Sex-based disparities in postoperative outcomes after catheter ablation for atrial fibrillation: a systematic review and meta-analysis of propensity-matched studies

Abstract

Abstract Background and aim Sex-related differences in outcomes after catheter ablation for atrial fibrillation (AF) remain incompletely understood, particularly regarding long-term arrhythmia recurrence and procedural safety. Current guidelines do not provide sex-specific recommendations. This systematic review and meta-analysis aimed to evaluate sex-based differences in efficacy, safety, and long-term outcomes following AF catheter ablation. Methods We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines and the Cochrane Handbook, with prospective registration in PROSPERO (CRD420251168422). PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to December 2025. Only studies adjusting for baseline differences using propensity score–based methods were included. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a restricted maximum likelihood random-effects model. Risk of bias was assessed using ROBINS-I, and certainty of evidence was evaluated using GRADE. Results A total of 21 studies involving 103,619 patients undergoing AF ablation were included, of whom approximately 32% were female. There were no significant sex-based differences in AF recurrence at 1 year (RR 1.22, 95% CI [0.78, 1.91], I 2 = 51.5%, τ²=0.0814, p = 0.3807), AF / atrial tachycardia (AT) recurrence at 1 year (RR 1.13, 95% CI [0.91, 1.39], I 2 = 0%, τ²=0, p = 0.2659), AT / atrial flutter (AFL) / AT recurrence at 1 year (RR 1.03, 95% CI [0.68, 1.58], I 2 = 79%, τ²=0.1067, p = 0.8744), early all-cause mortality (RR 1.07, 95% CI [0.50, 2.29], I 2 = 0%, τ²=0, p = 0.8575), 1-year all-cause mortality (RR 0.49, 95% CI [0.14, 1.67], I 2 = 56.4%, τ²=0.6668, p = 0.2523), follow-up stroke/TIA (RR 1.12, 95% CI [0.72, 1.76], I 2 = 0%, τ²=0, p = 0.6107), follow-up repeat ablation (RR 1.03, 95% CI [0.86, 1.22], I 2 = 0%, τ²=0, p = 0.7755). However, women had a higher risk of AF / AT recurrence at 2 years (RR 1.22, 95% CI [1.04, 1.42], I 2 = 0.0%, τ²<0.0001, p = 0.0120), early complication rate (RR 1.37, 95% CI [1.10, 1.70], I 2 = 59.6%, τ²=0.0368, p = 0.0051), early cardiac tamponade (RR 2.46, 95% CI [1.49, 4.07], I 2 = 0.0%, τ²=0, p = 0.0004), and follow-up cardiac failure (RR 2.80, 95% CI [1.45, 5.38], I 2 = 0%, τ²=0, p = 0.0020). Conclusion Catheter ablation yields similar short-term rhythm control and mortality in women and men with AF. However, women have higher early procedural complications and worse long-term outcomes, including increased 2-year AF/AT recurrence and heart failure, highlighting the need for tailored strategies and closer follow-up in female patients.