Recurrence of Atrial Fibrillation After Cryoballoon Ablation in Women Is Less Pulmonary Vein Mediated as Compared to Men: Lessons From Repeat Ablation Procedures

Background

Data on sex-related outcomes of pulmonary vein isolation (PVI) of cryoballoon ablation (CBA) in atrial fibrillation (AF) are sparse.

Aim

To compare sex-differences in PV reconnection, strategy and outcome of repeat ablations after CBA.

Methods

Repeat procedures were performed using radiofrequency ablation guided by 3D mapping. PV reconnection characteristics were compared in 229 patients (77 (33.6%) females). In durable PVI patients, we compared left atrial voltage maps, ablation strategy and 1-year outcome. Clinical success was defined as freedom of documented AF or atrial tachycardia (AT) > 30 s.

Results

Female patients had a lower overall number of PV reconnections (0.8 ± 0.9 vs 1.2 ± 1.0, p < 0.001) driven by less reconnected left PVs: 13/77 (16.9%) vs 51/152 (33,6%), p = 0.008 and 7/77 (9.1%) vs 39/152 (25.7%), p = 0.003 for LSPV and LIPV, respectively. Durable PVI was more frequent in women (34/77 (44.1%) vs 37/152 (24.4%), p = 0.001). Female sex was the only independent predictor for durable PVI (HR = 2.003; 95% CI 1.090–3.682; p = 0.025). In durable PVI patients, substrate ablation was more frequently performed in women (21/35 (60%) vs 13/35 (37.1%), p = 0.044), mainly targeting the higher prevalent atrial low-voltage zones (21/35 (60.0%) vs 12/36 (33.3%), p = 0.017). At 1 year, recurrence of AF/AT did not differ between sexes: 6/35 (17.1%) versus 8/35 (22.9%), p = 0.591.

Conclusions

The higher persistence of durable PVI in women points to a sex difference in AF recurrence driver after CBA. In durable PVI patients, a higher prevalence of low-voltage regions results in more substrate ablation in women. Despite sex differences in ablation strategy, 1-year outcome was similar.