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Penny-Dimri JC, Bergmeir C, Reid CM, Williams-Spence J, Perry LA, Smith JA. Tree-based survival analysis improves mortality prediction in cardiac surgery. Front Cardiovasc Med 2023; 10:1211600. [PMID: 37492161 PMCID: PMC10365268 DOI: 10.3389/fcvm.2023.1211600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/16/2023] [Indexed: 07/27/2023] Open
Abstract
Objectives Machine learning (ML) classification tools are known to accurately predict many cardiac surgical outcomes. A novel approach, ML-based survival analysis, remains unstudied for predicting mortality after cardiac surgery. We aimed to benchmark performance, as measured by the concordance index (C-index), of tree-based survival models against Cox proportional hazards (CPH) modeling and explore risk factors using the best-performing model. Methods 144,536 patients with 147,301 surgery events from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) national database were used to train and validate models. Univariate analysis was performed using Student's T-test for continuous variables, Chi-squared test for categorical variables, and stratified Kaplan-Meier estimation of the survival function. Three ML models were tested, a decision tree (DT), random forest (RF), and gradient boosting machine (GBM). Hyperparameter tuning was performed using a Bayesian search strategy. Performance was assessed using 2-fold cross-validation repeated 5 times. Results The highest performing model was the GBM with a C-index of 0.803 (0.002), followed by RF with 0.791 (0.003), DT with 0.729 (0.014), and finally CPH with 0.596 (0.042). The 5 most predictive features were age, type of procedure, length of hospital stay, drain output in the first 4 h (ml), and inotrope use greater than 4 h postoperatively. Conclusion Tree-based learning for survival analysis is a non-parametric and performant alternative to CPH modeling. GBMs offer interpretable modeling of non-linear relationships, promising to expose the most relevant risk factors and uncover new questions to guide future research.
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Affiliation(s)
- Jahan C. Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Christoph Bergmeir
- Department of Data Science and Artificial Intelligence, Faculty of Information Technology, Monash University, Melbourne, Australia
- Department of Computer Science and Artificial Intelligence, University of Granada, Melbourne, Spain
| | - Christopher M. Reid
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jenni Williams-Spence
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Luke A. Perry
- Department of Anaesthesia, Victorian Heart Hospital, Monash Health, Clayton, Vic, Australia
| | - Julian A. Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Varadarajan P, Pai RG. Gender Effects on Left Ventricular Responses and Survival in Patients with Severe Aortic Regurgitation: Results from a Cohort of 756 Patients with up to 22 Years of Follow-Up. Med Sci (Basel) 2023; 11:36. [PMID: 37367735 DOI: 10.3390/medsci11020036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVES We sought to evaluate the effect of gender on biology, therapeutic decisions, and survival in patients with severe aortic regurgitation (AR). BACKGROUND Gender affects adaptive response to the presence of valvular heart diseases and therapeutic decisions. The impact of these on survival in severe AR patients is not known. METHODS This observational study was compiled from our echocardiographic database which was screened (1993-2007) for patients with severe AR. Detailed chart reviews were performed. Mortality data were obtained from the Social Security Death Index and analyzed as a function of gender. RESULTS Of the 756 patients with severe AR, 308 (41%) were women. Over a follow-up of up to 22 years, there were 434 deaths. Women compared to men were older (64 ± 18 vs. 59 ± 17 years, p = 0.0002). Women also had smaller left ventricular (LV) end diastolic dimension (5.2 ± 1.1 vs. 6.0 ± 1.0 cm, p < 0.0001), higher EF (56% ± 17% vs. 52% ± 18%, p = 0.003), higher prevalence of diabetes mellitus (18% vs. 11%, p = 0.006), and higher prevalence of ≥2+ mitral regurgitation (52% vs. 40%, p = 0.0008) despite a smaller LV size. Women were also less likely to receive aortic valve replacement (AVR) (24% vs. 48%, p < 0.0001) compared to men and had a lower survival on univariate analysis (p = 0.001). However, after adjusting for group differences including AVR rates, gender was not an independent predictor of survival. However, the survival benefit associated with AVR was similar in both women and men. CONCLUSIONS This study strongly suggests that female gender is associated with different biological responses to AR compared to men. There is also a lower AVR rate in women, but women derive similar survival benefit as men with AVR. Gender does not seem to affect survival in an independent fashion in patients with severe AR after adjusting for group differences and AVR rates.
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Affiliation(s)
- Padmini Varadarajan
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92521, USA
- Division of Cardiology, Riverside School of Medicine, University of California, Riverside, CA 92521, USA
| | - Ramdas G Pai
- Division of Cardiology, Riverside School of Medicine, University of California, Riverside, CA 92521, USA
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Bradley S, White RS, Jiang SY, Ma X, Hoyler MM, Muehlschlegel JD, Karamnov S, Tangel VE, Lanahan J, Rong LQ. Sex Differences in In-Hospital Mortality After Open Cardiac Valve Surgery. Anesth Analg 2022; 135:944-953. [PMID: 36029223 PMCID: PMC9588500 DOI: 10.1213/ane.0000000000006076] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cardiac valvular disease affects millions of people worldwide and is a major cause of morbidity and mortality. Female patients have been shown to experience inferior clinical outcomes after nonvalvular cardiac surgery, but recent data are limited regarding open valve surgical cohorts. The primary objective of our study was to assess whether female sex is associated with increased in-hospital mortality after open cardiac valve operations. METHODS Utilizing the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), we conducted a retrospective cohort study of patients who underwent open cardiac valve surgery from 2007 to 2018 in Washington, Maryland, Kentucky, and Florida; from 2007 to 2011 in California; and from 2007 to 2016 in New York. The primary objective of this study was to estimate the confounder-adjusted association between sex and in-hospital mortality (as recorded and coded by SID HCUP) after open cardiac valve surgery. We used multilevel multivariable models to account for potential confounders, including intrahospital practice patterns. RESULTS A total of 272,954 patients (108,443 women; 39.73% of sample population with mean age of 67.6 ± 14.3 years) were included in our analysis. The overall mortality rates were 3.8% for male patients and 5.1% for female patients. The confounder-adjusted odds ratio (OR) for in-hospital mortality for female patients compared to male patients was 1.41 (95% confidence interval [CI], 1.35-1.47; P < .001). When stratifying by surgical type, female patients were also at increased odds of in-hospital mortality ( P < .001) in populations undergoing aortic valve replacement (adjusted OR [aOR], 1.38; 95% CI, 1.25-1.52); multiple valve surgery (aOR, 1.38; 95% CI, 1.22-1.57); mitral valve replacement (aOR, 1.22; 95% CI, 1.12 - 1.34); and valve surgery with coronary artery bypass grafting (aOR, 1.64; 95% CI, 1.54 - 1.74; all P < .001). Female patients did not have increased odds of in-hospital mortality in populations undergoing mitral valve repair (aOR, 1.26; 95% CI, 0.98 - 1.64; P = .075); aortic valve repair (aOR, 0.87; 95% CI, 0.67 - 1.14; P = .32); or any other single valve repair (aOR, 1.10; 95% CI, 0.82 - 1.46; P = .53). CONCLUSIONS We found an association between female patients and increased confounder-adjusted odds of in-hospital mortality after open cardiac valve surgery. More research is needed to better understand and categorize these important outcome differences. Future research should include observational analysis containing granular and complete patient- and surgery-specific data.
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Affiliation(s)
- Stephanie Bradley
- From the Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Silis Y Jiang
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Xiaoyue Ma
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Marguerite M Hoyler
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Jochen D Muehlschlegel
- From the Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sergey Karamnov
- From the Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Virginia E Tangel
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Jill Lanahan
- From the Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Qia Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
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Bansal A, Cremer PC, Jaber WA, Rampersad P, Menon V. Sex Differences in the Utilization and Outcomes of Cardiac Valve Replacement Surgery for Infective Endocarditis: Insights From the National Inpatient Sample. J Am Heart Assoc 2021; 10:e020095. [PMID: 34632795 PMCID: PMC8751869 DOI: 10.1161/jaha.120.020095] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The data on the differential impact of sex on the utilization and outcomes of valve replacement surgery for infective endocarditis are limited to single‐center and small sample size patient population. Methods and Results We utilized the National Inpatient Sample database to identify patients with a discharge diagnosis of infective endocarditis from 2004 to 2015 to assess differences in the characteristics and clinical outcomes of patients hospitalized with infective endocarditis stratified by sex. We also evaluated trends in utilization of cardiac valve replacement and individual valve replacement surgeries in women versus men over a 12‐year period, and compared in‐hospital mortality after surgical treatment in women versus men. A total of 81 942 patients were hospitalized with a primary diagnosis of infective endocarditis from January 2004 to September 2015, of whom 44.31% were women. Women were less likely to undergo overall cardiac valve replacement (6.92% versus 12.12%), aortic valve replacement (3.32% versus 8.46%), mitral valve replacement (4.60% versus 5.57%), and combined aortic and mitral valve replacement (0.85% versus 1.81%) but had similar in‐hospital mortality rates. From 2004 to 2015, the overall rates of cardiac valve replacement increased from 11.76% to 13.96% in men and 6.34% to 9.26% in women and in‐hospital mortality declined in both men and women. Among the patients undergoing valve replacement surgery, in‐hospital mortality was higher in women (9.94% versus 6.99%, P<0.001). Conclusions Despite increased utilization of valve surgery for infective endocarditis in both men and women and improving trends in mortality, we showed that there exists a treatment bias with underutilization of valve surgeries for infective endocarditis in women and demonstrated that in‐hospital mortality was higher in women undergoing valve surgery in comparison to men.
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Affiliation(s)
- Agam Bansal
- Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Paul C Cremer
- Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Wael A Jaber
- Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Penelope Rampersad
- Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Venu Menon
- Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
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Trenson S, Hermans H, Craps S, Pokreisz P, de Zeeuw P, Van Wauwe J, Gillijns H, Veltman D, Wei F, Caluwé E, Gijsbers R, Baatsen P, Staessen JA, Ghesquiere B, Carmeliet P, Rega F, Meuris B, Meyns B, Oosterlinck W, Duchenne J, Goetschalckx K, Voigt JU, Herregods MC, Herijgers P, Luttun A, Janssens S. Cardiac Microvascular Endothelial Cells in Pressure Overload-Induced Heart Disease. Circ Heart Fail 2021; 14:e006979. [PMID: 33464950 DOI: 10.1161/circheartfailure.120.006979] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronic pressure overload predisposes to heart failure, but the pathogenic role of microvascular endothelial cells (MiVEC) remains unknown. We characterized transcriptional, metabolic, and functional adaptation of cardiac MiVEC to pressure overload in mice and patients with aortic stenosis (AS). METHODS In Tie2-Gfp mice subjected to transverse aortic constriction or sham surgery, we performed RNA sequencing of isolated cardiac Gfp+-MiVEC and validated the signature in freshly isolated MiVEC from left ventricle outflow tract and right atrium of patients with AS. We next compared their angiogenic and metabolic profiles and finally correlated molecular and pathological signatures with clinical phenotypes of 42 patients with AS (50% women). RESULTS In mice, transverse aortic constriction induced progressive systolic dysfunction, fibrosis, and reduced microvascular density. After 10 weeks, 25 genes predominantly involved in matrix-regulation were >2-fold upregulated in isolated MiVEC. Increased transcript levels of Cartilage Intermediate Layer Protein (Cilp), Thrombospondin-4, Adamtsl-2, and Collagen1a1 were confirmed by quantitative reverse transcription polymerase chain reaction and recapitulated in left ventricle outflow tract-derived MiVEC of AS (P<0.05 versus right atrium-MiVEC). Fatty acid oxidation increased >2-fold in left ventricle outflow tract-MiVEC, proline content by 130% (median, IQR, 58%-474%; P=0.008) and procollagen secretion by 85% (mean [95% CI, 16%-154%]; P<0.05 versus right atrium-MiVEC for all). The altered transcriptome in left ventricle outflow tract-MiVEC was associated with impaired 2-dimensional-vascular network formation and 3-dimensional-spheroid sprouting (P<0.05 versus right atrium-MiVEC), profibrotic ultrastructural changes, and impaired diastolic left ventricle function, capillary density and functional status, especially in female AS. CONCLUSIONS Pressure overload induces major transcriptional and metabolic adaptations in cardiac MiVEC resulting in excess interstitial fibrosis and impaired angiogenesis. Molecular rewiring of MiVEC is worse in women, compromises functional status, and identifies novel targets for intervention.
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Affiliation(s)
- Sander Trenson
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Hadewich Hermans
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Sander Craps
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Peter Pokreisz
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Pauline de Zeeuw
- Department of Oncology, Laboratory of Angiogenesis and Vascular Metabolism (P.d.Z., P.C.), KU Leuven, Belgium.,Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium (P.d.Z., P.C.)
| | - Jore Van Wauwe
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Hilde Gillijns
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Denise Veltman
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Fangfei Wei
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Ellen Caluwé
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Rik Gijsbers
- Department of Pharmacological and Pharmaceutical Sciences, Laboratory for Viral Vector Technology and Gene therapy and Leuven Viral Vector Core (R.G.), KU Leuven, Belgium
| | - Pieter Baatsen
- VIB-University of Leuven Center for Brain and Disease Research, Leuven, Belgium (P.B.)
| | - Jan A Staessen
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Bart Ghesquiere
- Metabolomics Expertise Center, Center for Cancer biology, VIB, Leuven, Belgium (B.G.)
| | - Peter Carmeliet
- Department of Oncology, Laboratory of Angiogenesis and Vascular Metabolism (P.d.Z., P.C.), KU Leuven, Belgium.,Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium (P.d.Z., P.C.)
| | - Filip Rega
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Bart Meyns
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Jürgen Duchenne
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Kaatje Goetschalckx
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Marie-Christine Herregods
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Paul Herijgers
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Aernout Luttun
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Sciences (S.T., H.H., S.C., P.P., J.V.W., H.G., D.V., F.W., E.C., J.A.S., F.R., B. Meuris, B. Meyns, W.O., J.D., K.G., J.-U.V., M.-C.H., P.H., A.L., S.J.), KU Leuven, Belgium
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Myllykangas ME, Aittokallio J, Gunn J, Sipilä J, Rautava P, Kytö V. Sex Differences in Long-Term Outcomes After Surgical Aortic Valve Replacement: A Nationwide Propensity-matched Study. J Cardiothorac Vasc Anesth 2020; 34:932-939. [DOI: 10.1053/j.jvca.2019.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/28/2019] [Accepted: 10/06/2019] [Indexed: 11/11/2022]
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Goel H, Kumar A, Garg N, Mills JD. Men are from mars, women are from venus: Factors responsible for gender differences in outcomes after surgical and trans-catheter aortic valve replacement. Trends Cardiovasc Med 2019; 31:34-46. [PMID: 31902553 DOI: 10.1016/j.tcm.2019.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 11/21/2019] [Accepted: 11/23/2019] [Indexed: 01/09/2023]
Abstract
Females suffer higher operative (30-day) mortality than males after surgical aortic valve replacement (SAVR). In contrast, outcomes after trans-catheter aortic valve replacement (TAVR) seem to favor females, both in terms of procedural mortality, and more prominently, medium to long-term survival. With an ever-greater number of TAVR procedures being performed, an understanding of factors responsible for gender differences in outcomes after the two AVR modalities is critical for better patient selection. Current evidence suggests that this gender difference in outcomes after SAVR and TAVR stems from differences in baseline risk profiles, as well as inherent anatomic/physiological differences between genders. This review attempts to examine these clinical and physiological factors, with a goal of guiding better patient selection for each AVR modality, and to highlight areas that beg further investigation.
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Affiliation(s)
- Harsh Goel
- Department of Medicine, St. Luke's University Hospital, Bethlehem, PA, United States; Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States.
| | - Ashish Kumar
- Department of Medicine, Wellspan York Hospital, York, PA, United States
| | - Nadish Garg
- Department of Medicine, St Barnabas Medical Center, Livingston, NJ, United States
| | - James D Mills
- Department of Medicine, Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV, United States
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8
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Singh A, Musa TA, Treibel TA, Vassiliou VS, Captur G, Chin C, Dobson LE, Pica S, Loudon M, Malley T, Rigolli M, Foley JRJ, Bijsterveld P, Law GR, Dweck MR, Myerson SG, Prasad SK, Moon JC, Greenwood JP, McCann GP. Sex differences in left ventricular remodelling, myocardial fibrosis and mortality after aortic valve replacement. Heart 2019; 105:1818-1824. [PMID: 31467152 PMCID: PMC6900227 DOI: 10.1136/heartjnl-2019-314987] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/07/2019] [Accepted: 06/08/2019] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To investigate sex differences in left ventricular remodelling and outcome in patients undergoing surgical or transcatheter aortic valve replacement (SAVR/TAVR). METHODS In this multicentre, observational, outcome study with imaging core-lab analysis, patients with severe aortic stenosis (AS) listed for intervention at one of six UK centres were prospectively recruited and underwent cardiovascular magnetic resonance imaging. The primary endpoint was all-cause mortality and secondary endpoint was cardiovascular mortality. RESULTS 674 patients (425 men, 249 women, age 75±14 years) were included: 399 SAVR, 275 TAVR. Women were older, had higher surgical risk scores and underwent TAVR more frequently (53% vs 33.6%, p<0.001). More men had bicuspid aortic valves (BAVs) (26.7% vs 14.9%, p<0.001) and demonstrated more advanced remodelling than women. During a median follow-up of 3.6 years, 145 (21.5%) patients died, with no significant sex difference in all-cause mortality (23.3% vs 20.5%, p=0.114), but higher cardiovascular mortality in women (13.7% vs 8.5%, p=0.012). There were no significant sex-related differences in outcome in the SAVR or TAVR subgroups, or after excluding those with BAV. Factors independently associated with all-cause mortality were age, left ventricular ejection fraction (LVEF), BAV (better) and myocardial fibrosis detected with late gadolinium enhancement (LGE) in men, and age, LVEF and LGE in women. Age and LGE were independently associated with cardiovascular mortality in both sexes. CONCLUSIONS Men demonstrate more advanced remodelling in response to a similar severity of AS. The higher cardiovascular mortality observed in women following AVR is accounted for by women having less BAV and higher risk scores resulting in more TAVR. LGE is associated with a worse prognosis in both sexes.
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Affiliation(s)
- Anvesha Singh
- Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Tarique Al Musa
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Treibel
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Vassiliou S Vassiliou
- Cardiovascular Sciences, Imperial College London, Royal Brompton Hospital, London, UK,University of East Anglia and Norfolk and Norwich University Hospitals, Norwich, Norfolk, United Kingdom
| | - Gabriella Captur
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Calvin Chin
- Cardiovascular Medicine, National Heart Center Singapore, Singapore, Singapore
| | - Laura E Dobson
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Silvia Pica
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Margaret Loudon
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | - Tamir Malley
- Cardiovascular Sciences, Imperial College London, Royal Brompton Hospital, London, UK
| | - Marzia Rigolli
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | - James Robert John Foley
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Petra Bijsterveld
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Graham R Law
- Medical Statistics, School of Health and Social Care, University of Lincoln and Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Lincoln and Leeds, UK
| | - Marc Richard Dweck
- Cardiovascular Sciences, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Saul G Myerson
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | | | - James C Moon
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - John P Greenwood
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Gerry P McCann
- Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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9
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Johnston A, Mesana TG, Lee DS, Eddeen AB, Sun LY. Sex Differences in Long-Term Survival After Major Cardiac Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2019; 8:e013260. [PMID: 31438770 PMCID: PMC6755832 DOI: 10.1161/jaha.119.013260] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Little attention has been paid to the importance of sex in the long‐term prognosis of patients undergoing cardiac surgery. Methods and Results We conducted a retrospective cohort study of Ontario residents, aged ≥40 years, who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral, or tricuspid valve surgery between October 1, 2008, and December 31, 2016. The primary outcome was all‐cause mortality. The mortality rate in each surgical group was calculated using the Kaplan‐Meier method. The risk of death was assessed using multivariable Cox proportional hazard models. Sex‐specific mortality risk factors were identified using multiplicative interaction terms. A total of 72 824 patients were included in the study (25% women). The median follow‐up period was 5 (interquartile range, 3–7) years. The long‐term age‐standardized mortality rate was lowest in patients who underwent isolated CABG and highest among those who underwent combined CABG/multiple valve surgery. Women had significantly higher age‐standardized mortality rate than men after CABG and combined CABG/mitral valve surgery. Men had lower rates of long‐term mortality than women after isolated mitral valve repair, whereas women had lower rates of long‐term mortality than men after isolated mitral valve replacement. We observed a statistically significant association between female sex and long‐term mortality after adjustment for key risk factors. Conclusions Female sex was associated with long‐term mortality after cardiac surgery. Perioperative optimization and long‐term follow‐up should be tailored to younger women with a history of myocardial infarction and percutaneous coronary intervention and older men with a history of chronic obstructive pulmonary disease and depression.
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Affiliation(s)
- Amy Johnston
- Cardiovascular Research Methods Centre University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Thierry G Mesana
- Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa Ontario Canada
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences Ontario Canada.,Peter Munk Cardiac Centre University Health Network University of Toronto Toronto Ontario Canada
| | | | - Louise Y Sun
- Institute for Clinical Evaluative Sciences Ontario Canada.,Division of Cardiac Anesthesiology University of Ottawa Heart Institute and School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada
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10
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ter Woorst JF, Hoff AH, van Straten AH, Houterman S, Soliman-Hamad MA. Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles. J Cardiothorac Vasc Anesth 2019; 33:1237-1243. [DOI: 10.1053/j.jvca.2018.08.196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/11/2022]
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11
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Mokhles MM, Soloukey Tbalvandany S, Siregar S, Versteegh MIM, Noyez L, van Putte B, Vonk ABA, Roos-Hesselink JW, Bogers AJJC, Takkenberg JJM. Male-female differences in aortic valve and combined aortic valve/coronary surgery: a national cohort study in the Netherlands. Open Heart 2018; 5:e000868. [PMID: 30228910 PMCID: PMC6135410 DOI: 10.1136/openhrt-2018-000868] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/05/2018] [Accepted: 07/24/2018] [Indexed: 11/05/2022] Open
Abstract
Objective The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery. Methods All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included. Results In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women. Conclusions There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title:
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Affiliation(s)
- M Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Sabrina Siregar
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel I M Versteegh
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Luc Noyez
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart van Putte
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, Free University Medical Center, Amsterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Congenital Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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12
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Hervault M, Clavel MA. Sex-related Differences in Calcific Aortic Valve Stenosis: Pathophysiology, Epidemiology, Etiology, Diagnosis, Presentation, and Outcomes. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2018. [DOI: 10.1080/24748706.2017.1420273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Maxime Hervault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
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13
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Aortic valve replacement in small patients. Asian J Surg 2017; 41:578-584. [PMID: 29031428 DOI: 10.1016/j.asjsur.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/18/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Asians are smaller than Europeans and North Americans, but aortic valve replacement (AVR) in small patients has not been examined. We aimed to compare short- and mid-term outcomes of AVR between small and non-small patients. METHODS We retrospectively divided 173 patients who underwent AVR into small (S, n = 95) and non-small (NS, n = 78) groups according to body surface area (≤1.6 in men, ≤1.5 in women) and analyzed differences in baseline characteristics, procedural and post-procedural variables, and survival. RESULTS Mean age differed significantly between the S and NS groups (71.9 ± 11.2 vs. 66.2 ± 9.8 years), as did the proportion of women (60.0% vs. 24.4%). Implanted valves (19.6 ± 1.6 mm vs. 20.7 ± 1.7 mm) were significantly smaller and more bioprosthetic valves (57.9% vs. 41.0%) were used in the S group. Effective orifice area index and the rate of moderate and severe patient-prosthesis mismatch were not significantly different. No significant intergroup differences were found in hospitalization duration, 30-day mortality, survival rates, or valve related complications. CONCLUSIONS Small patients were older and the proportion of women was higher. The implanted aortic valves were smaller and more were biological prostheses. However, mortality rate did not differ and short- and mid-term outcomes were safe and favorable.
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14
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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.
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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
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15
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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]
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16
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Pasipoularides A. Calcific Aortic Valve Disease: Part 2-Morphomechanical Abnormalities, Gene Reexpression, and Gender Effects on Ventricular Hypertrophy and Its Reversibility. J Cardiovasc Transl Res 2016; 9:374-99. [PMID: 27184804 PMCID: PMC4992466 DOI: 10.1007/s12265-016-9695-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
In part 1, we considered cytomolecular mechanisms underlying calcific aortic valve disease (CAVD), hemodynamics, and adaptive feedbacks controlling pathological left ventricular hypertrophy provoked by ensuing aortic valvular stenosis (AVS). In part 2, we survey diverse signal transduction pathways that precede cellular/molecular mechanisms controlling hypertrophic gene expression by activation of specific transcription factors that induce sarcomere replication in-parallel. Such signaling pathways represent potential targets for therapeutic intervention and prevention of decompensation/failure. Hypertrophy provoking signals, in the form of dynamic stresses and ligand/effector molecules that bind to specific receptors to initiate the hypertrophy, are transcribed across the sarcolemma by several second messengers. They comprise intricate feedback mechanisms involving gene network cascades, specific signaling molecules encompassing G protein-coupled receptors and mechanotransducers, and myocardial stresses. Future multidisciplinary studies will characterize the adaptive/maladaptive nature of the AVS-induced hypertrophy, its gender- and individual patient-dependent peculiarities, and its response to surgical/medical interventions. They will herald more effective, precision medicine treatments.
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Affiliation(s)
- Ares Pasipoularides
- Duke University School of Medicine, Durham, NC, USA.
- Duke/NSF Research Center for Emerging Cardiovascular Technologies, Duke University, Durham, NC, 27710, USA.
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17
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Huygens SA, Mokhles MM, Hanif M, Bekkers JA, Bogers AJJC, Rutten-van Mölken MPMH, Takkenberg JJM. Contemporary outcomes after surgical aortic valve replacement with bioprostheses and allografts: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2016; 50:605-616. [PMID: 27026750 PMCID: PMC5052462 DOI: 10.1093/ejcts/ezw101] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/17/2016] [Accepted: 02/26/2016] [Indexed: 11/14/2022] Open
Abstract
Many observational studies have reported outcomes after surgical aortic valve replacement (AVR), but there are no recent systematic reviews and meta-analyses including all available bioprostheses and allografts. The objective of this study is to provide a comprehensive and up-to-date overview of the outcomes after AVR with bioprostheses and allografts reported in the last 15 years. We conducted a systematic literature review (PROSPERO register: CRD42015017041) of studies published between 2000–15. Inclusion criteria were observational studies or randomized controlled trials reporting on outcomes of AVR with bioprostheses (stented or stentless) or allografts, with or without coronary artery bypass grafting (CABG) or valve repair procedure, with study population size n ≥ 30 and mean follow-up length ≥5 years. Fifty-four bioprosthesis studies and 14 allograft studies were included, encompassing 55 712 and 3872 patients and 349 840 and 32 419 patient-years, respectively. We pooled early mortality risk and linearized occurrence rates of valve-related events, reintervention and late mortality in a random-effects model. Sensitivity, meta-regression and subgroup analyses were performed to investigate the influence of outliers on the pooled estimates and to explore sources of heterogeneity. Funnel plots were used to investigate publication bias. Pooled early mortality risks for bioprostheses and allografts were 4.99% (95% confidence interval [CI], 4.44–5.62) and 5.03% (95% CI, 3.61–7.01), respectively. The late mortality rate was 5.70%/patient-year (95% CI, 4.99–5.62) for bioprostheses and 1.68%/patient-year (95% CI, 1.23–2.28) for allografts. Pooled reintervention rates for bioprostheses and allografts were 0.75%/patient-year (95% CI, 0.61–0.91) and 1.87%/patient-year (95% CI, 1.52–2.31), respectively. There was substantial heterogeneity in most outcomes. Meta-regression analyses identified covariates that could explain the heterogeneity: implantation period, valve type, patient age, gender, pre-intervention New York Heart Association class III/IV, concomitant CABG, study design and follow-up length. There is possible publication bias in all outcomes. This comprehensive systematic review and meta-analysis provides an overview of the outcomes after AVR with bioprostheses and allografts reported during the last 15 years. The results of this study can support patients and doctors in the prosthetic valve choice and can be used in microsimulation models to predict patient outcomes and estimate the cost-effectiveness of AVR with bioprostheses or allografts compared with current and future heart valve prostheses.
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Affiliation(s)
- Simone A Huygens
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands .,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands.,Department of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Milad Hanif
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands.,Department of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
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18
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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: 18] [Impact Index Per Article: 2.0] [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.
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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
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19
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Oterhals K, Hanssen TA, Haaverstad R, Nordrehaug JE, Eide GE, Norekvål TM. Factors associated with poor self-reported health status after aortic valve replacement with or without concomitant bypass surgery. Eur J Cardiothorac Surg 2014; 48:283-92. [DOI: 10.1093/ejcts/ezu425] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 10/16/2014] [Indexed: 11/12/2022] Open
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20
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Petrov G, Dworatzek E, Schulze TM, Dandel M, Kararigas G, Mahmoodzadeh S, Knosalla C, Hetzer R, Regitz-Zagrosek V. Maladaptive Remodeling Is Associated With Impaired Survival in Women But Not in Men After Aortic Valve Replacement. JACC Cardiovasc Imaging 2014; 7:1073-80. [DOI: 10.1016/j.jcmg.2014.06.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/21/2014] [Accepted: 06/12/2014] [Indexed: 10/24/2022]
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21
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Conrotto F, D'Ascenzo F, Salizzoni S, Presbitero P, Agostoni P, Tamburino C, Tarantini G, Bedogni F, Nijhoff F, Gasparetto V, Napodano M, Ferrante G, Rossi ML, Stella P, Brambilla N, Barbanti M, Giordana F, Grasso C, Biondi Zoccai G, Moretti C, D'Amico M, Rinaldi M, Gaita F, Marra S. A gender based analysis of predictors of all cause death after transcatheter aortic valve implantation. Am J Cardiol 2014; 114:1269-74. [PMID: 25159239 DOI: 10.1016/j.amjcard.2014.07.053] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/10/2014] [Accepted: 07/10/2014] [Indexed: 02/05/2023]
Abstract
The impact of gender-related pathophysiologic features of severe aortic stenosis on transcatheter aortic valve implantation (TAVI) outcomes remains to be determined, as does the consistency of predictors of mortality between the genders. All consecutive patients who underwent TAVI at 6 institutions were enrolled in this study and stratified according to gender. Midterm all-cause mortality was the primary end point, with events at 30 days and at midterm as secondary end points. All events were adjudicated according to Valve Academic Research Consortium definitions. Eight hundred thirty-six patients were enrolled, 464 (55.5%) of whom were female. At midterm follow-up (median 365 days, interquartile range 100 to 516) women had similar rates of all-cause mortality compared with men (18.1% vs 22.6%, p = 0.11) and similar incidence of myocardial infarction and cerebrovascular accident. Gender did not affect mortality also on multivariate analysis. Among clinical and procedural features, glomerular filtration rate <30 ml/min/1.73 m(2) (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.36 to 4.79) and systolic pulmonary arterial pressure >50 mm Hg (HR 2.26, 95% CI 1.26 to 4.02) independently predicted mortality in women, while insulin-treated diabetes (HR 3.45, 95% CI 1.47 to 8.09), previous stroke (HR 3.42, 95% CI 1.43 to 8.18), and an ejection fraction <30% (HR 3.82, 95% CI 1.41 to 10.37) were related to mortality in men. Postprocedural aortic regurgitation was independently related to midterm mortality in the 2 groups (HR 11.19, 95% CI 3.3 to 37.9). In conclusion, women and men had the same life expectancy after TAVI, but different predictors of adverse events stratified by gender were demonstrated. These findings underline the importance of a gender-tailored clinical risk assessment in TAVI patients.
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Affiliation(s)
- Federico Conrotto
- Division of Cardiology 2, Città della Salute e della Scienza Hospital, Turin, Italy.
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiac Surgery, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Giuseppe Tarantini
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesco Bedogni
- Department of Cardiology, Istituto Clinico S. Ambrogio, IRCCS San Donato, Milan, Italy
| | | | - Valeria Gasparetto
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Massimo Napodano
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | | | | | - Nedy Brambilla
- Department of Cardiology, Istituto Clinico S. Ambrogio, IRCCS San Donato, Milan, Italy
| | - Marco Barbanti
- Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Francesca Giordana
- Division of Cardiology, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Costanza Grasso
- Division of Cardiology 2, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Claudio Moretti
- Division of Cardiology, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Maurizio D'Amico
- Division of Cardiology 2, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Città Della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Sebastiano Marra
- Division of Cardiology 2, Città della Salute e della Scienza Hospital, Turin, Italy
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Elhmidi Y, Piazza N, Mazzitelli D, Wottke M, Lange R, Bleiziffer S. Sex‐Related Differences in 2197 Patients Undergoing Isolated Surgical Aortic Valve Replacement. J Card Surg 2014; 29:772-8. [DOI: 10.1111/jocs.12442] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yacine Elhmidi
- Clinic for Cardiovascular SurgeryGerman Heart CentreMunichGermany
| | - Nicolo Piazza
- Clinic for Cardiovascular SurgeryGerman Heart CentreMunichGermany
| | | | - Michael Wottke
- Clinic for Cardiovascular SurgeryGerman Heart CentreMunichGermany
| | - Rüdiger Lange
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart AllianceMunichGermany
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23
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D’Ascenzo F, Gonella A, Moretti C, Omedè P, Salizzoni S, La Torre M, Giordana F, Barbanti M, Ussia GP, Brambilla N, Bedogni F, Gaita F, Tamburino C, Sheiban I. Gender differences in patients undergoing TAVI: a multicentre study. EUROINTERVENTION 2013; 9:367-372. [DOI: 10.4244/eijv9i3a59] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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24
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Buja P, Napodano M, Tamburino C, Petronio AS, Ettori F, Santoro G, Ussia GP, Klugmann S, Bedogni F, Ramondo A, Maisano F, Marzocchi A, Poli A, Gasparetto V, Antoniucci D, Colombo A, Tarantini G. Comparison of variables in men versus women undergoing transcatheter aortic valve implantation for severe aortic stenosis (from Italian Multicenter CoreValve registry). Am J Cardiol 2013; 111:88-93. [PMID: 23245837 DOI: 10.1016/j.amjcard.2012.08.051] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 12/20/2022]
Abstract
Although transcatheter aortic valve implantation (TAVI) for severe aortic stenosis is becoming an established technique, the effect of gender-related differences is poorly described. We performed a gender-based comparison of high-risk patients undergoing TAVI with the self-expandable CoreValve Revalving System for severe aortic stenosis to evaluate early and mid-term clinical outcomes. From the Italian prospective CoreValve registry, 659 consecutive patients (55.8% women) who underwent TAVI were included in the present study. We analyzed the gender-based differences in terms of clinical, angiographic, and procedural features and the differences in the rate of early and mid-term major adverse cardiac and cerebrovascular events. The men were younger, presented more often with severe left ventricular dysfunction, and had a greater rate of previous myocardial infarction, coronary revascularization, peripheral artery disease, renal failure, and heart conduction disorders than the women. The logistic European System for Cardiac Operative Risk Evaluation score did not differ between the 2 groups. The overall unadjusted and adjusted analyses failed to show significant differences between genders in terms of major adverse cardiac and cerebrovascular events at a median follow-up of 13 months (range 8 to 18). At late follow-up (landmark analysis >12 months), a survival benefit was observed in women (hazard ratio 0.27, 95% confidence interval 0.09 to 0.84, p = 0.02). In conclusion, in this multicenter registry, the gender-based comparison of TAVI patients showed that men, despite the younger age, had more extensive atherosclerotic burden compared to women. Overall, the early and mid-term outcomes were similar between genders, although women might have a survival benefit with longer follow-up.
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Affiliation(s)
- Paolo Buja
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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