101
|
Stolcova M, Ristalli F, Sorini Dini C, Valente S. The perks of being a female in the TAVI era. Int J Cardiol 2018; 250:104-105. [PMID: 29169747 DOI: 10.1016/j.ijcard.2017.09.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/11/2017] [Accepted: 09/25/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Miroslava Stolcova
- Structural Heart Interventions Unit, Cardio-Thoraco-Vascular Department, Careggi Hospital, Florence, Italy.
| | - Francesca Ristalli
- Structural Heart Interventions Unit, Cardio-Thoraco-Vascular Department, Careggi Hospital, Florence, Italy
| | - Carlotta Sorini Dini
- Structural Heart Interventions Unit, Cardio-Thoraco-Vascular Department, Careggi Hospital, Florence, Italy
| | - Serafina Valente
- Structural Heart Interventions Unit, Cardio-Thoraco-Vascular Department, Careggi Hospital, Florence, Italy
| |
Collapse
|
102
|
What Does Sex Have to Do With Transcatheter Aortic Valve Replacement? JACC Cardiovasc Interv 2018; 11:21-23. [DOI: 10.1016/j.jcin.2017.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 11/20/2022]
|
103
|
Ando T, Akintoye E, Telila T, Briasoulis A, Takagi H, Schreiber T, Afonso L, Grines CL. Hospital outcomes of transcatheter versus surgical aortic valve replacement in female in the United States. Catheter Cardiovasc Interv 2017; 91:813-819. [DOI: 10.1002/ccd.27362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/02/2017] [Accepted: 09/09/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Tomo Ando
- Wayne State University, Harper hospital/Detroit Medical Center, Division of Cardiology; Detroit Michigan
| | - Emmanuel Akintoye
- Wayne State University, Harper hospital/Detroit Medical Center, Division of Cardiology; Detroit Michigan
| | - Tesfaye Telila
- Wayne State University, Harper hospital/Detroit Medical Center, Division of Cardiology; Detroit Michigan
| | | | - Hisato Takagi
- Shizuoka Medical Center, Division of Cardiovascular Surgery; Shizuoka Japan
| | - Theodore Schreiber
- Wayne State University, Harper hospital/Detroit Medical Center, Division of Cardiology; Detroit Michigan
| | - Luis Afonso
- Wayne State University, Harper hospital; Michigan
| | - Cindy L. Grines
- North Shore University Hospital, Northwell Health System, Department of Internal Medicine, Division of Cardiology, Manhasset; New York, United States
| |
Collapse
|
104
|
|
105
|
Sex-related differences in clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic stenosis. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:233-239. [PMID: 29056996 PMCID: PMC5644042 DOI: 10.5114/aic.2017.70195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction There are inconsistent data on the sex-related differences in clinical outcomes and quality of life (QoL) after transcatheter aortic valve implantation (TAVI). Aim We sought to investigate sex-related differences in procedural, clinical and QoL outcomes of TAVI. Material and methods A total of 101 consecutive patients undergoing TAVI were enrolled. Patients were stratified by gender. Baseline characteristics, procedural and long-term clinical outcomes as well as frailty and QoL indices (EQ-5D-3L questionnaire) were compared between women and men. Results Women represented 60.4% of the study population. Periprocedural risk measured with the Logistic EuroSCORE and STS scale was similar for women and men. There were no differences in 30-day or 12-month all-cause mortality between groups (women vs. men: 9.8% vs. 12.5%; age-adjusted odds ratio (OR) (95% CI): 1.38 (0.39–4.94); 13.1% vs. 25.0%; age-adjusted OR (95% CI): 2.51 (0.87–7.25)). Men were at higher risk of new onset atrial fibrillation at follow-up (1.6% vs. 17.5%; age-adjusted OR (95% CI): 14.61 (1.68–127.37)). In multivariable Cox regression analysis, a history of stroke/transient ischemic attack (TIA) (hazard ratio (HR)) (95% CI): 3.93 (1.39–11.07) and blood transfusion (HR (95% CI): 2.84 (1.06–7.63)) were identified as independent factors affecting 12-month mortality. No differences in QoL parameters were noted. Conclusions The TAVI can be considered as an effective and safe treatment in high-risk patients with severe aortic stenosis, regardless of gender.
Collapse
|
106
|
Chaker Z, Badhwar V, Alqahtani F, Aljohani S, Zack CJ, Holmes DR, Rihal CS, Alkhouli M. Sex Differences in the Utilization and Outcomes of Surgical Aortic Valve Replacement for Severe Aortic Stenosis. J Am Heart Assoc 2017; 6:JAHA.117.006370. [PMID: 28935681 PMCID: PMC5634288 DOI: 10.1161/jaha.117.006370] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Studies assessing the differential impact of sex on outcomes of aortic valve replacement (AVR) yielded conflicting results. We sought to investigate sex‐related differences in AVR utilization, patient risk profile, and in‐hospital outcomes using the Nationwide Inpatient Sample. Methods and Results In total, 166 809 patients (63% male and 37% female) who underwent AVR between 2003 and 2014 were identified, and 48.5% had a concomitant cardiac surgery procedure. Compared with men, women were older and had more nonatherosclerotic comorbid conditions including hypertension, diabetes mellitus, obstructive pulmonary disease, atrial fibrillation/flutter, and anemia but fewer incidences of coronary and peripheral arterial disease and prior sternotomies. In‐hospital mortality was significantly higher in women (5.6% versus 4%, P<0.001). Propensity matching was performed to assess the impact of sex on the outcomes of isolated AVR and yielded 28 237 matched pairs of male and female participants. In the propensity‐matched groups, in‐hospital mortality was higher in women (3.3% versus 2.9%, P<0.001). Along with vascular complications and blood transfusion (6% versus 5.6%, P=0.027 and 40.4% versus 33.9%, P<0.001, respectively). Rates of stroke, permanent pacemaker implantation, and acute kidney injury requiring dialysis were similar (2.4% versus 2.4%, P=0.99; 6% versus 6.3%, P=0.15; and 1.4% versus 1.3%, P=0.14, respectively). Length of stay median and interquartile range were both similar between groups (7±6 days). Rates of nonhome discharge were higher among women (27.9% versus 19.6%, P<0.001). Conclusions Women have worse in‐hospital mortality following AVR compared with men. Coupled with the accumulating evidence suggesting higher magnitude of benefit of transcatheter AVR over AVR in women, women should perhaps be offered transcatheter AVR over AVR at a lower threshold than men.
Collapse
Affiliation(s)
- Zakeih Chaker
- West Virginia University Heart & Vascular Institute, Morgantown, WV
| | - Vinay Badhwar
- West Virginia University Heart & Vascular Institute, Morgantown, WV
| | - Fahad Alqahtani
- West Virginia University Heart & Vascular Institute, Morgantown, WV
| | - Sami Aljohani
- West Virginia University Heart & Vascular Institute, Morgantown, WV
| | - Chad J Zack
- West Virginia University Heart & Vascular Institute, Morgantown, WV
| | | | | | - Mohamad Alkhouli
- West Virginia University Heart & Vascular Institute, Morgantown, WV .,Department of Cardiology, Mayo Clinic, Rochester, MN
| |
Collapse
|
107
|
Chandrasekhar J, Dangas G, Mehran R. Valvular Heart Disease in Women, Differential Remodeling, and Response to New Therapies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:74. [DOI: 10.1007/s11936-017-0573-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
108
|
Faerber G, Zacher M, Reents W, Boergermann J, Kappert U, Boening A, Diegeler A, Doenst T. Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: A secondary analysis of the GOPCABE trial. PLoS One 2017; 12:e0184038. [PMID: 28854266 PMCID: PMC5576733 DOI: 10.1371/journal.pone.0184038] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/23/2017] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Female sex is considered a significant risk in cardiac surgery and is included in the majority of scores for risk assessment. However, the evidence is controversial and older women undergoing cardiac surgery have not specifically been investigated. We assessed the influence of female sex on surgical risk (30-day mortality) in a secondary analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass grafting in the Elderly (GOPCABE) trial, comparing on- to off-pump) and also evaluated its impact on risk prediction from commonly used risk scores. METHODS We performed logistic regression analyses on the GOPCABE trial population, where patients were randomized to either on- or off-pump CABG. The study was performed in 12 cardiac surgery centers in Germany and analyzed 2394 patients having undergone CABG at age ≥75 years (1187 on-pump, 1207 off-pump). Of the 2394 patients, 755 (32%) were women. The logistic EuroSCORE and the German KCH score were calculated as expected (E) mortality and values were compared to observed (O) 30-day mortality (O/E ratio). RESULTS There was no difference in mortality or major cardiovascular adverse events after 30 days between men and women for both on- and off-pump CABG (men: on- vs. off-pump OR = 0.90, 95%-CI: [0.63;1.27]; women: on- vs. off-pump OR = 1.07, 95%-CI: [0.62;1.87]). Therefore, groups were combined for further analyses. Both men and women had considerable and similar comorbidities. Expected mortality was significantly higher for women than for men (logistic EuroSCORE: 8.88±6.71% vs. 7.99±6.69%, p = 0.003; KCH score: 4.42±3.97% vs. 3.57±3.65%, p = 0.001). However, observed mortality rates (O) tended to be even lower in women (2.1% vs. 3.0%). The O/E ratio was closer to 1 in men than in women (0.84 vs. 0.47). Excluding female sex from the risk models increased O/E ratio to 0.69. CONCLUSIONS Female sex is not a risk factor in coronary bypass surgery in the GOPCABE population. The result is the same for on- and off-pump surgery. Since female sex is a component of most risk scores, the findings may identify a potential inaccuracy in current surgical risk assessment, specifically for elderly women. TRIAL REGISTRATION Clinicaltrials.gov GOPCABE trial No. NCT00719667.
Collapse
Affiliation(s)
- Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Michael Zacher
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Wilko Reents
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Jochen Boergermann
- Clinic for Heart, Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, Cardiovascular Institute, University of Dresden, Dresden, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, University of Gießen, Gießen, Germany
| | - Anno Diegeler
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | | |
Collapse
|
109
|
Fraccaro C, Ueshima D, Tarantini G. Another passenger for the TAVR speeding train. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:334. [PMID: 28861431 PMCID: PMC5566722 DOI: 10.21037/atm.2017.04.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 04/10/2017] [Indexed: 08/30/2023]
Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Italy
| | - Daisuke Ueshima
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Italy
| |
Collapse
|
110
|
Bauer T, Möllmann H, Beckmann A, Ensminger S, Frerker C, Holzhey D, Berkowitsch A, Zahn R, Mohr F, Hamm C, Walther T. Left ventricular function determines the survival benefit for women over men after transcatheter aortic valve implantation (TAVI). EUROINTERVENTION 2017; 13:467-474. [DOI: 10.4244/eij-d-16-00622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
111
|
Sritharen Y, Enriquez-Sarano M, Schaff HV, Casaclang-Verzosa G, Miller JD. Pathophysiology of Aortic Valve Stenosis: Is It Both Fibrocalcific and Sex Specific? Physiology (Bethesda) 2017; 32:182-196. [PMID: 28404735 PMCID: PMC6148342 DOI: 10.1152/physiol.00025.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 12/24/2022] Open
Abstract
Our understanding of the fundamental biology and identification of efficacious therapeutic targets in aortic valve stenosis has lagged far behind the fields of atherosclerosis and heart failure. In this review, we highlight the most clinically relevant problems facing men and women with fibrocalcific aortic valve stenosis, discuss the fundamental biology underlying valve calcification and fibrosis, and identify key molecular points of intersection with sex hormone signaling.
Collapse
Affiliation(s)
- Yoginee Sritharen
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Grace Casaclang-Verzosa
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Jordan D Miller
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota;
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; and the
- Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
112
|
Terzian Z, Urena M, Himbert D, Gardy-Verdonk C, Iung B, Bouleti C, Brochet E, Ghodbane W, Depoix JP, Nataf P, Vahanian A. Causes and temporal trends in procedural deaths after transcatheter aortic valve implantation. Arch Cardiovasc Dis 2017; 110:607-615. [PMID: 28411108 DOI: 10.1016/j.acvd.2016.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 09/10/2016] [Accepted: 12/16/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND The causes of procedural deaths after transcatheter aortic valve implantation (TAVI) have been scarcely detailed. AIMS To assess these causes and their temporal trends since the beginning of the TAVI era. METHODS From October 2006 to April 2014, 601 consecutive high-risk/inoperable patients with severe aortic stenosis underwent TAVI using the Edwards SAPIEN or SAPIEN XT or the Medtronic CoreValve. The transfemoral route was the default approach; the transapical or left subclavian approaches were alternative options. Patients were divided into three tertiles according to the date of the procedure. RESULTS Procedural death occurred in 45 patients (7.5%), with a median±standard deviation age of 83±7 years; 23 were men (51%) and the mean logistic EuroSCORE was 26±16%. The main cause of death was heart failure (n=19, 42%), followed by cardiac rupture (n=12, 27%), intensive care complications (n=9, 20%) and vascular complications (n=5, 11%). The mortality rate was higher after transapical than transfemoral TAVI (17% vs. 5%; P<0.001). The mortality rate decreased over time (11.9% in the first tertile, 6.0% in the second and 4.5% in the third [P=0.007]), driven by a reduction in heart failure-related deaths (6.5% in the first tertile vs. 1.5% in the third; P=0.011). Vascular complication-related deaths disappeared in the third tertile. However, there was no decrease in deaths related to cardiac ruptures and intensive care complications. CONCLUSIONS The procedural mortality rate of TAVI decreased over time, driven by the decrease in heart failure-related deaths. However, efforts should continue to prevent cardiac ruptures and improve the outcomes of patients requiring intensive care after TAVI.
Collapse
Affiliation(s)
- Zaven Terzian
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Marina Urena
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Dominique Himbert
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France.
| | | | - Bernard Iung
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Claire Bouleti
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Eric Brochet
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Walid Ghodbane
- Cardiac Surgery Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Jean-Pol Depoix
- Anaesthesiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Patrick Nataf
- Cardiac Surgery Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| | - Alec Vahanian
- Cardiology Department, DHU FIRE, Bichat Hospital, AP-HP, 75018 Paris, France
| |
Collapse
|
113
|
Chen J, Hahn RT. Sex-Related Differences in the Physiology, Risk, and Outcomes of Transcatheter Aortic Valve Replacement. GENDER AND THE GENOME 2017. [DOI: 10.1089/gg.2016.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is a less-invasive alternative to surgical aortic valve replacement (SAVR) for the management of symptomatic severe aortic stenosis in patients with inoperable, high, or intermediate surgical risk. Females undergoing TAVR exhibit distinct physiology and baseline characteristics from their male counterparts. Although rates of procedural complications are higher, medium-term survival appears better for females than males. These sex-based differences are discussed in depth in this review of TAVR in the female population.
Collapse
Affiliation(s)
- Jennifer Chen
- Columbia University Medical Center/New York–Presbyterian Hospital, New York, New York
| | - Rebecca T. Hahn
- Columbia University Medical Center/New York–Presbyterian Hospital, New York, New York
| |
Collapse
|
114
|
Thromboinflammatory response and predictors of outcomes in patients undergoing transcatheter aortic valve replacement. J Thromb Thrombolysis 2016; 41:384-93. [PMID: 26743061 DOI: 10.1007/s11239-015-1326-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has been increasingly used to treat patients with symptomatic aortic stenosis. Despite improvements in valve deployment, patients that have undergone TAVR are at high risk for major adverse events following the procedure. Blood cell numbers, platelet function, and biomarkers of systemic inflammation were analyzed in 58 patients undergoing TAVR with the Edward's SAPIEN valve. Following valve deployment, platelet count and agonist-induced platelet activity declined and plasma markers of systemic inflammation (interleukin-6 and S100A8/A9) increased. Baseline platelet activity prior to TAVR correlated with perioperative changes plasma interleukin-6 levels. Moreover, perioperative changes in plasma inflammatory markers predicted the decline in platelet count in the days following the TAVR procedure. Additionally, a significant effect of gender on platelet count following TAVR and was observed. Finally, post-procedural mortality was associated with sustained thrombocytopenia after TAVR. Our findings suggest that TAVR elicits a thromboinflammatory state that may contribute to post-procedural thrombocytopenia. Importantly, our results add to the growing body of literature that suggests the thromboinflammatory changes that occur early after TAVR may predict long-term outcomes.
Collapse
|
115
|
Comparison in Men Versus Women of Co-morbidities, Complications, and Outcomes After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis. Am J Cardiol 2016; 118:1692-1697. [PMID: 27666174 DOI: 10.1016/j.amjcard.2016.08.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 01/09/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) decreases mortality in high-risk patients with severe aortic stenosis, but it remains unclear if female gender is associated with more favorable outcomes after TAVI. All patients who underwent TAVI at a single institution were retrospectively analyzed and stratified by gender. Procedural, in-hospital, 30-day, and 1-year outcomes were defined according to the second Valve Academic Research Consortium. The primary end point was all-cause mortality at 1 year. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression were conducted. Overall, 755 patients underwent TAVI and were included in the study; 50.7% were women. Average age was 83.0 ± 7.7 years, with a mean Society of Thoracic Surgeons score of 8.9 ± 4.6. Women were older than men and more likely to be black. Most co-morbidities were less common among women, and they were more likely than men to suffer both in-hospital (8.4% vs 4.3%, p = 0.021) and 30-day (9.4% vs 5.4%, p = 0.035) all-cause mortality. Life-threatening bleeding, transfusion, and iliofemoral dissection or perforation were more common among women. There was no difference in mortality between women and men at 1 year (20.6% vs 21.5%, log-rank p = 0.87). After multivariable adjustment, however, female gender was independently associated with lower mortality at 1 year after TAVI. In conclusion, despite higher rates of major bleeding, vascular complications, and 30-day mortality, female gender was independently associated with improved survival at 1 year after TAVI.
Collapse
|
116
|
Sex-Based Differences in Outcomes With Transcatheter Aortic Valve Therapy. J Am Coll Cardiol 2016; 68:2733-2744. [DOI: 10.1016/j.jacc.2016.10.041] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 11/24/2022]
|
117
|
Simard L, Côté N, Dagenais F, Mathieu P, Couture C, Trahan S, Bossé Y, Mohammadi S, Pagé S, Joubert P, Clavel MA. Sex-Related Discordance Between Aortic Valve Calcification and Hemodynamic Severity of Aortic Stenosis: Is Valvular Fibrosis the Explanation? Circ Res 2016; 120:681-691. [PMID: 27879282 DOI: 10.1161/circresaha.116.309306] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/11/2016] [Accepted: 11/22/2016] [Indexed: 01/07/2023]
Abstract
RATIONALE Calcific aortic stenosis (AS) is characterized by calcium deposition in valve leaflets. However, women present lower aortic valve calcification loads than men for the same AS hemodynamic severity. OBJECTIVE We, thus, aimed to assess sex differences in aortic valve fibrocalcific remodeling. METHODS AND RESULTS One hundred and twenty-five patients underwent Doppler echocardiography and multidetector computed tomography within 3 months before aortic valve replacement. Explanted stenotic tricuspid aortic valves were weighed, and fibrosis degree was determined. Sixty-four men and 39 women were frequency matched for age, body mass index, hypertension, renal disease, diabetes mellitus, and AS severity. Mean age (75±9 years), mean gradient (41±18 mm Hg), and indexed aortic valve area (0.41±0.12 cm2/m2) were similar between men and women (all P≥0.18). Median aortic valve calcification (1973 [1124-3490] Agatston units) and mean valve weight (2.36±0.99 g) were lower in women compared with men (both P<0.0001). Aortic valve calcification density correlated better with valve weight in men (r2=0.57; P<0.0001) than in women (r2=0.26; P=0.0008). After adjustment for age, body mass index, aortic valve calcification density, and aortic annulus diameter, female sex was an independent risk factor for higher fibrosis score in AS valves (P=0.003). Picrosirius red staining of explanted valves showed greater amount of collagen fibers (P=0.01), and Masson trichrome staining revealed a greater proportion of dense connective tissue (P=0.02) in women compared with men. CONCLUSIONS In this series of patients with tricuspid aortic valve and similar AS severity, women have less valvular calcification but more fibrosis compared with men. These findings suggest that the pathophysiology of AS and thus potential targets for drug development may be different according to sex.
Collapse
Affiliation(s)
- Louis Simard
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Nancy Côté
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - François Dagenais
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Patrick Mathieu
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Christian Couture
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Sylvain Trahan
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Yohan Bossé
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Siamak Mohammadi
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Sylvain Pagé
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Philippe Joubert
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada.
| |
Collapse
|
118
|
Schmidt T, Akdag O, Wohlmuth P, Thielsen T, Schewel D, Schewel J, Alessandrini H, Kreidel F, Bader R, Romero M, Ladich E, Virmani R, Schäfer U, Kuck KH, Frerker C. Histological Findings and Predictors of Cerebral Debris From Transcatheter Aortic Valve Replacement: The ALSTER Experience. J Am Heart Assoc 2016; 5:JAHA.116.004399. [PMID: 27930358 PMCID: PMC5210356 DOI: 10.1161/jaha.116.004399] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Histopathological analyses of debris captured by a cerebral protection system during transcatheter aortic valve replacement have been reported, but the origin of the captured debris was not determined and risk factors were not defined. Methods and Results Embolic debris was analyzed from 322 filters used in a dual‐cerebral‐filter protection system implemented during transcatheter aortic valve replacement for 161 patients (mean age 81 years, 82 male [51%], logistic EuroSCORE 19% [interquartile range 12–31%]). The debris capture rate was high, with debris from 97% of all patients (156 of 161). No differences by filter location were found (brachiocephalic trunk 86% [139 of 161], left carotid artery 91% [147 of 161]; adjusted P=0.999). Five prevalent types of debris were identified: thrombus (91%), arterial wall tissue (68%), valve tissue (53%), calcification (46%), and foreign material (30%). Female sex (P=0.0287, odds ratio 1.364, 95% CI 1.032–1.812) and diabetes mellitus (P=0.0116, odds ratio 1.474, 95% CI 1.089–2.001) were significant risk factors for embolic debris. Additional analysis showed significantly more valve tissue in patients with predilation (P=0.0294). Stroke and transient ischemic attack rates were 0.6% each (1 of 161). Conclusion This study showed a high rate of embolic debris consisting of typical anatomic structures known to be altered in patients with aortic stenosis undergoing transcatheter aortic valve replacement. Female patients with diabetes mellitus have increased risk of embolic debris and should be protected by a cerebral protection system during transcatheter aortic valve replacement. Because valve tissue embolizes more often in patients with predilation, procedural planning should consider this finding. Both cerebral arteries (brachiocephalic trunk, left carotid artery) should be protected in the same way.
Collapse
Affiliation(s)
- Tobias Schmidt
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Ozan Akdag
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Thomas Thielsen
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Dimitry Schewel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jury Schewel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Felix Kreidel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Ralf Bader
- Department of Cardiothoracic Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | | | | | - Ulrich Schäfer
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Christian Frerker
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| |
Collapse
|
119
|
Benamer H, Chevalier B, Roy A, Bouzid MA, Perdrix C, Garot P, Hovasse T, Unterseeh T, Champagne S, Lefèvre T. [Transfemoral TAVI procedure in women: Minimally-invasive technique]. Ann Cardiol Angeiol (Paris) 2016; 65:425-432. [PMID: 27816175 DOI: 10.1016/j.ancard.2016.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Demographic data point to a substantial proportion of women in the population of elderly patients with an increasing prevalence of aortic stenosis. Implantation of an aortic bioprosthesis via an endovascular approach known as Transcatheter aortic valve implantation (TAVI) in patients presenting with a symptomatic tight aortic stenosis (severe aortic stenosis) (AS) is an alternative therapeutic option to surgical aortic valve replacement in patients at high surgical risk or ineligible for surgery. The literature has shown that this technique seems to be particularly beneficial in female patients. In the Partner A trial, the 1-year mortality rate was significantly lower in women compared to their male counterparts. Other data revealed that although women have a higher risk of experiencing periprocedural complications (vascular events, bleeding and stroke), their outcome is good and often better than that of men. These results are continuously improving thanks to the enhancement of techniques and devices. In view of the published reports reflecting the increasing experience of the teams, it clearly appears that the simplification of TAVI procedures has resulted in improved outcomes. We report here the case of a patient treated by means of a "minimalist" approach to TAVI allowing a reduction of the risks inherent in the procedure. This simplified strategy relies on an optimal use of CT scan findings prior to TAVI. The procedure is carried out under local anesthesia and the main access site is sutured percutaneously (Proglides). The radial artery is used as a secondary access site. Contrast medium is diluted and stimulation is administered via the intraventricular guidewire. Direct stenting is performed when deemed feasible on the basis of CT scan results. Simplified procedures such as these contribute to the improvement of TAVI outcomes. However, further studies focusing on female patients are warranted in order to corroborate these findings.
Collapse
Affiliation(s)
- H Benamer
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; ICV-GVM La Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92151 Suresnes, France.
| | - B Chevalier
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - A Roy
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - M A Bouzid
- ICV-GVM La Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Foch, 40, rue Worth, 92151 Suresnes, France
| | - C Perdrix
- ICV-GVM La Roseraie, 120, avenue de la République, 93300 Aubervilliers, France
| | - P Garot
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - T Hovasse
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - T Unterseeh
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - S Champagne
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; ICV-GVM La Roseraie, 120, avenue de la République, 93300 Aubervilliers, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| | - T Lefèvre
- ICPS Jacques-Cartier, Ramsay générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France; Hôpital Claude-Gallien, 91480 Quincy Sous-Senart, France
| |
Collapse
|
120
|
Patel JS, Krishnaswamy A, Svensson LG, Tuzcu EM, Mick S, Kapadia SR. Access Options for Transcatheter Aortic Valve Replacement in Patients with Unfavorable Aortoiliofemoral Anatomy. Curr Cardiol Rep 2016; 18:110. [DOI: 10.1007/s11886-016-0788-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
121
|
Beydoun HA, Beydoun MA, Liang H, Dore GA, Shaked D, Zonderman AB, Eid SM. Sex, Race, and Socioeconomic Disparities in Patients With Aortic Stenosis (from a Nationwide Inpatient Sample). Am J Cardiol 2016; 118:860-865. [PMID: 27481471 DOI: 10.1016/j.amjcard.2016.06.039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
Abstract
Aortic stenosis (AS) is the third most prevalent cardiovascular disease following hypertension and coronary artery disease. The primary objective of this cross-sectional study is to examine gender, racial, and socioeconomic disparities in AS-related health care utilization in patients aged ≥50 years using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AS was identified among inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1. Using stratum-specific weighted totals, means, proportions, and regression models, we examined time trends and disparities for inhospital AS prevalence according to gender, race, and income over the 2002 to 2012 period, predictors of AS (gender, race, income, age, health insurance, co-morbidities, and hospital-level characteristics), and AS's role as a predictor of inhospital death, length of stay, and total charges. Inhospital AS prevalence increased from 2.10% in 2002 to 2.37% in 2012, with similar trends observed within gender, race, and income strata. Women were less likely to have AS compared with men (adjusted odds ratio [ORadj] 0.84; 95% confidence interval [CI] 0.83 to 0.86). Blacks (ORadj 0.68; 95% CI 0.66 to 0.71), Hispanics (ORadj 0.79; 95% CI 0.76 to 0.84), and Asians/Pacific Islanders (ORadj 0.68; 95% CI 0.64 to 0.74) were less likely than whites to have AS diagnosis that was directly associated with income. AS was inversely related to inhospital death but positively linked to total charges overall and longer hospital stays among men, whites, and middle-income patients. However, shorter stays with AS were observed among blacks. In conclusion, among older inpatients, AS prevalence was ∼2% and was higher among males, whites, and higher income groups. Although inhospital death was lower and total charges were higher in AS, length of stay's association with AS varied by gender, race, and income.
Collapse
|
122
|
|
123
|
Asgar A, Chandrasekhar J, Mikhail G, Webb J, Lefèvre T, Tamburino C, Hildick-Smith D, Hambrecht R, Van Belle E, Widder J, Dumonteil N, Hink U, Jeger R, Linke A, Deliargyris E, Gao P, Mehran R, Hengstenberg C, Anthopoulos P, Dangas G. Sex-based differences in outcomes with bivalirudin or unfractionated heparin for transcatheter aortic valve replacement: Results from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv 2016; 89:144-153. [DOI: 10.1002/ccd.26607] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 12/19/2022]
Affiliation(s)
- A. Asgar
- Division of Cardiology; Montreal Heart Institute; Montreal Canada
| | - J. Chandrasekhar
- Icahn School of Medicine at Mount Sinai; The Zena and Michael a. Wiener Cardiovascular Institute; New York New York
| | - G. Mikhail
- Imperial College Healthcare NHS Trust, Hammersmith Hospital; London United Kingdom
| | - J. Webb
- Division of Cardiology; St. Paul's Hospital; Vancouver British Columbia Canada
| | - T. Lefèvre
- Ramsay Générale De Santé; Institut Hospitalier Jacques Cartier; Massy France
| | - C. Tamburino
- Department of Cardiology; University of Catania; Catania Italy
| | - D. Hildick-Smith
- Sussex Cardiac Centre-Brighton & Sussex University Hospitals NHS Trust; Brighton East Sussex, United Kingdom
| | - R. Hambrecht
- Department of Cardiology and Angiology; Klinikum Links Der Weser; Bremen Germany
| | - E. Van Belle
- Centre Hospitalier Universitaire De Lille; Lille France
| | - J. Widder
- Department of Cardiology and Angiology; Hannover Medical School; Hannover Germany
| | - N. Dumonteil
- Department of Cardiology; Rangueil University Hospital; Toulouse France
| | - U Hink
- Cardiology Department; Johannes Gutenberg University Hospital; Mainz Germany
| | - R. Jeger
- Department of Cardiology; University Hospital Basel; Basel Switzerland
| | - A. Linke
- Department of Internal Medicine/Cardiology; University of Leipzig, Heart Centre; Germany
| | | | - P. Gao
- The Medicines Company; Parsippany New Jersey
| | - R. Mehran
- Icahn School of Medicine at Mount Sinai; The Zena and Michael a. Wiener Cardiovascular Institute; New York New York
| | - C. Hengstenberg
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany, and Deutsches Herzzentrum München; Technische Universität München; Munich Germany
| | | | - G. Dangas
- Icahn School of Medicine at Mount Sinai; The Zena and Michael a. Wiener Cardiovascular Institute; New York New York
| | | |
Collapse
|
124
|
Skelding KA, Yakubov SJ, Kleiman NS, Reardon MJ, Adams DH, Huang J, Forrest JK, Popma JJ. Transcatheter Aortic Valve Replacement Versus Surgery in Women at High Risk for Surgical Aortic Valve Replacement (from the CoreValve US High Risk Pivotal Trial). Am J Cardiol 2016; 118:560-6. [PMID: 27381665 DOI: 10.1016/j.amjcard.2016.05.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/13/2016] [Accepted: 05/13/2016] [Indexed: 11/26/2022]
Abstract
The objective of this study was to compare outcomes in women after surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) using a self-expanding prosthesis in patients with severe aortic stenosis who were at high risk for SAVR. Although registries and meta-analyses have suggested that TAVR is of considerable benefit in women, perhaps even more so than in men, a rigorous evaluation of TAVR with a self-expanding valve versus SAVR in women from a randomized trial has not been performed. Patients with severe aortic stenosis were randomized 1:1 to either TAVR or SAVR. Outcomes at 1 year are reported. Treatment was attempted in a total of 353 women (183 TAVR and 170 SAVR). Baseline characteristics and predicted risk of the 2 groups were comparable, although the frequency of diabetes mellitus was lower in patients undergoing TAVR (33.3% vs 45.3%; p = 0.02). TAVR-treated patients experienced a statistically significant 1-year survival advantage compared with SAVR patients (12.7% vs 21.8%; p = 0.03). The composite all-cause mortality or major stroke rate also favored TAVR (14.9% vs 24.2%; p = 0.04). Quality of life, as measured by the Kansas City Cardiomyopathy Questionnaire summary score, for both the TAVR and SAVR groups increased significantly from baseline to 1 year. In conclusion, female TAVR patients had lower 1-year mortality and lower 1-year all-cause mortality or major stroke compared with women undergoing SAVR, with both cohorts experiencing improved quality of life. Further studies specifically in women are warranted to validate these findings.
Collapse
|
125
|
Chieffo A, Petronio AS, Mehilli J, Chandrasekhar J, Sartori S, Lefèvre T, Presbitero P, Capranzano P, Tchetche D, Iadanza A, Sardella G, Van Mieghem NM, Meliga E, Dumonteil N, Fraccaro C, Trabattoni D, Mikhail GW, Sharma S, Ferrer MC, Naber C, Kievit P, Faggioni M, Snyder C, Morice MC, Mehran R. Acute and 30-Day Outcomes in Women After TAVR. JACC Cardiovasc Interv 2016; 9:1589-600. [DOI: 10.1016/j.jcin.2016.05.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
|
126
|
Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement. J Am Coll Cardiol 2016; 67:29-38. [PMID: 26764063 DOI: 10.1016/j.jacc.2015.10.046] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/23/2015] [Accepted: 10/12/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Previous studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system. OBJECTIVES The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk. METHODS We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S. RESULTS Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years ([QALY]; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ∼$1,650 would lead to an incremental cost-effectiveness ratio <$50,000/QALY gained. CONCLUSIONS In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S. STANDARDS With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902).
Collapse
|
127
|
Naoum C, Blanke P, Dvir D, Pibarot P, Humphries K, Webb J, Leipsic J. Clinical Outcomes and Imaging Findings in Women Undergoing TAVR. JACC Cardiovasc Imaging 2016; 9:483-93. [DOI: 10.1016/j.jcmg.2016.02.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/12/2016] [Accepted: 02/18/2016] [Indexed: 01/09/2023]
|
128
|
Tigges E, Kalbacher D, Thomas C, Appelbaum S, Deuschl F, Schofer N, Schlüter M, Conradi L, Schirmer J, Treede H, Reichenspurner H, Blankenberg S, Schäfer U, Lubos E. Transcatheter Mitral Valve Repair in Surgical High-Risk Patients: Gender-Specific Acute and Long-Term Outcomes. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3934842. [PMID: 27042662 PMCID: PMC4793092 DOI: 10.1155/2016/3934842] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/19/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Analyses emphasizing gender-related differences in acute and long-term outcomes following MitraClip therapy for significant mitral regurgitation (MR) are rare. METHODS 592 consecutive patients (75 ± 8.7 years, 362 men, 230 women) underwent clinical and echocardiographic follow-up for a median of 2.13 (0.99-4.02) years. RESULTS Significantly higher prevalence of cardiovascular comorbidities, renal failure, and adverse echocardiographic parameters in men resulted in longer device time (p = 0.007) and higher numbers of implanted clips (p = 0.0075), with equal procedural success (p = 1.0). Rehospitalization for heart failure did not differ (p[logrank] = 0.288) while survival was higher in women (p[logrank] = 0.0317). Logarithmic increase of NT-proBNP was a common independent predictor of death. Hypercholesterolemia and peripheral artery disease were predictors of death only in men while ischemic and dilative cardiomyopathy (CM) and age were predictors in women. Independent predictors of rehospitalization for heart failure were severely reduced ejection fraction and success in men while both ischemic and dilative CM, logistic EuroSCORE, and MR severity were predictive in women. CONCLUSIONS Higher numbers of implanted clips and longer device time are likely related to more comorbidities in men. Procedural success and acute and mid-term clinical outcomes were equal. Superior survival for women in long-term analysis is presumably attributable to a comparatively better preprocedural health.
Collapse
Affiliation(s)
- Eike Tigges
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Daniel Kalbacher
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Christina Thomas
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sebastian Appelbaum
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Florian Deuschl
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Niklas Schofer
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Michael Schlüter
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmühlenstraße 5, 20099 Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Ulrich Schäfer
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Edith Lubos
- Department of General and Interventional Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
129
|
Torres-Llergo J, Fernández-Olmo MR, Alania-Torres E, Lozano-Cabezas C, Padilla-Pérez M, Fernández-Guerrero JC. Diferencias en la presentación clínica y manejo terapéutico de la estenosis aórtica severa en mujeres en un centro de tercer nivel. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.carcor.2015.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
130
|
Hahn RT. Sex-related differences in transcatheter aortic valve replacement outcomes: what do interventionalists need to know? Interv Cardiol 2015. [DOI: 10.2217/ica.15.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
|
131
|
Regitz-Zagrosek V, Oertelt-Prigione S, Prescott E, Franconi F, Gerdts E, Foryst-Ludwig A, Maas AHEM, Kautzky-Willer A, Knappe-Wegner D, Kintscher U, Ladwig KH, Schenck-Gustafsson K, Stangl V. Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes. Eur Heart J 2015; 37:24-34. [PMID: 26530104 DOI: 10.1093/eurheartj/ehv598] [Citation(s) in RCA: 425] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/12/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Vera Regitz-Zagrosek
- Institute of Gender in Medicine, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany International Society for Gender Medicine DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Sabine Oertelt-Prigione
- Institute of Gender in Medicine, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany International Society for Gender Medicine DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Eva Prescott
- Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Flavia Franconi
- International Society for Gender Medicine Dep Scienze Biomediche, Regione Basilicata and National Laboratory of Gender Medicine, Consorzio Interuniversitario INBB, University of Sassari, Via Muroni 23a, 07100 Sassari, Italy
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, PO Box 7804, 5020 Bergen, Norway
| | - Anna Foryst-Ludwig
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Institute of Pharmacology, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Route 616, 6525 GA Nijmegen, The Netherlands
| | - Alexandra Kautzky-Willer
- International Society for Gender Medicine Gender Medicine Unit, Internal Medicine III, Endocrinology, Medical University of Vienna, International Society for Gender Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Dorit Knappe-Wegner
- International Society for Gender Medicine University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Ulrich Kintscher
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Institute of Pharmacology, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany
| | - Karl Heinz Ladwig
- Helmholtz Center Munich, Institute of Epidemiology II, German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany
| | - Karin Schenck-Gustafsson
- International Society for Gender Medicine Karolinska Institutet Stockholm, Centre for Gender Medicine, Thorax N3:05, International Society for Gender Medicine, 17176 Stockholm, Sweden
| | - Verena Stangl
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Clinic for Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| |
Collapse
|
132
|
Clinical Aspects and Current Evidence Base for Transcatheter Aortic Valve Implantation. J Thorac Imaging 2015; 30:341-8. [DOI: 10.1097/rti.0000000000000166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
133
|
Abstract
For the year 2014, more than 17,000 published references can be found in Pubmed when entering the search term "cardiac surgery". The last year has been characterized by a vivid discussion in the fields where classic cardiac surgery and modern interventional techniques overlap. Specifically, there have been important contributions in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery as well as in the fields of interventional valve therapy. Here, the US core valve trial with the first demonstration of a survival advantage at 1 year with transcatheter valves compared to surgical aortic valve replacement or the 5-year outcome of the SYNTAX trial with significant advantages for bypass surgery has been the landmark. However, in addition to these most visible publications, there have been several highly relevant and interesting contributions. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices) and aortic surgery. This condensed summary will provide the reader with "solid ground" for up-to-date decision-making in cardiac surgery.
Collapse
|
134
|
Schoenfeld AJ, Reamer EN, Wynkoop EI, Choi H, Bono CM. Does Patient Sex Affect the Rate of Mortality and Complications After Spine Surgery? A Systematic Review. Clin Orthop Relat Res 2015; 473:2479-86. [PMID: 25518806 PMCID: PMC4488194 DOI: 10.1007/s11999-014-4102-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Available studies disagree regarding the influence of patient sex on mortality and complications after spine surgery. We sought to conduct a systematic review and pool the results of existing research to better understand this issue. QUESTIONS/PURPOSES We performed a systematic review to address two questions: (1) Does sex (male versus female) influence mortality after spine surgery? (2) Does sex impact the development of postoperative complications after spine surgery? METHODS This systematic review was performed through a query of PubMed using a structured search algorithm. Additional queries of Embase, SCOPUS, Web of Science, and the tables of contents of orthopaedic and neurosurgical journals were also conducted using search terms such as "sex factors", "male or female", "risk factors", and "spine surgery". Selected papers were independently abstracted by three of the authors (AJS, ENR, EIW) and pooling was performed. Our literature search returned 720 studies, of which 99 underwent full review. Of these, 50 were selected for final abstraction. The Cochrane Q test was used to assess study heterogeneity; significant study heterogeneity was present and so a random-effects model was used. A Harbord test was used to evaluate for the presence of publication bias; this analysis found no statistically significant evidence of publication bias. RESULTS Males were at increased odds of mortality after spine surgery (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.35-1.97; p<0.001). No differences between the sexes were identified for the odds of complications (OR, 1.04; 95% CI, 0.95-1.13; p=0.42). CONCLUSIONS Our results determined that males were at elevated odds of mortality but not of complications after spine surgery. These results should be used to inform preoperative discussion and decision-making at the time of surgical consent. Future work should be directed at determining the underlying factors responsible for increased mortality among males and prospective studies specifically designed to evaluate sex-based differences in outcomes after spine surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI, 48109, USA,
| | | | | | | | | |
Collapse
|
135
|
O’Connor SA, Morice MC, Gilard M, Leon MB, Webb JG, Dvir D, Rodés-Cabau J, Tamburino C, Capodanno D, D’Ascenzo F, Garot P, Chevalier B, Mikhail GW, Ludman PF. Revisiting Sex Equality With Transcatheter Aortic Valve Replacement Outcomes. J Am Coll Cardiol 2015; 66:221-228. [DOI: 10.1016/j.jacc.2015.05.024] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/27/2015] [Accepted: 05/07/2015] [Indexed: 01/09/2023]
|
136
|
Dobson LE, Fairbairn TA, Plein S, Greenwood JP. Sex Differences in Aortic Stenosis and Outcome Following Surgical and Transcatheter Aortic Valve Replacement. J Womens Health (Larchmt) 2015; 24:986-95. [PMID: 26653869 DOI: 10.1089/jwh.2014.5158] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Aortic stenosis is the commonest valve defect in the developed world and is associated with a high mortality once symptomatic. There is a difference in the way that male and female hearts remodel in the face of chronic pressure overload: women develop a concentrically hypertrophied, small cavity left ventricle (LV), whereas men are more prone to the development of eccentric hypertrophy. At a cellular level, there is an increase in collagen and metalloproteinase gene expression in males suggesting a different regulation of extracellular volume composition according to sex. Male hearts with aortic stenosis appear to have more fibrosis than their female comparators. The trigger for this appears to be in part related to estrogen receptor signaling, but other factors such as renin-angiotensin activation, nitric oxide, and circulating noradrenaline levels may also be implicated. Treatment options include surgical valve replacement (SAVR) and more recently transcatheter aortic valve replacement (TAVR). Female sex may be a risk factor for adverse outcome following SAVR and conversely appears to confer a survival advantage when undergoing TAVR. Whether the lower mortality seen following TAVR in women compared with men (despite their increased age and frailty) reflects their longer life expectancy, smaller annular size (and less post-TAVR aortic regurgitation), more favorable LV reverse remodeling, or more likely, a combination of these factors remains to be established.
Collapse
Affiliation(s)
- Laura E Dobson
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds , Leeds, United Kingdom
| | - Timothy A Fairbairn
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds , Leeds, United Kingdom
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds , Leeds, United Kingdom
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds , Leeds, United Kingdom
| |
Collapse
|
137
|
Abstract
Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis for high-risk and inoperable patients. The 10-year experience in Europe has proven the technology to be safe and effective in select populations. The PARTNER trial, the first prospective, randomized, controlled trial for TAVR, showed the technology to be superior to medical management for inoperable patients and equivalent to surgical aortic valve replacement for high-risk patients. Research in cardiovascular medicine has been dominated by studies on the male sex, due to the incidence of the disease process and partly due to historic predominance of male subjects in research studies. Alternatively, TAVR studies focused on high-risk and inoperable patients who are equally distributed by sex. Although sex-related differences are apparent in their baseline characteristics, outcomes have been mixed, with evidence suggesting that female patients may have a mortality advantage with TAVR. Herein we review the TAVR procedure and devices currently available and focus our discussion on outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis.
Collapse
|
138
|
Walsh JA, Teirstein PS, Stinis C, Price MJ. Risk Assessment in Patient Selection for Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2015; 4:1-12. [PMID: 28582117 DOI: 10.1016/j.iccl.2014.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Risk assessment models for transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement in high-risk patients and TAVR versus palliation in inoperable patients are based on surgical data and have limited discrimination and calibration in the setting of TAVR. Several novel risk models specifically designed for TAVR have improved discrimination over existing models but require further validation. Several clinical and echocardiographic variables, such as chronic lung disease, mitral regurgitation, and stroke volume index, influence outcomes. This article reviews current and novel risk models and important predictors of TAVR outcomes and proposes a framework to integrate them into clinical decision-making for patients with severe, symptomatic aortic stenosis.
Collapse
Affiliation(s)
- Joseph A Walsh
- Division of Cardiovascular Diseases, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Paul S Teirstein
- Division of Cardiovascular Diseases, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Curtiss Stinis
- Division of Cardiovascular Diseases, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA.
| |
Collapse
|
139
|
Szerlip M, Holper E. Editorial: Sex and TAVR: game, set, match to women. J Interv Cardiol 2014; 27:540-1. [PMID: 25421834 DOI: 10.1111/joic.12163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
140
|
Cramariuc D, Rogge BP, Lønnebakken MT, Boman K, Bahlmann E, Gohlke-Bärwolf C, Chambers JB, Pedersen TR, Gerdts E. Sex differences in cardiovascular outcome during progression of aortic valve stenosis. Heart 2014; 101:209-14. [PMID: 25301859 PMCID: PMC4316939 DOI: 10.1136/heartjnl-2014-306078] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective Women with severe aortic valve stenosis (AS) have better LV systolic function and more concentric LV geometry than their male counterparts. However, sex differences in cardiovascular (CV) outcome during progression of AS have not been reported from a longitudinal prospective study. Methods Doppler echocardiography and CV events were recorded during a median of 4.0 years in 979 men and 632 women aged 28–86 (mean 67±10) years in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study. LV systolic function was assessed by EF and midwall shortening (MWS). Study outcomes were AS-related events, ischaemic CV events and total mortality. Results The annular cumulative incidence of AS events, ischaemic CV events and death was 8.1%, 3.4% and 2.8% in women, and 8.9%, 4.4% and 2.4% in men, respectively. Women and men had similar AS progression rate whether measured by peak jet velocity, mean gradient or valve area. In multivariate analyses, female sex independently predicted less reduction in LV MWS and EF during follow-up (both p<0.05). In time-varying Cox analyses, women had a 40% lower rate of ischaemic CV events (95% CI 21% to 54%), in particular, more than 50% lower rate of stroke and coronary artery bypass grafting, and a 31% lower all-cause mortality (95% CI 1% to 51%), independent of active study treatment, age and hypertension, as well as time-varying valve area, low systolic function and abnormal LV geometry. AS event rate did not differ by sex. Conclusions In the SEAS study, women and men had similar rates of AS progression and AS-related events. However, women had lower total mortality and ischaemic CV event rate than men independent of confounders. Trial registration number ClinicalTrials.gov identifier: NCT00092677.
Collapse
Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Barbara Patricia Rogge
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Kurt Boman
- Research unit, Medicine, Umeaa University, Skellefteaa, Sweden
| | | | | | | | - Terje R Pedersen
- Department of Preventive Cardiology, Ullevål University Hopital, Oslo, Norway
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
141
|
STANGL VERENA, BALDENHOFER GERD, LAULE MICHAEL, BAUMANN GERT, STANGL KARL. Influence of Sex on Outcome Following Transcatheter Aortic Valve Implantation (TAVI): Systematic Review and Meta-Analysis. J Interv Cardiol 2014; 27:531-9. [DOI: 10.1111/joic.12150] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- VERENA STANGL
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte, Charité-Universitätsmedizin Berlin; Berlin Germany
- DZHK (German Center for Cardiovascular Research); Berlin Germany
| | - GERD BALDENHOFER
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte, Charité-Universitätsmedizin Berlin; Berlin Germany
| | - MICHAEL LAULE
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte, Charité-Universitätsmedizin Berlin; Berlin Germany
| | - GERT BAUMANN
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte, Charité-Universitätsmedizin Berlin; Berlin Germany
| | - KARL STANGL
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte, Charité-Universitätsmedizin Berlin; Berlin Germany
| |
Collapse
|