Influence of Sex-Based Differences in Cardiac Phenotype on Atrial Fibrillation Recurrence in Patients Undergoing Pulmonary Vein Isolation

Alena Yakimenka; Dina Labib; Steven Dykstra; Yoko Mikami; Alessandro Satriano; Jacqueline Flewitt; Patricia Feuchter; Sandra Rivest; Andrew G Howarth; Carmen P Lydell; F Russell Quinn; Stephen B Wilton; James A White

doi:10.3389/fcvm.2022.894592

Influence of Sex-Based Differences in Cardiac Phenotype on Atrial Fibrillation Recurrence in Patients Undergoing Pulmonary Vein Isolation

Front Cardiovasc Med. 2022 Jul 28:9:894592. doi: 10.3389/fcvm.2022.894592. eCollection 2022.

Authors

Alena Yakimenka^{1

2}, Dina Labib^{1

3}, Steven Dykstra¹, Yoko Mikami¹, Alessandro Satriano¹, Jacqueline Flewitt¹, Patricia Feuchter¹, Sandra Rivest¹, Andrew G Howarth^{1

4}, Carmen P Lydell^{1

5}, F Russell Quinn⁴, Stephen B Wilton⁴, James A White^{1

4}

Affiliations

¹ Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.
² Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
³ Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt.
⁴ Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
⁵ Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Abstract

Background: Pulmonary vein isolation (PVI) is a commonly engaged therapy for symptomatic atrial fibrillation (AF). Prior studies have documented elevated AF recurrence rates among females vs. males. Sex-specific mechanisms underlying this phenomenon are poorly understood. This prospective cohort study aimed to evaluate the sex-based differences in cardiac phenotype and their influence on (AF) recurrence following first-time PVI.

Methods: A total of 204 consecutive patients referred for first-time PVI and 101 healthy subjects were prospectively studied by cardiovascular magnetic resonance (CMR) imaging. Multi-chamber volumetric and functional measures were assessed by sex-corrected Z-score analyses vs. healthy subjects. Patients were followed for a median of 2.6 years for the primary outcome of clinical AF recurrence. Multivariable analyses adjusting for age and comorbidities were performed to identify independent predictors of AF recurrence.

Results: AF recurrence following first PVI occurred in 41% of males and 59% of females (p = 0.03). Females were older with higher prevalence of hypertension and thyroid disorders. Z-score-based analyses revealed significantly reduced ventricular volumes, greater left atrial (LA) volumes, and reduced LA contractility in females vs. males. Multivariable analysis revealed each of LA minimum and pre-systolic volumes and booster EF Z-scores to be independently associated with AF recurrence, providing respective hazard ratios of 1.10, 1.19, and 0.89 (p = 0.001, 0.03, and 0.01).

Conclusion: Among patients referred for first time PVI, females were older and demonstrated significantly poorer LA contractile health vs. males, the latter independently associated with AF recurrence. Assessment of LA contractile health may therefore be of value to identify female patients at elevated risk of AF recurrence. Factors influencing female patient referral for PVI at more advanced stages of atrial disease warrant focused investigation.

Keywords: atrial fibrillation; cardiovascular magnetic resonance imaging; gender differences; left atrial booster pump function; left atrial function; left atrial volume; pulmonary vein isolation; women cardiovascular health.