Aims: Sex-specific differences in atrial fibrillation (AF) ablation have been described. Female sex is associated with a higher risk for procedural complications and arrhythmia recurrence. It is unclear whether these sex-specific differences persist in elderly cohorts or if they are offset by other concomitant age-related risk factors. Very long-term outcome data (>1 year) in this context are limited. This study aimed to assess sex-specific outcomes of >10 years follow-up after AF-ablation in patients aged ≥70 years, including arrhythmia recurrence, functional status, and cardiovascular events.
Methods: A total of 995 patients ≥70 years (45.7% women) from the German Ablation Registry who underwent catheter ablation (2007-2010) were included. Follow-up was performed after one year and an additional multiyear follow-up (mean duration 10.7 ± 4.3 years), using standardized questionnaires or structured telephone interviews.
Results: Mean age was higher in women (f: 74.1, m: 73.4, p=0.005). Men exhibited a greater burden of cardiovascular comorbidities (f: 48.4%, m: 58.9%, p=0.001). Radiofrequency ablation was the predominant ablation method (f: 84.6%, m: 86.1%, p=0.51), followed by cryoballoon ablation (f: 14.9%, m: 13.5%, p=0.52). Acute procedural success was achieved in 96.1% of patients (f: 95.4%, m: 96.7%, p=0.30). The procedure duration was comparable between sexes (f: 160 min, m: 160 min, p=0.71).
There were no significant differences in major complications (stroke, myocardial infarction, major bleeding) (f: 3.1%, m: 1.3%, p=0.074). Moderate complications occurred in 5.5% of women and 3.4% of men (p=0.14), mainly due to pericardial effusion and arteriovenous fistula. Minor complications, including bleeding not requiring intervention, AV or bundle branch block, were numerically more frequent in women (f: 3.1%, m: 1.3%, p=0.29). Non-fatal complications occurred more frequently in women (f: 2.4%, m: 0.7%, p=0.002), driven by minor complications.
At 1-year follow-up, symptom recurrence was more frequent in females than in males (f: 86.0%, m: 79.7%, p=0.014). Women demonstrated higher arrhythmia recurrence rates (f: 48.3%, m: 41.0%, p=0.025) and greater functional impairment (NYHA class II or higher: f: 58.6%, m: 40.6%, p=0.001) at 1-year-follow-up. During extended long-term follow-up after a mean of 10.7 years, arrhythmia recurrence was higher in women (f: 76.0%, m: 69.8%, p=0.20). In addition, recurrent arrhythmias in men were more commonly managed in the outpatient setting, whereas women more often required inpatient treatment (f: 62.3%, m: 35.4%, p=0.003) Women were more likely to present with advanced functional limitation (NYHA class III/IV: f: 46.1%, m: 25.6%, p=0.001) and had numerically higher rates of stroke or transient ischemic attack (f: 15.1%, m: 11.0%, p=0.25).
Conclusion: Catheter ablation is safe in elderly patients. The long-term follow-up shows high recurrence rates and relevant sex-specific differences, with less favourable rhythm and symptom outcomes in women. These findings highlight the importance of considering age- and sex-specific factors to improve AF ablation outcomes and equity in care.
