Sex differences in procedural characteristics, safety, and clinical outcomes of pulsed field ablation for atrial fibrillation

Background Previous studies on pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) using conventional thermal techniques have shown inconsistent sex-related outcomes. Pulsed-field ablation (PFA) is a novel energy source offering myocardial-selective ablation. However, sex-specific data on its performance are limited. Objective To compare procedural characteristics, safety, and clinical outcomes of PFA in female and male patients undergoing AF ablation. Methods This prospective study included consecutive patients with paroxysmal or persistent AF undergoing PFA-based PVI using a pentaspline catheter. Follow-up was conducted at 3, 6, and 12 months. A 1:1 propensity score-matched cohort was created to evaluate sex-specific outcomes. Results Among 425 patients, 134 (32%) were female. Compared to males, females were older (median 70 vs. 65 years; p <.001), had more frequently paroxysmal AF (60% vs. 45%; p =.006), and lower rates of coronary artery disease (CAD, 6% vs. 14%; p =.029). While overall procedural times were similar, female patients with paroxysmal AF had significantly longer procedure, left atrial dwell, and fluoroscopy times than males. Complication rates were comparable (1.5% in females vs. 0.7% in males; p =.371). After propensity score matching (133 females to 133 males), arrhythmia recurrence at 1-year follow-up was higher in females (23% vs. 12%; p =.017; HR 2.2, SE 0.34). Conclusion Significant sex-related differences exist in clinical outcomes after PVI with PFA in AF. Further studies exploring underlying mechanisms and tailored approaches may enhance outcomes in female patients.