Sex‐based differences in procedural complications associated with atrial fibrillation catheter ablation: A systematic review and meta‐analysis

Abstract

Background: Women undergoing atrial fibrillation catheter ablation (AFCA) have higher rates of vascular complications and major bleeding. However, most studies have been underpowered to detect differences in rarer complications such as stroke/transient ischemic attack (TIA) and procedural mortality. Methods: We performed a systematic review of databases (PubMed, World of Science, and Embase) to identify studies published since 2010 reporting AFCA complications by sex. Six complications of interest were (1) vascular/groin complications; (2) pericardial effusion/tamponade; (3) stroke/TIA; (4) permanent phrenic nerve injury; (5) major bleeding; and (6) procedural mortality. For meta-analysis, random effects models were used when heterogeneity between studies was ≥50% (vascular complications and major bleeding) and fixed effects models for other endpoints. Results: Of 5716 citations, 19 studies met inclusion criteria, comprising 244,353 patients undergoing AFCA, of whom 33% were women. Women were older (65.3 ± 11.2 vs. 60.4 ± 13.2 years), more likely hypertensive (60.6% vs. 55.5%) and diabetic (18.3% vs. 16.5%), and had higher CHA 2 DS 2-VASc scores (3.0 ± 1.8 vs. 1.4 ± 1.4) (p < .0001 for all comparisons). The rates of all six complications were significantly higher in women. However, despite statistically significant differences, the overall incidences of major complications were very low in both sexes: stroke/ TIA (women 0.51% vs. men 0.39%) and procedural mortality (women 0.25% vs. men 0.19%). Conclusion: Women experience significantly higher rates of AFCA complications. However, the incidence of major procedural complications is very low in both sexes. The higher rate of complications in women may be partially attributable to older age and a higher prevalence of comorbidities at the time of ablation. More detailed studies are needed to better define the mechanisms of increased risk in women and to identify strategies for closing the sex gap.

Sex differences in atrial fibrillation ablation in‐hospital outcomes from the National Inpatient Sample database 2016–2019

“…The total unadjusted complication rate was higher for females than males (9.58% vs. 7.09%, p = .001); however, it was not significant when adjusted for risks (adjusted OR: 1.23, 95% CI: 0.99–1.53, p = .06). This was despite a lower overall comorbidity burden in females as determined by the Elixhauser comorbidity index, contrary to previous studies 7–9,11 . Other authors had identified that females had higher complications than males attributed to higher comorbidities and later stage presentation 11,15 .…”

“…Most importantly, studies were discrepant in the incidence of in‐hospital death, which was significantly higher in women than in men in some studies, 7,8 while other studies have shown no significant differences 9,10,12–14,19,21 . Complication rates that were higher in females compared to males included pericardial effusion, 7–10 cardiac tamponade, 11,16 major bleeding, 11,13,21 and cerebrovascular events, 7,8 while others have reported no difference in pericardial effusion, 12,14,15,19–21 cardiac tamponade, 12,13,15,19 major bleeding, 17 and cerebrovascular events 10,12,13,15,19 . It is unclear whether these complication rates contribute to overall in‐hospital death rates, length of stay, and costs.…”

“…Trials that address the safety and efficacy of catheter ablation in females compared to males have mixed results 6–21 . In most studies, females undergoing catheter ablation were older, with more comorbidities than males and higher CHADS 2 7,11 and CHA 2 DS 2− VASc scores, 6,7,11–13,17–19 possibly contributing to worsened outcomes 7–9,11 .…”

“…In most studies, females undergoing catheter ablation were older, with more comorbidities than males and higher CHADS 2 7,11 and CHA 2 DS 2− VASc scores, 6,7,11–13,17–19 possibly contributing to worsened outcomes 7–9,11 . Most importantly, studies were discrepant in the incidence of in‐hospital death, which was significantly higher in women than in men in some studies, 7,8 while other studies have shown no significant differences 9,10,12–14,19,21 . Complication rates that were higher in females compared to males included pericardial effusion, 7–10 cardiac tamponade, 11,16 major bleeding, 11,13,21 and cerebrovascular events, 7,8 while others have reported no difference in pericardial effusion, 12,14,15,19–21 cardiac tamponade, 12,13,15,19 major bleeding, 17 and cerebrovascular events 10,12,13,15,19 .…”

Sex, age, type of diabetes and incidence of atrial fibrillation in patients with diabetes mellitus: a nationwide analysis

“…Our observations suggest that specific studies investigating more aggressive preventive measures in diabetic women are warranted. Of note, a higher rate of complications has been reported in women with catheter ablation of AF, which may be partially attributable to older age and a higher prevalence of comorbidities (including diabetes) at the time of ablation [38].…”