Abstract
<title>Abstract</title> <p>Introduction Women referred for atrial fibrillation (AF) ablation often present with distinct baseline characteristics compared with men and appear to face higher rates of procedure-related complications. High-power short-duration radiofrequency ablation and ablation index–guided pulmonary vein isolation (PVI) using the CLOSE protocol have improved procedural efficiency and lesion durability, yet women have been underrepresented in pivotal studies and have not been evaluated in dedicated all-female cohorts. Therefore, we assessed the safety and effectiveness of CLOSE-guided, ablation index–guided high-power short-duration ablation in women undergoing first-time PVI for AF. Methods We included consecutive women undergoing first-time PVI between January 2019 and December 2024. Patients were enrolled prospectively (24.2%) or identified retrospectively (75.8%). All procedures were performed using 50-W high-power short-duration radiofrequency ablation and the CLOSE protocol (inter-lesion distance ≤ 6 mm; ablation index targets 400 on the posterior and 550 on the anterior wall). Results A total of 363 women (mean age 71.6 ± 9.4 years) underwent first-time PVI; 180 (49.6%) had paroxysmal AF. Median CHADS-VA-score was 2.0 (IQR 2.0–3.0) and median LVEF was 58% (IQR 51–60). Low-voltage areas (LVAs) were present in 120/325 patients (36.9%), most commonly involving the septum (110/325, 33.8%). Major complications occurred in 7 patients (1.7%) and minor complications in 36 (9.9%); there were no procedure-related deaths or strokes. During a median follow-up of 14 months (IQR 8–34), arrhythmia recurrence occurred in 144 patients (39.7%), with a median time to recurrence of 10 months. On univariable analysis, recurrence was associated with age (p = 0.036), persistent AF (p < 0.001), moderate or severe mitral regurgitation (p = 0.032), left atrial volume (p = 0.045), and presence of LVA (p < 0.001). In multivariable analysis, persistent AF remained independently associated with recurrence. In subgroup analyses, LVA predicted recurrence in paroxysmal AF (HR 3.30, 95% CI 1.86–5.95; p < 0.001) but not in persistent AF (HR 1.53, 95% CI 0.98–2.39; p = 0.062). Conclusion Contemporary HPSD, CLOSE-guided PVI appears safe in women, with low complication rates. Although arrhythmia recurrence was frequent, outcomes were comparable to those reported in prior studies. Risk stratification in women may require attention to sex-specific predictors, with low-voltage areas emerging as an important marker of recurrence risk, particularly in paroxysmal AF.</p>