Sex-related risks of recurrence of atrial fibrillation after ablation: Insights from the Guangzhou Atrial Fibrillation Ablation Registry

Risk factors for the recurrence of atrial fibrillation after catheter ablation: a meta-analysis

BACKGROUND

The rate at which atrial fibrillation (AF) patients experience a return of symptoms after catheter ablation is significant, and there are multiple risk factors involved. This research intends to perform a meta-analysis to explore the risk factors connected to the recurrence of AF in patients following catheter ablation.

METHODS

The PubMed, Cochrane Library, WOS, Embase, SinoMed, CNKI, Wanfang, and VIP databases were explored for studies from January 1, 2000 to August 10, 2021, and research meeting the established inclusion requirements was chosen. Two authors separately gathered details regarding the study structure. The strength of the link between various risk factors and AF returning after CA was evaluated using odds ratios. All statistical evaluations were conducted with RevMan5.3 software.

RESULTS

In total, 44 articles and 62,674 patients were included. The OR for AF recurrence in patients with diabetes was 2.04 compared with the reference group (95% CI 1.51-2.76, p < 0.00001); that of lower left ventricular ejection fraction was 1.38 (95% CI 1.25-1.52, p < 0.00001); that of female was 1.34 (95% CI 1.18-1.52, p < 0.00001); that of increased age was 1.03 (95% CI 1.02-1.04, p < 0.00001); that of persistent AF was 1.72 (95% CI 1.58-1.87, p < 0.00001); that of AF duration over 2 years was 1.17 (95% CI 1.08-1.26, p < 0.00001); that of increased left atrial diameter (LAD) was 1.12 (95% CI 1.08-1.17, p < 0.00001); that of larger left atrial volume index (LAVi) was 1.02 (95% CI 1.01-1.03, p < 0.00001); that of higher hs-CRP was 1.19 (95% CI 1.04-1.36, p = 0.04); that of early recurrence (ER) was 3.22 (95% CI 2.74-3.77, p < 0.00001); and that of long ablation duration was 1.00 (95% CI 0.98-1.02, p = 0.72). Heterogeneity and slight publication bias were observed for each factor.

CONCLUSIONS

Evidence indicates that diabetes, low left ventricular ejection fraction, being female, older age, longer duration of atrial fibrillation, elevated high-sensitivity C-reactive protein levels, large left atrial dimension, large left atrial volume index, persistent atrial fibrillation, and exercise rehabilitation are factors that increase the chances of getting atrial fibrillation again after catheter ablation. However, the length of the ablation procedure does not relate to the recurrence of AF.

Role of a new inflammation predictor in predicting recurrence of atrial fibrillation after radiofrequency catheter ablation

BACKGROUND

Radiofrequency catheter ablation (RFCA) has become an important strategy for treating atrial fibrillation (AF), and postoperative recurrence represents a significant and actively discussed clinical concern. The recurrence after RFCA is considered closely related to inflammation. Systemic immune inflammation index (SII) is a novel inflammation predictor based on neutrophils, platelets, and lymphocytes, and is considered a biomarker that comprehensively reflects the immune inflammatory status of the body.

AIM

To explore the predictive effect of the SII on AF recurrence after RFCA and its predictive value in combination with the existing APPLE score for AF recurrence after RFCA in patients with non-valvular AF (NVAF).

METHODS

We retrospectively included 457 patients with NVAF first receiving RFCA and classified them into the recurrent or non-recurrent group. We also investigated the predictive role of SII on AF recurrence following RFCA. Finally, we explored and compared the additional predictive value of the SII after combining with the APPLE score.

RESULTS

After 12 months of follow-up, 113 (24.7%) patients experienced recurrence. High SII has been demonstrated to be an independent predictor for postoperative AF recurrence. Receiver operating characteristic and decision curve analysis (DCA), as well as net reclassification improvement (NRI) and integrated discrimination improvement (IDI) results, showed that SII combined with the APPLE score had higher predictive efficiency than using the SII or APPLE score alone. The area under the curve of the combined model (0.662, 95% confidence interval: 0.602-0.722) significantly increased compared with that of the SII and APPLE scores alone (P < 0.001). The combined model resulted in an NRI of 29.6% and 34.1% and IDI of 4.9% and 3.5% in predicting AF recurrence compared with the SII and APPLE scores alone, respectively (all P < 0.001). The SII, APPLE score, and their combination demonstrated greater clinical utility than did the treat-all and treat-none strategies over the 20-80% risk threshold according to the DCA.

CONCLUSION

The SII was a predictor of recurrence after RFCA of AF. Moreover, the SII enhanced the predictability of the APPLE score for post-RFCA AF recurrence, providing valuable insights for physicians to optimise patient selection and develop personalised treatment plans.

L-shaped association of plasma low-density lipoprotein cholesterol with atrial fibrillation recurrence after catheter ablation: a prospective cohort study

The association between plasma low-density lipoprotein cholesterol (LDL-C) and atrial fibrillation (AF) recurrence after catheter ablation remains unclear. We aimed to assess the relationship between preprocedural LDL-C and the AF recurrence in patients undergoing catheter ablation. The cohort study consecutively included AF patients who underwent de novo catheter ablation between April 2021 and January 2023 in the Second Affiliated Hospital of Nanchang University in Jiangxi Province, China. Patients were divided into quartiles based on their baseline fasting LDL-C level (Q1-Q4). Multivariable Cox proportional hazards models were used to evaluate the relationship between LDL-C and AF recurrence. Our analysis included the use of a generalized additive model and smooth curve fitting (penalized spline method), and two-piecewise Cox proportional hazards models, to address the nonlinearity between preprocedural LDL-C and AF recurrence. A total of 482 AF patients with de novo catheter ablation were enrolled, with a median follow-up period of 15.00 months, AF recurrence occurred in 96 (19.92%) patients. The relationship between preprocedural LDL-C and AF recurrence after ablation presented as an L-shape, and the inflection point for the curve was found at the LDL-C level of 3.20 mmol/L (Log likelihood ratio P = 0.031). The hazard ratios (HR) [(95% confidence intervals (CI)] for AF recurrence were 0.50 (0.33-0.74) and 2.11 (0.76-5.89) to the left and right of the inflection point, respectively. Lower LDL-C level is associated with increased AF recurrence risk after catheter ablation were consistent across all subgroups.

Sex-based differences and risk of recurrence in patients with atrial fibrillation undergoing pulmonary vein isolation

INTRODUCTION

Studies suggest increased likelihood of atrial fibrillation (AF) recurrence after catheter ablation (CA) in women than in men, indicating that sex may be an independent risk factor for recurrence. Nevertheless, the influence of sex on AF recurrence and underlying mechanisms remains unclear.

METHODS

Retrospective, single-centre study including patients undergoing AF CA between 2017 and 2021. Late recurrence (LR) was defined as AF recurrence ≥90 days after ablation, whereas early recurrence (ER) occurred within 90 days.

RESULTS

656 patients (32% women) were included, with a median follow-up period of 26 months. Compared to men, women undergoing CA were older, had higher body mass indexes, and had higher rates of hypertension, thyroid dysfunction, and valvular disease. Women also had increased LR risk after CA (HR 1.76, 95% CI [1.19, 2.59]). A time-split multivariable analysis at one year of follow-up showed no difference in LR risk during the first 12 months after CA (HR 1.19, 95% CI [0.73, 1.94]); however, LR risk increased in women (HR 2.90, 95% CI [1.68, 5.01]) after 12 months. In a sex-stratified analysis, coronary calcium score (CCS) >100 was associated with increased LR risk in men (HR 1.81, 95% CI [1.06, 3.08]), but not in women. Cardiac adipose tissue volume was not associated with increased LR risk.

CONCLUSIONS

Fewer women underwent CA than men and LR was more frequent in women, particularly one year after the procedure. CCS was associated with increased LR risk in men.

Better performance of the APPLE score for the prediction of very early atrial fibrillation recurrence post-ablation

OBJECTIVE

The benefits of rhythm control in early atrial fibrillation (AF) are increasingly recognized. This study aimed to investigate whether early AF ablation contributes to long-term sinus rhythm maintenance and to identify a suitable predictive score.

METHODS

According to diagnosis-to-ablation time, this study prospectively enrolled 245 patients with very early AF, 262 with early AF, and 588 with late AF for radiofrequency ablation from June 2017 to December 2022. Clinical data, risk scores, and follow-up results were collected and analyzed.

RESULTS

Baseline characteristics were similar among the three cohorts. During a median follow-up period of 26 months, AF recurrence was observed in 61 (24.9%), 66 (25.2%), and 216 (36.7%) patients in the very early, early, and late AF cohorts, respectively. In the multivariable-adjusted model, very early and early AF were associated with a reduced risk of AF recurrence, with hazard ratios of 0.72 (95% confidence interval [CI] 0.52-0.99) and 0.57 (95% CI 0.41-0.78), respectively. The APPLE score demonstrated the highest predictive power for very early AF, with an area under the curve (AUC) of 0.74. However, its predictive power decreased with time from diagnosis, showing low predictive power for late AF (AUC = 0.58). In addition, the time-dependent concordance index showed consistent results. For very early AF, the Akaike information criterion and decision curve analysis showed that APPLE had the highest predictive value.

CONCLUSION

Very early AF ablation was associated with a lower recurrence rate, and the APPLE score provided a higher predictive value for these patients. (URL: https://www.chictr.org.cn/; Unique identifier: ChiCTR-OIN-17013021).

Including hemoglobin levels and female sex provide the additional predictive value of the APPLE score for atrial fibrillation recurrence post-catheter ablation

OBJECTIVE

We probed whether the addition of hemoglobin (HGB) or the female sex (SEX) as variables would provide additional prognostic value to the APPLE score.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Ablation to Reduce Atrial Fibrillation Burden and Improve Outcomes: JACC Review Topic of the Week

Atrial fibrillation is the most common atrial arrhythmia and accounts for a significant burden of cardiovascular disease globally. With advances in implanted and wearable cardiac monitoring technology, it is now possible to readily and accurately quantify an individual's time spent in atrial fibrillation. This review summarizes the relationship between atrial fibrillation burden and adverse cardiovascular and cerebrovascular outcomes and discusses the role of catheter ablation to mitigate the morbidity and mortality associated with greater burden of atrial fibrillation.

Sex differences involved in persistent atrial fibrillation recurrence after radiofrequency ablation

BACKGROUND

In recent years, the difference in outcomes of radiofrequency catheter ablation (RFCA) in persistent atrial fibrillation patients has risen. In particular, biological sex seems involved in a different response to the AF ablation procedure. In our study, we analyzed the AF recurrences after RFCA assessing the other association between male/female patients with the outcomes.

METHODS

We enrolled 106 patients (74.5% men) with persistent atrial fibrillation with scheduled follow-up. The baseline clinical characteristics and AF recurrence after RFCA were compared between men and women. Cox regression analyses were performed to determine the risk predictors of AF recurrence.

RESULTS

The proportion of RFCA in women was lower than that in men. Men with persistent AF were younger than women (58.6 ± 10.4 years vs. 65.1 ± 8.7 years, respectively; p = 0.003). The left atrium (LA) diameter was higher in males (43.7 ± 4.6 mm vs. 41.3 ± 5.5 mm; p = 0.028), and the level of left heart ejection fraction (LVEF) was higher in females (59.4 ± 6.9% vs. 64.1 ± 5.5%; p = 0.001). Sex differences in AF recurrence after RFCA were significant during the median 24.4-month (interquartile range: 15.2-30.6 months) follow-up period, and the recurrence rate of AF in women was significantly higher than that in men (p = 0.005). Univariable Cox regression analysis showed that female sex was a risk factor for persistent AF recurrence after RFCA [HR: 2.099 (1.087-4.053)]. Univariate Cox regression analysis revealed that non-PV ablation not associated with AF recurrence [HR: 1.003 (0.516-1.947)].

CONCLUSION

In a monocentric cohort of persistent AF patients, the female biological sex was associated with a higher risk of AF recurrence after RFCA.

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.

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.

Factors Influencing Sex-Related Differences in the Quality of Life of Patients With Atrial Fibrillation: A Systematic Review

Atrial fibrillation (AF) is a growing public health concern, the impact of which is frequently underestimated. It has a profound effect on the quality of life (QoL) which appears to be disproportionately lower in female patients compared to men. We aim to explore the factors contributing to sex-related disparities in the QoL of AF patients by conducting a systematic review using the PubMed electronic search database. We used the following combination of medical subject heading (MeSH) parameters: "atrial fibrillation" and "sex" and "quality of life" with specific inclusion and exclusion criteria. We identified 13 relevant studies published between 2010 and 2020 for our review. These studies evaluated sex-related differences in QoL scores, symptom burden, and AF-related complications originating across different continents in Asia, Europe, and North America. We found that female patients reported a reduced QoL as compared to men and they were more likely to be older with multiple co-morbidities at presentation. Women also reported more frequent and severe symptoms, potentially explained by the greater prevalence of anxiety and depression and thus enhancing symptom perception. Moreover, they were less likely to be managed by anti-arrhythmic medications and invasive rhythm control strategies such as catheter ablation. Female patients with AF experienced more severe strokes, but no sex disparities were found in AF-related cognitive decline. We determined that the more prominent contributory factors towards a lowered QoL in female AF patients appear to be secondary to a higher burden and perception of symptoms as well as under-utilization of invasive treatment modalities. However, further studies are warranted to confirm these findings.