Real-World Data of Sex Differences in Atrial Fibrillation Catheter Ablation: Insights from a Prospective Multicenter Registry

<h2>Abstract</h2><h3>Background</h3> Sex differences in atrial fibrillation (AF) ablation strategies and outcomes remain insufficiently characterized. <h3>Objective</h3> To evaluate the impact of sex on ablation strategies and clinical outcomes in patients with paroxysmal (PAF) and persistent AF (PsAF) in real-world settings. <h3>Methods</h3> Data from the REAL-AF Registry were analyzed (January 2018-May 2023). Demographics, intraoperative parameters, and outcomes were compared by sex, stratified by AF type. <h3>Results</h3> A total of 4,202 patients (41.1% women) were included. Women were older (69.02 ± 9.18 vs. 65.32 ± 10.49 years), had higher CHA2DS2-VASc scores (3.36±1.43 vs. 2.33±1.45), and were more frequently diagnosed with PAF (72.8% vs. 61.3%) (p<.001 for all). Across both AF types, women underwent more complex ablation procedures, including additional substrate modification (SM) (pulmonary vein isolation [PVI] + cavotricuspid isthmus [CTI] + SM: 25.8% vs. 22.7%, p=0.020), particularly posterior wall isolation (53.9% vs. 45.7% in PsAF; 18.2% vs. 12.3% in PAF). Generalized linear mixed models revealed similar acute success (first-pass PVI) between sexes; however, women required more repeat ablations after the blanking period (7.2% vs. 5.5%, p=0.022). Multivariable COX analysis showed women had a significantly higher long-term recurrence risk (adjusted HR 1.24, 95% CI: 1.06–1.45, p=0.009). Subgroup analysis identified female sex as an independent predictor of recurrence in ablation strategies incorporating SM, while PVI-only and PVI+CTI approaches yielded comparable outcomes. Complication rates were comparable, but women with PsAF had a higher incidence of vascular access complications (1.3% vs. 0.1%, p=0.010). <h3>Conclusions</h3> Women face higher long-term arrhythmia recurrence risks, especially in ablation strategies involving SM, despite comparable acute and short-term outcomes.