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. 2023 Apr 2;12(7):2650.
doi: 10.3390/jcm12072650.

Women Have More Recurrences of Atrial Fibrillation than Men after Thoracoscopic Ablation and Suffer More from Established Risk Factors

Robin Wesselink  1   2 , Bente Mossink  1   2 , Eva R Meulendijks  1   2 , Nicoline W E van den Berg  1   2 , Jolien Neefs  1   2 , Makiri Kawasaki  1   2 , Benedetta Fabrizi  1   2 , Femke R Piersma  1   2 , Rushd F M Al-Shama  1   2 , Tim A C de Vries  1   2   3 , Jonas S S G de Jong  4 , Wim Jan P van Boven  1   2 , Antoine H G Driessen  1   2 , Joris R de Groot  1   2
Affiliations

Women Have More Recurrences of Atrial Fibrillation than Men after Thoracoscopic Ablation and Suffer More from Established Risk Factors

Robin Wesselink et al. J Clin Med. .

Abstract

Introduction: Atrial fibrillation (AF) is more prevalent in men than in women. However, women with AF are more symptomatic, have a worse quality of life, a higher stroke risk and may therefore benefit most from ablation. In this study we aim to identify the risk of recurrent AF after thoracoscopic ablation, and assess the differential impact of the risk factors for recurrence between women and men.

Method: This is a single center cohort study, including patients undergoing thoracoscopic ablation for advanced AF between 2008 and 2019. All patients were clinically followed up for two years with quarterly 24 h Holter monitoring and ECGs for the detection of recurrent AF. Left atrial appendage (LAA) tissue was collected for collagen analysis.

Results: We included 571 patients, of whom 143 (25%) were women. Women were older than men (63 ± 8.3 y vs. 59 ± 8.5, p < 0.001), but had fewer cardiovascular risk factors, myocardial infarctions (1.4% vs. 6.5%, p = 0.03) and, in particular, vascular disease (7.0% vs. 16.1%, p = 0.01). Women suffered more from AF recurrence, driven by more atrial tachycardias, and sex was an independent risk factor for recurrence (HR1.41 [1.04-1.91], p = 0.028]). The presence of vascular disease was associated with an increased risk for AF recurrence in women, but not in men. In LAA histology, women had more collagen than men, as had patients with persistent compared to paroxysmal AF.

Conclusion: Women had 15% more recurrences, driven by more atrial tachycardias, which may be explained by a more fibrotic atrial substrate. What's new? Women undergoing thoracoscopic AF ablation have a higher risk of recurrent AF, driven by more atrial tachycardias. Among patients with left atrial enlargement or persistent AF, women have worse outcomes than men. Vascular disease was a risk factor for recurrence in women, but not in men. In a histopathologic analysis of the left atrial appendage, women had more collagen than men, as had patients with persistent compared to paroxysmal AF.

Keywords: atrial fibrillation; risk factors; sex differences; thoracoscopic AF ablation.

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Conflict of interest statement

A.H.G.: Consultant for Atricure, last 5 years no revenue, J.R. de Groot is supported by research grants through his institution from Abbot, Atricure, Bayer, Boston Scientific, Daiichi Sankyo, Johnson & Johnson and Medtronic, and received speaker fees/consulting fees from Atrian Medical, Atricure, Bayer, Biotronik, Daiichi Sankyo, IPPMed, Medtronic, Novartis and Servier. The other authors report no disclosures.

Figures

Figure 1
Figure 1
Kaplan–Meier analysis of women and men during two years follow-up. Men: solid blue line, women: dashed red line. AF = atrial fibrillation.
Figure 2
Figure 2
Univariate and multivariable Cox regression of patient characteristics and freedom of AF recurrence, for all included patients. AF atrial fibrillation, BMI body mass index, CI confidence interval, cm centimeter, CRP c-reactive protein, HR hazard ratio, kg kilogram, LAVI left atrial volume index, LVEF left ventricular ejection fraction, m meter, mL milliliter, MV mitral valve, ng nanogram, NT-proBNP n-terminal pro-brain natriuretic peptide, pg pictogram, y years, µg microgram.
Figure 3
Figure 3
Univariate Cox regression of patient characteristics and freedom from AF recurrence for women (first, red) and men (second, blue) separately. AF atrial fibrillation, BMI body mass index, CI confidence interval, cm centimeter, CRP c-reactive protein, HR hazard ratio, kg kilogram, LAVI left atrial volume index, LVEF left ventricular ejection fraction, m meter, ml milliliter, MV mitral valve, ng nanogram, NT-proBNP n-terminal pro-brain natriuretic peptide, pg pictogram, y years, µg microgram.
Figure 4
Figure 4
Different impact of the risk factors between women and men. (A) Patients with paroxysmal AF (left) and persistent AF (right); (B) young (first quartile, <55 y) and old patients (fourth quartile, >67 y); (C) normal LA size (LAVI < 34 mL/m2) and enlarged LA (LAVI > 33 mL/m2).
Figure 5
Figure 5
Percentage of collagen in Picrosirius red-stained histologic sections. (A) Total percentage of collagen in the histologic sections. (B) Percentage of epicardial and endocardial collagen, (C) Percentage of interstitial collagen.
Figure 6
Figure 6
Typical example of histologic collagen analysis of the left atrial appendage tissue. Red = collagen, yellow = myocardial cells. (A) Relatively thick epicardial layer of a woman, (B) relatively thin epicardial layer of a man.
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