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Original research
Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation
  1. Hui-Nam Pak,
  2. Je-Wook Park,
  3. Song-Yi Yang,
  4. Min Kim,
  5. Hee Tae Yu,
  6. Tae-Hoon Kim,
  7. Jae-Sun Uhm,
  8. Boyoung Joung,
  9. Moon-Hyoung Lee
  1. Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea (the Republic of)
  1. Correspondence to Professor Hui-Nam Pak, Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul 03722, Korea (the Republic of); hnpak{at}


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.

  • atrial fibrillation
  • catheter ablation

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  • Contributors H-NP designed the study, analysed and interpreted the data, drafted the manuscript, and did the final approval of the manuscript submitted. J-WP analysed and interpreted the data. S-YY analysed the data and prepared the tables and figures. MK, HTY, T-HK and J-SU contributed to acquiring patients’ clinical data. BJ and M-H revised the manuscript critically for important intellectual content.

  • Funding This work was supported by a grant (HI19C0114) from the Korea Health 21 R&D Project, Ministry of Health and Welfare, and by a grant (NRF-2020R1A2B01001695) from the Basic Science Research Program run by the National Research Foundation of Korea (NRF).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This study protocol adhered to the principles of the Declaration of Helsinki and was approved by the Institutional Review Board at the Yonsei University Health System.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. Data, analytic methods and study materials are available upon reasonable request to other researchers who want to reproduce the results or replicate the procedure.

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