL and a longer history of AF. No sex differences in ablation procedure were found. Women stayed in hospital longer than men (2.1 ± 2.3 vs. 1.6 ± 1.3 days, P = 0.004). The primary outcome occurred in 19 (9.1%) women and 26 (6.1%) men, P = 0.19. Women experienced more bleeding events requiring medical attention (5.7% vs. 2.1%, P = 0.03), while rates of tamponade (1.0% vs. 1.2%) or intracranial haemorrhage (0.5% vs. 0%) did not differ. Improvement in QoL after ablation was similar between the sexes [12-item Short Form Health Survey (SF-12) physical 5.1% and 5.9%, P = 0.26; and SF-12 mental 3.7% and 1.6%, P = 0.17]. At baseline, mild cognitive impairment according to the Montreal Cognitive Assessment (MoCA) was present in 65 (32%) women and 123 (30%) men and declined to 23% for both sexes at end of follow-up.

CONCLUSION

Women and men experience similar improvement in QoL and MoCA score after AF ablation on continuous anticoagulation. Longer hospital stay, a trend towards more nuisance bleeds, and a lower overall QoL in women were the main differences observed.

Population-Level Sex Differences and Predictors for Treatment With Catheter Ablation in Patients With Atrial Fibrillation and Heart Failure

Background

Current guidelines are relatively general regarding the type of patient with heart failure (HF) who should be considered for catheter ablation (CA) of atrial fibrillation (AF). The aim of the present study was to identify clinical predictors and sex differences for treatment with CA in the AF-HF population.

Methods

A population-based AF-HF cohort was created using the Quebec administrative data (2000-2017). Patients were followed from the date of diagnosis of both diseases to the date of CA or death. Predictors for CA, represented by time-varying covariates, were assessed in a multivariable Cox model that accounted for the competing risk of death.

Results

Among 101,931 patients with AF-HF with medication information (median age, 80.7 years; interquartile range [IQR], 73.9-86.3; 51.4% were female, median CHA₂DS₂-VASc, 4; IQR, 3-4), only 432 (0.4%) underwent CA after a median of 0.8 years (IQR, 0.1-2.7). Independent of multiple comorbidities and advanced age, which were associated with a lower likelihood of CA, women were approximately half as likely to undergo a CA (26% were women; adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-0.7). Prior use of direct-acting oral anticoagulants and antiarrhythmics, and the presence of an implantable cardioverter-defibrillator were also predictors for CA treatment (P < 0.05 for all).

Conclusion

In a real-world population, CA was infrequently used to treat AF among patients with HF, and the likelihood of CA was further reduced in women. Because patients with CA had few comorbidities, future studies need to be conducted to determine whether CA can be beneficial in subjects whose clinical characteristics are more representative of the AF-HF population.

Sex differences of resource utilisation and outcomes in patients with atrial arrhythmias and heart failure

Objective

Atrial fibrillation or atrial flutter (AF) and heart failure (HF) often go hand in hand and, in combination, lead to an increased risk of death compared with patients with just one of both entities. Sex-specific differences in patients with AF and HF are under-reported. Therefore, the aim of this study was to investigate sex-specific catheter ablation (CA) use and acute in-hospital outcomes in patients with AF and concomitant HF in a retrospective cohort study.

Methods

Using International Statistical Classification of Diseases and Related Health Problems and Operations and Procedures codes, administrative data of 75 hospitals from 2010 to 2018 were analysed to identify cases with AF and HF. Sex differences were compared for baseline characteristics, right and left atrial CA use, procedure-related adverse outcomes and in-hospital mortality.

Results

Of 54 645 analysed cases with AF and HF, 46.2% were women. Women were significantly older (75.4±9.5 vs 68.7±11.1 years, p<0.001), had different comorbidities (more frequently: cerebrovascular disease (2.4% vs 1.8%, p<0.001), dementia (5.3% vs 2.2%, p<0.001), rheumatic disease (2.1% vs 0.8%, p<0.001), diabetes with chronic complications (9.7% vs 9.1%, p=0.033), hemiplegia or paraplegia (1.7% vs 1.2%, p<0.001) and chronic kidney disease (43.7% vs 33.5%, p<0.001); less frequently: myocardial infarction (5.4% vs 10.5%, p<0.001), peripheral vascular disease (6.9% vs 11.3%, p<0.001), mild liver disease (2.0% vs 2.3%, p=0.003) or any malignancy (1.0% vs 1.3%, p<0.001), underwent less often CA (12.0% vs 20.7%, p<0.001), had longer hospitalisations (6.6±5.8 vs 5.2±5.2 days, p<0.001) and higher in-hospital mortality (1.6% vs 0.9%, p<0.001). However, in the multivariable generalised linear mixed model for in-hospital mortality, sex did not remain an independent predictor (OR 0.96, 95% CI 0.82 to 1.12, p=0.579) when adjusted for age and comorbidities. Vascular access complications requiring interventions (4.8% vs 4.2%, p=0.001) and cardiac tamponade (0.3% vs 0.1%, p<0.001) occurred more frequently in women, whereas stroke (0.6% vs 0.5%, p=0.179) and death (0.3% vs 0.1%, p=0.101) showed no sex difference in patients undergoing CA.

Conclusions

There are sex differences in patients with AF and HF with respect to demographics, resource utilisation and in-hospital outcomes. This needs to be considered when treating women with AF and HF, especially for a sufficient patient informed decision making in clinical practice.

Assessment of Sex Differences in the Initial Symptom Burden, Applied Treatment Strategy, and Quality of Life in Japanese Patients With Atrial Fibrillation

IMPORTANCE

The clinical characteristics and outcomes of women and men with atrial fibrillation (AF) are reported to be different. However, whether sex-related differences extend to patients' symptom burden and perceived quality of life (QOL) or the management pattern of AF has been rarely studied, particularly in Asian countries.

OBJECTIVE

To assess the differences in symptoms, treatment, and QOL between Japanese female and male patients with AF.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using data from the multicenter outpatient registry Keio Interhospital Cardiovascular Studies-Atrial Fibrillation (KiCS-AF), which collects information regarding health status and the treatment of patients with newly diagnosed or referred AF. One-year follow-up data were available for 1534 patients at 11 referral centers in the Tokyo, Japan, area who were enrolled between September 2012 and December 2015. All data available up to the 1-year follow-up examination through July 31, 2017, were included.

MAIN OUTCOMES AND MEASURES

Sex, symptoms, AF treatment, and QOL as determined by Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaires at their initial visit and 1 year later.

RESULTS

Of 1534 patients, 1076 (70.1%) were men. Compared with men, women were more likely to be older (median age, 73 years [interquartile range {IQR}, 65-78 years] vs 65 years [IQR, 57-73 years], P < .001) and have higher median brain-type natriuretic peptide levels (102.8 pg/mL [IQR, 47.3-235.5 pg/mL] vs 74.1 pg/mL [IQR, 28.5-150.5 pg/mL], P < .001). Women also had lower median AFEQT overall summary scores than men (75 [IQR, 61-85] vs 80 [IQR, 69-90]; P < .001) but similar treatment satisfaction at baseline. During follow-up, women were less likely to be treated with a rhythm control strategy (48.1% [n = 214] vs 58.0% [n = 621], P < .001), including catheter ablation of AF (adjusted hazard ratio, 0.77 [95% CI, 0.62-0.95]; P = .02). At 1-year follow-up, women and men had improved QOL scores, regardless of their baseline characteristics (eg, age or brain-type natriuretic peptide levels) or treatment strategies, yet the sex gap persisted and grew (adjusted change in AFEQT overall summary score during 12 months, 5.89 [95% CI, 2.24-9.54] in women vs 8.94 [95% CI, 5.59-12.30] in men; P = .02).

CONCLUSIONS AND RELEVANCE

In contemporary Japanese clinical practice among unselected patients with AF, women were initially seen with greater QOL impairment, and the sex gap grew 1 year after presentation. The present study underscores the need for focused efforts to better understand and close this observed sex gap over the initial year of treatment for patients with AF.

Less Pulmonary Vein Reconnection at Redo Procedures Following Radiofrequency Point-by-Point Antral Pulmonary Vein Isolation With the Use of Contemporary Catheter Ablation Technologies

OBJECTIVES

This study investigated whether real-world use of contemporary technologies changed pulmonary vein (PV) reconnection and redo pulmonary vein isolation (PVI) procedure frequencies.

BACKGROUND

Previous studies consistently reported that following PVI recurrence of PV conduction is observed in >80% of patients.

METHODS

Consecutive patients undergoing 529 first and/or redo radiofrequency point-by-point PVI between January 2013 and December 2016 were included.

RESULTS

Between 2013 and 2016, redo PVI rate in atrial fibrillation significantly decreased (p < 0.001); in ≤12 months, first redo PVI rate decreased from 19% to 4%. The percentage of patients having PV reconnection at second PVI significantly decreased from 90% to 29% (p = 0.001). One PVI was performed in 393 and >1 in 79 patients. Female sex was associated with >1 PVI (hazard ratio [HR]: 1.86; 95% confidence interval [CI]: 1.10 to 3.13; p = 0.02). Sixty patients underwent first and second PVI in the study period. Female sex (HR: 2.79; 95% CI: 1.67 to 4.64; p < 0.001) and left atrial diameter (HR: 1.05; 95% CI: 1.01 to 1.08; p = 0.01) were associated with more and use of automatic ablation annotation algorithm during first PVI with fewer (HR: 0.54; 95% CI: 0.32 to 0.92; p = 0.02) redo PVI procedures. In 31 of 60 patients, ≥1 PV was reconnected at second PVI. The need for "touch-up" applications at the first PVI was the only predictor of PV reconnection.

CONCLUSIONS

Redo rate in atrial fibrillation and PV reconnection at redo PVI significantly decreased in recent years. Male sex, left atrial diameter, and use of automatic ablation annotation algorithm at first PVI were associated with fewer redo procedures. First-pass isolation was associated with lower PV reconnection rate at second procedure. Female sex was associated with more redo procedures but not higher PV reconnection frequencies.

Prevention of venous thrombosis after electrophysiology procedures: a survey of national practice

PURPOSE

Femoral venous access is required for most electrophysiology procedures. Limited data are available regarding post-procedure venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE). Potential preventative strategies are unclear. We aimed to survey Canadian centers regarding incidence of VTE and strategies for prevention of VTE after procedures that do not require post-procedure anticoagulation.

METHODS

An online survey was distributed to electrophysiologists representing major Canadian EP centers. Participants responded regarding procedural volume, incidence of VTE post-procedure, and their practice regarding pharmacological and non-pharmacological peri-procedural VTE prophylaxis.

RESULTS

The survey included 17 centers that performed a total of 6062 procedures in 2016. Ten patients (0.16%) had VTE (including 9 DVTs and 6 PEs) after diagnostic electrophysiology studies and right-sided ablation procedures excluding atrial flutter. Five centers (41.6%) administered systemic intravenous heparin during both diagnostic electrophysiology studies and right-sided ablation procedures. For patients taking oral anticoagulants, 10 centers (58.8%) suspend therapy prior to the procedure. Two centers (11.8%) routinely prescribed post-procedure pharmacologic prophylaxis for VTE. Four centers (23.5%) used compression dressings post-procedure and all prescribed bed rest for a maximum of 6 h. Of the variables collected in the survey, none were found to be predictive of VTE.

CONCLUSIONS

VTE is not a common complication of EP procedures. There is significant variability in the strategies used to prevent VTE events. Future research is required to evaluate strategies to reduce the risk of VTE that may be incorporated into EP practice guidelines.

Poor Rhythm Outcome of Catheter Ablation for Early-Onset Atrial Fibrillation in Women - Mechanistic Insight

BACKGROUND

Catheter ablation is a good treatment option for atrial fibrillation (AF) in young symptomatic patients. However, there is little information on the efficacy of catheter ablation of early-onset AF between sexes.

METHODS AND RESULTS

This study included 1,060 patients under the age 60 years old (837 men, 49.8±7.7 years old, 70.8% paroxysmal AF) who underwent catheter ablation for AF. Sex differences in clinical presentation and ablation outcomes were compared with and without propensity score-matching. During 24.5±18.9 months of follow-up, women showed significantly higher clinical recurrence of AF than men (log-rank, P=0.002). Female sex was independently associated with post-ablation clinical recurrence of AF (adjusted hazard ratio (HR) 2.58 [1.06-6.30], P=0.037). Women had a higher proportion of left ventricular diastolic dysfunction (E/Em, P<0.001), higher prevalence of heart failure (P=0.017), greater left atrial (LA) volume index (P=0.001), lower LA endocardial voltage (P<0.001), and higher parasympathetic nervous activity (root-mean square of differences, P<0.001; high-frequency (HF), P=0.010) than men. After a second ablation procedure (n=111), women still showed a higher clinical recurrence rate than men (log-rank, P=0.003) during 22.9±15.0 months of follow-up.

CONCLUSIONS

Among patients with early-onset AF who underwent catheter ablation, women showed poorer clinical outcomes than men after de novo and second procedures. Left ventricular dysfunction, LA remodeling, and autonomic nervous function may be potential mechanisms underlying sex differences in catheter ablation outcomes of early-onset AF.

Real-world outcomes, complications, and cost of catheter-based ablation for atrial fibrillation: an update

PURPOSE OF REVIEW

Catheter-based ablation for atrial fibrillation is a useful and effective form of rhythm-control therapy for symptomatic patients. This article reviews the 'real-world' experience on the outcomes, complications, and costs of atrial fibrillation ablation.

RECENT FINDINGS

Currently, real-world outcomes of atrial fibrillation ablation are derived from retrospective analysis of administrative databases or prospective registries from selected centers and patients. The rate of atrial fibrillation recurrence was reported to be as high as 60% and the rate of repeat ablation ranged from ≈10 to 18% within 1 year after ablation. All-cause hospitalizations after atrial fibrillation ablation were frequent, at up to ≈30% within 1 year and with up to half of them related to atrial fibrillation recurrence or repeat procedures. Rates of periprocedural complications were relatively low (≈3%). Female sex was associated with higher risk of complications such as bleeding, vascular injury, and tamponade. Markov models examining the cost-effectiveness of ablation yielded favorable results when success rates of more than 70% were assumed with long time horizons (>5 years).

SUMMARY

The real-world outcomes of atrial fibrillation ablation are sobering. Confirmation of these findings with prospective, population-based, minimally biased studies is needed. There is a critical need to delineate the downstream economic impact of atrial fibrillation ablation on society to justify its continued delivery and growth.

Paroxysmal Atrial Fibrillation in Females: Understanding gender diferences

Background

The catheter ablation of atrial fibrillation (AF) is performed less frequently in women. In addition, there is divergent information in the literature regarding the effectiveness and safety for the ablative procedure to females.

Objectives

The objective of this study was to compare the clinical characteristics and outcomes in men and women undergoing paroxysmal atrial fibrillation (PAF) ablation.

Methods

Cohort study of patients undergoing first-ever PAF catheter ablation procedure refractory to antiarrhythmic drugs. The information was taken from patients’ records by means of a digital collection instrument and indexed to an online database (Syscardio®). Clinical characteristics and procedures were compared between each gender (M x F), adopting a level of statistical significance of 5%. The primary endpoint associated with efficacy was freedom from atrial arrhythmia over the follow-up time.

Results

225 patients were included in the study, 64 (29%) women and 161 (71%) men. Women presented more symptoms due to AF according to the CCS-SAF score (1.8 ± 0.8M x 2.3 ± 0.8F p = 0.02) and higher CHADS2 score compared to men (0.9 ± 0.8M x 1.2 ± 1F). Post-ablation recurrence occurred in 20% of the patients, with no difference based on gender (21% M x 20% F p = 0.52). The rate of complications was less than 3% for both groups (p = 0.98).

Conclusion

Women undergoing the first-ever PAF catheter ablation procedure present similar complication rate and clinical outcome compared to men. These findings suggest that the current underutilization of AF catheter ablation in women may represent a discrepancy in care.

Effect of Electrophysiology Assessment on Mortality and Hospitalizations in Patients With New-Onset Atrial Fibrillation

Few patients with atrial fibrillation (AF) receive care by cardiac electrophysiologists. Although previous work has highlighted differential care for patients with AF treated by electrophysiologists, it is unclear whether this is associated with improved clinical outcomes. This retrospective population-level propensity score-matched cohort study included patients aged 20 to 80 years with new-onset AF presenting to an emergency department (ED) in Ontario, Canada, between 2010 and 2012. Patients were followed until March 31, 2015. Patients who saw an electrophysiologist within 1 year of the index ED visit were matched to patients who did not see an electrophysiologist. Linked administrative databases were used for cohort construction and allow 1-year follow-up to assess for the clinical end points of all-cause mortality and hospitalization for AF, heart failure, bleeding, and stroke. A total of 5,221 unique pairs of patients were matched. One hundred seventeen patients (2.2%) in the electrophysiologist cohort underwent an AF ablation procedure during the 1-year follow-up period. All-cause mortality (hazard ratio [HR] = 1.1, p = 0.17) and stroke (HR = 1.4, p = 0.09) were not significantly different between the 2 groups. Hospitalization for AF (HR = 1.4, p <0.001), bleeding (HR = 1.5, p = 0.0001), and congestive heart failure (HR = 1.5, p <0.0001) was increased in the group that saw an electrophysiologist. In conclusion, electrophysiologist care was not associated with improved clinical outcomes in patients with new-onset AF.

Prospective Assessment of Sex-Related Differences in Symptom Status and Health Perception Among Patients With Atrial Fibrillation

Background

We prospectively assessed sex‐specific differences in health perception, overall symptom status, and specific symptoms in a large cohort of patients with atrial fibrillation.

Methods and Results

We performed a prospective multicenter observational cohort study of 1553 patients with atrial fibrillation. Patients completed questionnaires about personal characteristics, comorbidities, and symptoms on a yearly basis. Mean age was 70±11 years among women and 67±12 years among men. Health perception on a visual analogue scale ranging from 0 to 100 (with higher scores indicating better health perception) was significantly lower in women than in men (70 [interquartile range: 50–80] versus 75 [interquartile range: 60–85]; P<0.0001). More women than men had any symptoms (85.0% versus 68.3%; P<0.0001), palpitations (65.2% versus 44.4%; P<0.0001), dizziness (25.6% versus 13.5%; P<0.0001), dyspnea (35.7% versus 21.8%; P<0.0001), and fatigue (25.3% versus 19.1%; P=0.006). At 1‐year follow‐up, symptoms decreased in both sexes but remained more frequent in women (49.1% versus 32.6%, P<0.0001). In multivariable adjusted longitudinal regression models, female sex remained an independent predictor for lower health perception (ß=−4.8; 95% CI, −6.5 to −3.1; P<0.0001), any symptoms (odds ratio [OR]: 2.6; 95% CI, 2.1–3.4; P<0.0001), palpitations (OR: 2.6; 95% CI, 2.1–3.2; P<0.0001), dizziness (OR: 2.9; 95% CI, 2.1–3.9; P<0.0001), dyspnea (OR: 2.1; 95% CI, 1.6–2.8; P<0.0001), fatigue (OR: 1.6; 95% CI, 1.2–2.2; P=0.0008), and chest pain (OR: 1.8; 95% CI, 1.3–2.6; P=0.001).

Conclusions

Women with atrial fibrillation have a substantially higher symptom burden and lower health perception than men. These relationships persisted after multivariable adjustment and during prospective follow‐up.

Venous Thrombosis After Electrophysiology Procedures: A Systematic Review

BACKGROUND

Femoral venous access for catheter introduction represents the cornerstone of electrophysiology (EP) procedures. Limited data are available regarding postprocedure VTE. The aim of this systematic review is to determine the incidence of DVT and pulmonary embolism (PE) associated with femoral vein catheterization during EP procedures.

METHODS

An electronic search was conducted for studies documenting the incidence of DVT and PE after EP procedures. Studies were classified as atrial fibrillation (AF) or non-AF ablation procedures.

RESULTS

Two thousand eight-hundred sixty-four studies were evaluated, 16 of which were included in the analysis. The incidence of DVT after AF and non-AF ablations reached as high as 0.33% and 2.38%, respectively, with a pooled incidence of 0% (95% CI, 0%-0.0003%) and 0.24% (95% CI, 0.08%-0.39%), respectively. The incidence of PE was 0.29% after AF ablation and ranged from 0% to 1.67% for non-AF procedures; the pooled incidence after non-AF ablations was 0.12% (95% CI, 0%-0.25%). Asymptomatic DVT was documented in up to 21.2% of patients. Hematomas occurred in 1.05% of AF ablations (95% CI, 0.30%-1.8%) and 0.3% of non-AF ablations (95% CI, 0.09%-0.51%).

CONCLUSIONS

A lower incidence of symptomatic DVT and PE was observed after AF ablations as opposed to non-AF ablations, likely due to the use of routine periprocedural anticoagulation. Asymptomatic DVTs appear to be common, although their significance is unclear. Future studies are required to weigh the risk of hematoma against the risk of VTE associated with the use of prophylactic anticoagulation after non-AF ablation procedures.

Atrial Fibrillation and Ventricular Arrhythmias: Sex Differences in Electrophysiology, Epidemiology, Clinical Presentation, and Clinical Outcomes

Sex-specific differences in the epidemiology, pathophysiology, clinical presentation, clinical treatment, and clinical outcomes of atrial fibrillation (AF), sustained ventricular arrhythmias, and sudden cardiac death are recognized. Sex hormones cause differences in cardiac electrophysiological parameters between men and women that may affect the risk for arrhythmias. The incidence and prevalence of AF is lower in women than in men. However, because women live longer and AF prevalence increases with age, the absolute number of women with AF exceeds that of men. Women with AF are more symptomatic, present with more atypical symptoms, and report worse quality of life in comparison with men. Female sex is an independent risk factor for death or stroke attributable to AF. Oral anticoagulation therapy for stroke prevention has similar efficacy for men and women, but older women treated with warfarin have a higher residual risk of stroke in comparison with men. Women with AF are less likely to receive rhythm control antiarrhythmic drug therapy, electric cardioversion, or catheter ablation in comparison with men. The incidence and prevalence of sustained ventricular arrhythmias and sudden cardiac death are lower in women than in men. Women receiving implantable cardioverter defibrillators for primary prevention of sudden cardiac death are less likely to experience sustained ventricular arrhythmias in comparison with men. In contrast, women receiving a cardiac resynchronization therapy implantable cardioverter defibrillator for the treatment of heart failure are more likely to benefit than men. Women are less likely to be referred for implantable cardioverter defibrillator therapy despite current guideline recommendations. Women are more likely to experience a significant complication related to implantable cardioverter defibrillator implantation in comparison with men. Whether sex differences in treatment decisions reflect patient preferences or treatment biases requires further study.