Discussion
Our study aimed to unravel the long-term outcomes of AF ablation in
relation to gender differences, focusing on the recurrence of AF and the
incidence of MACCE in a representative Chinese cohort. The main findings
of this study include: gender differences are a significant risk factor
for AF recurrence after catheter ablation in patients with AF; gender
differences are also present in patients with early ablation treatment;
there is no significant difference in the incidence of MACCE between men
and women; the risk factors for AF recurrence and MACCE after the
procedure are not the same in males and females. The findings have
significant implications as they reinforce and expand our comprehension
of gender disparities in clinical outcomes following catheter ablation
treatment for AF.
The collection of sex-specific data has expanded in areas such as
myocardial infarction21, heart failure,
stroke22, sudden cardiac death, and
AF4,5,23,24. Women with AF who are treated with
warfarin therapy may face a higher risk of stroke compared to
men3. However, studies indicate that there is no
significant gender difference in the primary outcomes when undergoing
left atrial appendage occlusion25. Gender differences
in recurrence rates following catheter ablation for AF have been
observed over an extended period. The meta-analysis including 19
observational studies found the rate of freedom from AF recurrence was
lower in women than men at the 2.4-year follow-up9.
Our research revealed that throughout an extended follow-up period
(50.36 ± 19.65 months), women exhibited a significantly higher rate of
recurrence following catheter ablation compared to men. This finding was
consistent in the population matched by PSM, and gender remained an
independent predictor of recurrence in multivariate regression analysis.
Some studies suggest that there is no significant difference in
recurrence after catheter ablation between genders. These studies have
noted that women are typically older and have smaller left atrial
dimensions11,26. Meanwhile, Ma and colleagues, through
a study utilizing a 1:1 propensity-matched cohort, reported no
significant difference in arrhythmia recurrence rates between genders,
with the duration of AF being the lone predictor for its
recurrence27.
Early intervention has been posited to slow the progression of
AF-induced alterations in the heart’s electrical and structural
integrity, vascular endothelium, and metabolic
functions28,29. As demonstrated by Masuda et al.,
women show a higher prevalence of left atrial low-voltage areas which
are associated with more frequent AF recurrences30.
Consequently, it is worth investigating whether similar gender
differences in prognosis exist for patients undergoing early catheter
ablation. In our present study, the gender differences in AF recurrence
post-catheter ablation were evident regardless of whether the
intervention was early or late. When analyzing the recurrence risk
factors following catheter ablation for AF in different genders,
distinct factors emerge for men and women; however, LAD emerged as a
common risk factor across genders. Research has also highlighted that in
women, other predominant risk factors include left atrial size and AF
type26,30. Thus, it is important to incorporate gender
differences into clinical evaluations, taking a comprehensive approach
to assess the AF burden and the degree of left atrial remodeling.
The sex-based difference of long-term outcomes including death, stroke,
acute coronary syndrome etc. were main concerns for clinicians. In the
CABANA trial, the primary composite outcome (death, disabling stroke,
serious bleeding, or cardiac arrest) was comparable between
genders31. Our research also suggests that gender
differences are not a statistically significant factor affecting MACCE.
In the EAST-AFNET 4 study, the primary outcome showed no significant
difference between the sexes31. Kang and colleagues
conducted a study by drawing on data from the National Health Insurance
Service database to identify patients who received treatment for AF
within one year of their diagnosis. Their research findings indicated
that a rhythm control strategy was associated with a reduced risk of
primary composite outcomes when compared to rate control in both male
and female patients. The study further suggests that initiating
treatment at an earlier stage—specifically within six months of
diagnosis—may offer enhanced effectiveness in female
patients32. The observation that there was no
significant difference in the incidence of MACCE between the genders may
appear counterintuitive given the established increase in stroke risk in
women with AF22. However, it is imperative to
understand that this lack of difference might be reflecting the
effectiveness of the therapeutic interventions (including catheter
ablation and oral anticoagulation) which could potentially neutralize
the inherent gender-related risk for MACCE seen in AF populations.
While the gender-based disparities in AF care are notable—ranging from
symptom burden to the effectiveness of treatment interventions—the
findings of this study highlight the necessity for gender-informed
management strategies for AF. This implies that healthcare providers
might consider adjusting their therapeutic approach considering the
greater likelihood of AF recurrence in women, despite similar rates of
MACCE compared to men.
Limitations of the current study include its observational nature,
potential for residual confounding despite PSM, and the fact that data
were sourced from a single center, which may influence the
generalizability of the findings. It is also crucial to acknowledge the
dynamic nature of AF management guidelines and treatment innovations
that continue to influence outcomes over time. Furthermore, the study
participants received inconsistent medication regimens following their
operations, exhibiting a reduced frequency of anticoagulant
administration and a limited use of agents aimed at preventing atrial
remodeling. These factors could introduce biases in the reported
outcomes.
In conclusion, our research offers valuable evidence that gender
differences do influence long-term outcomes post-catheter ablation for
AF—particularly regarding AF recurrence rates—with important
implications for the customization of treatment plans. As we move toward
a more personalized medicine approach, factoring in gender-based risk
nuances might enhance clinical decision-making and, ultimately, patient
outcomes.