Sex Disparities in Hemodynamics and Outcomes in Patients Who Underwent Contemporary Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.amjcard.2022.03.028Get rights and content

Studies have reported worse outcomes after transcatheter aortic valve implantation (TAVI) in women receiving early generation transcatheter heart valves (THVs). They have smaller aortic annuli, which could result in higher gradients and more patient-prosthesis mismatch (PPM) after TAVI. We investigated the interactions between contemporary THV hemodynamics and outcomes in women who underwent TAVI. We conducted a retrospective, observational study of patients who underwent contemporary TAVI from 2015 to 2020. We compared baseline characteristics, in-hospital outcomes, and hemodynamics according to sex. We then dichotomized women according to aortic annular area (<430 or ≥430 mm2). Included were 869 patients who underwent TAVI with the SAPIEN 3 or CoreValve Evolut PRO/PRO+. Most patients with small annuli were female (82.5%). They had nonsignificantly higher mortality (30-day: 1.5% vs 0.6%, p = 0.313; 1-year: 4.1% vs 2.7%, p = 0.265). Those who received self-expanding THVs had lower gradients (8.0 mm Hg vs 13.8 mm Hg, p <0.001), resulting in less moderate PPM (21.2% vs 73.6%, p <0.001), similar severe PPM (19.5% vs 15.3%, p = 0.454), and higher rates of pacemaker implantation (14.4% vs 4.2%, p = 0.009). Women with small annuli who received a balloon-expandable THV had nonsignificantly higher mortality (30-day: 2.1% vs 0.8%, p = 0.631; 1-year: 6.3% vs 1.7%, p = 0.118). In conclusion, women who underwent contemporary TAVI had nonsignificantly higher mortality, which could be due to higher PPM rates. These findings were more pronounced in the subset of women with small annuli, in whom those who received self-expanding THVs demonstrated superior hemodynamics at the cost of increased rates of pacemaker implantation.

Section snippets

Methods

We conducted a retrospective, observational study of patients with symptomatic severe aortic stenosis (AS) who underwent TAVI using contemporary THVs at our institution from 2015 to 2020 and across all surgical risk categories. Contemporary THVs included the third-generation SAPIEN 3 (Edwards Lifesciences, Irvine, California) balloon-expandable valve (BEV) and the third-generation CoreValve Evolut PRO/PRO+ (Medtronic, Minneapolis, Minnesota) self-expanding valve (SEV). All included patients

Results

A total of 869 patients who underwent TAVI using a contemporary THV were included, of whom 389 were female (44.8%) and 480 were male (55.2%) (Figure 1). Women had a higher Society of Thoracic Surgeons Predicted Risk of Mortality (5.7% vs 4.2%, p <0.001). Women had smaller body surface area and smaller native aortic annuli (404.8 vs 525.6 mm2, p <0.001). The overwhelming majority of patients with an aortic annular area <430 mm2 were female (82.5%), and most patients with an aortic annular area

Discussion

To the best of our knowledge, this is the first study investigating potential mechanisms for sex disparities in TAVI by evaluating the interactions between sex and contemporary THV hemodynamics. The key findings of our study are as follows: (1) the overwhelming majority of patients with small aortic annuli who underwent TAVI are female; (2) women saw significantly higher rates of moderate PPM and slightly higher rates of severe PPM, although underpowered; (3) short-term mortality (30 days and 1

Disclosures

Dr. Rogers is a proctor and consultant at Medtronic and Edwards Lifesciences; is a member of the advisory board of Medtronic; and has equity interest in Transmural Systems.

Dr. Waksman is a member of the advisory boards of Abbott Vascular, Boston Scientific, Medtronic, Philips IGT, and Pi-Cardia Ltd.; is a consultant to Abbott Vascular, Biotronik, Boston Scientific, Cordis, Medtronic, Philips IGT, Pi-Cardia Ltd., Swiss Interventional Systems/SIS Medical AG, Transmural Systems Inc., and Venous

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