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Farooqui N, Killian JM, Smith J, Redfield MM, Dunlay SM. Advanced Heart Failure Characteristics and Outcomes in Women and Men. J Am Heart Assoc 2024; 13:e033374. [PMID: 38904243 PMCID: PMC11255701 DOI: 10.1161/jaha.123.033374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/15/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The epidemiology and pathophysiology of heart failure (HF) differ in women and men. Whether these differences extend to the subgroup of patients with advanced HF is not well defined. METHODS AND RESULTS This is a retrospective cohort study of all adult Olmsted County, Minnesota residents with advanced HF (European Society of Cardiology criteria) from 2007 to 2017. Differences in survival and hospitalization risks in women and men following advanced HF development were examined using Cox proportional hazard regression and Andersen-Gill models, respectively. Of 936 individuals with advanced HF, 417 (44.6%) were women and 519 (55.4%) were men (self-reported sex). Time from development of HF to advanced HF was similar in women and men (median 3.2 versus 3.6 years). Women were older at diagnosis (mean age 79 versus 75 years), less often had coronary disease and hyperlipidemia, but more often had hypertension and depression (P<0.05 for each). Advanced HF with preserved ejection fraction was more prevalent in women than men (60% versus 30%, p<0.001). There were no differences in adjusted risks of all-cause mortality (hazard ratio [HR], 0.89 [95% CI, 0.77-1.03]), cardiovascular mortality (HR, 0.85 [95% CI, 0.70-1.02]), all-cause hospitalizations (HR, 1.04 [95% CI, 0.90-1.20]), or HF hospitalizations (HR, 0.91 [95% CI, 0.75-1.11]) between women and men. However, adjusted cardiovascular mortality was lower in women versus men with advanced HF with reduced ejection fraction (HR, 0.72 [95% CI, 0.56-0.93]). CONCLUSIONS Women more often present with advanced HF with preserved ejection fraction and men with atherosclerotic disease and advanced HF with reduced ejection fraction. Despite these differences, survival and hospitalization risks are largely comparable in women and men with advanced HF.
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Affiliation(s)
- Naba Farooqui
- Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Jill M. Killian
- Department of Quantitative Health SciencesMayo ClinicRochesterMNUSA
| | - Jamie Smith
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMNUSA
| | | | - Shannon M. Dunlay
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMNUSA
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
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Severo Sánchez A, González Martín J, de Juan Bagudá J, Morán Fernández L, Muñoz Guijosa C, Arribas Ynsaurriaga F, Delgado JF, García-Cosío Carmena MD. Sex and Gender-related Disparities in Clinical Characteristics and Outcomes in Heart Transplantation. Curr Heart Fail Rep 2024:10.1007/s11897-024-00670-0. [PMID: 38861129 DOI: 10.1007/s11897-024-00670-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE OF REVIEW Limited research has been conducted on sex disparities in heart transplant (HT). The aim of this review is to analyse the available evidence on the influence of sex and gender-related determinants in the entire HT process, as well as to identify areas for further investigation. RECENT FINDINGS Although women make up half of the population affected by heart failure and related mortality, they account for less than a third of HT recipients. Reasons for this inequality include differences in disease course, psychosocial factors, concerns about allosensitisation, and selection or referral bias in female patients. Women are more often listed for HT due to non-ischaemic cardiomyopathy and have a lower burden of cardiovascular risk factors. Although long-term prognosis appears to be similar for both sexes, there are significant disparities in post-HT morbidity and causes of mortality (noting a higher incidence of rejection in women and of malignancy and cardiac allograft vasculopathy in men). Additional research is required to gain a better understanding of the reasons behind gender disparities in eligibility and outcomes following HT. This would enable the fair allocation of resources and enhance patient care.
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Affiliation(s)
- Andrea Severo Sánchez
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Javier González Martín
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Javier de Juan Bagudá
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Laura Morán Fernández
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Christian Muñoz Guijosa
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
- Cardiac Surgery Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Arribas Ynsaurriaga
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Juan Francisco Delgado
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Dolores García-Cosío Carmena
- Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.
- Centro Nacional de Investigaciones Biomédicas en Red de Enfermedades CardioVasculares (CIBERCV), Madrid, Spain.
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Chehade M, Murali KP, Dickson VV, McCarthy MM. Intersection of social determinants of health with ventricular assist device therapy: An integrative review. Heart Lung 2024; 66:56-70. [PMID: 38583277 DOI: 10.1016/j.hrtlng.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure. OBJECTIVES The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy. METHODS Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years). RESULTS 22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes. CONCLUSION This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.
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Affiliation(s)
- Mireille Chehade
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States.
| | - Komal Patel Murali
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Victoria Vaughan Dickson
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Margaret M McCarthy
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
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Mariani S, Ravaux JM, van Bussel BCT, De Piero ME, van Kruijk SMJ, Schaefer AK, Wiedemann D, Saeed D, Pozzi M, Loforte A, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Mazzeffi MA, Matteucci S, Sponga S, Sorokin V, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Features and outcomes of female and male patients requiring postcardiotomy extracorporeal life support. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00435-5. [PMID: 38762034 DOI: 10.1016/j.jtcvs.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/08/2024] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVES Although cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support. METHODS This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models. RESULTS This analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments. CONCLUSIONS This study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.
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Affiliation(s)
- Silvia Mariani
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Cardiac Surgery Unit, Cardio-Thoracic and Vascular Department, Fondazione IRCCS San Gerardo, Monza, Italy.
| | - Justine Mafalda Ravaux
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maria Elena De Piero
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands
| | - Sander M J van Kruijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands; Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia; St Vincent's Centre for Applied Medical Research, University of New South Wales, Sidney, New South Wales, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Michael A Mazzeffi
- Departments of Medicine and Surgery, University of Maryland, Baltimore, Md
| | - Sacha Matteucci
- Cardiac Surgery Unit, Cardiovascular Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Vitaly Sorokin
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, Cardio-Thoracic and Vascular Department, Fondazione IRCCS San Gerardo, Monza, Italy; Department of Medicine and Surgery, University of Parma, Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardio-Thoracic Surgery, University Hospital Henri-Mondor, Créteil, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- ECMO Unit, Departamento de Anestesia, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, Fla
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Giacomo Bianchi
- Department of Adult Cardiac Surgery, Ospedale del Cuore Fondazione Toscana "G. Monasterio," Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, Cardiovascular Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - José P Garcia
- Division of Cardiothoracic Surgery, Department of Surgery, IU Health Advanced Heart & Lung Care, Indiana University Methodist Hospital, Indianapolis, Ind
| | - Kiran Shekar
- Intensive Care Unit, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands; Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands
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5
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Thompson MP, Hou H, Fliegner M, Guduguntla V, Cascino T, Aaronson KD, Likosky DS, Sukul D, Keteyian SJ. Cardiac Rehabilitation Use After Heart Failure Hospitalization Associated With Advanced Heart Failure Center Status. J Cardiopulm Rehabil Prev 2024; 44:194-201. [PMID: 38300252 PMCID: PMC11065630 DOI: 10.1097/hcr.0000000000000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE Cardiac rehabilitation (CR) is an evidence-based, guideline-endorsed therapy for patients with heart failure with reduced ejection fraction (HFrEF) but is broadly underutilized. Identifying structural factors contributing to increased CR use may inform quality improvement efforts. The objective here was to associate hospitalization at a center providing advanced heart failure (HF) therapies and subsequent CR participation among patients with HFrEF. METHODS A retrospective analysis was performed on a 20% sample of Medicare beneficiaries primarily hospitalized with an HFrEF diagnosis between January 2008 and December 2018. Outpatient claims were used to identify CR use (no/yes), days to first session, number of attended sessions, and completion of 36 sessions. The association between advanced HF status (hospitals performing heart transplantation or ventricular assist device implantations) and CR participation was evaluated with logistic regression, accounting for patient, hospital, and regional factors. RESULTS Among 143 392 Medicare beneficiaries, 29 487 (20.6%) were admitted to advanced HF centers (HFCs) and 5317 (3.7%) attended a single CR session within 1 yr of discharge. In multivariable analysis, advanced HFC status was associated with significantly greater relative odds of participating in CR (OR = 2.20: 95% CI, 2.08-2.33; P < .001) and earlier initiation of CR participation (-8.5 d; 95% CI, -12.6 to 4.4; P < .001). Advanced HFC status had little to no association with the intensity of CR participation (number of visits or 36 visit completion). CONCLUSIONS Medicare beneficiaries hospitalized for HF were more likely to attend CR after discharge if admitted to an advanced HFC than a nonadvanced HFC.
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Affiliation(s)
- Michael P. Thompson
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Max Fliegner
- Oakland University William Beaumont School of Medicine, Auburn Hills, MI, USA
| | - Vinay Guduguntla
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thomas Cascino
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Donald S. Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI, USA
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Lucà F, Pavan D, Gulizia MM, Manes MT, Abrignani MG, Benedetto FA, Bisceglia I, Brigido S, Caldarola P, Calvanese R, Canale ML, Caretta G, Ceravolo R, Chieffo A, Chimenti C, Cornara S, Cutolo A, Di Fusco SA, Di Matteo I, Di Nora C, Fattirolli F, Favilli S, Francese GM, Gelsomino S, Geraci G, Giubilato S, Ingianni N, Iorio A, Lanni F, Montalto A, Nardi F, Navazio A, Nesti M, Parrini I, Pilleri A, Pozzi A, Rao CM, Riccio C, Rossini R, Scicchitano P, Valente S, Zuccalà G, Gabrielli D, Grimaldi M, Colivicchi F, Oliva F. Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'. Eur Heart J Suppl 2024; 26:ii264-ii293. [PMID: 38784671 PMCID: PMC11110461 DOI: 10.1093/eurheartjsupp/suae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Daniela Pavan
- Cardio-Cerebro-Rehabilitation Department, Azienda Sanitaria Friuli Occidentale, (AS FO) Via della Vecchia Ceramica, 1, Pordenone 33170, Italy
| | - Michele Massimo Gulizia
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | - Maria Teresa Manes
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | | | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Irma Bisceglia
- Cardio-Thoraco-Vascular Department, San Camillo Forlanini Hospital, 00152 Roma, Italy
| | - Silvana Brigido
- Cardiology Clinics, ‘F.’ Hospital Jaia’, 70014 Conversano, BA, Italy
| | | | | | | | - Giorgio Caretta
- Cardiology Unit, Sant’Andrea Hospital, 19100 La Spezia, SP, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospial, 88046 Lamezia Terme, CZ, Italy
| | - Alaide Chieffo
- Interventional Cardiology, IRCCS Ospedale San Raffaele, 20132 Milano, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, 00161 Roma, Italy
| | - Stefano Cornara
- Levante Cardiology, San Paolo Hospital, Savona, 17100 Savona, SV, Italy
| | - Ada Cutolo
- Cardiolog Unit, Ospedale dell’Angelo, 30172 Mestre, Italy
| | | | - Irene Di Matteo
- Cardiology Unit, Cariovascular Department, ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Concetta Di Nora
- Cardiac Surgery Unit, Santa Maria della Misericordia Hospital, 33100 Udine, UD, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, Florence University, 50121 Firenze, Italy
| | - Silvia Favilli
- Pediatric and Transition Cardiology Unit, Meyer University Hospital, 50139 Florence, Italy
| | - Giuseppina Maura Francese
- Cardiology Unit, Cardiology Spoke Cetraro-Paola, San Franceco di paola Hospital, 87027 Paola, CS, Italy
| | - Sandro Gelsomino
- Pediatric and Transition Cardiology Unit, Meyer University Hospital, 50139 Florence, Italy
| | - Giovanna Geraci
- Cardiology Unit, Sant'Antonio Abate di Erice, 91016 Erice, Trapani, Italy
| | | | | | - Annamaria Iorio
- Cardiology Unity 1, Cardiology 1, Cardiovascular Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Francesca Lanni
- Cardiology Unity, San Giuseppe Moscati Hospital, 83100 Avellino, Italy
| | - Andrea Montalto
- Cardiac Surgery Unit, San Camillo Forlanini Hospital, 00152 Roma, Italy
| | - Federico Nardi
- Dipartimento di Cardiologia, Ospedale Santo Spirito, Casale Monferrato, Italy
| | | | - Martina Nesti
- Cardiology Unity, San Donato Hospital, 52100 Arezzo, Italy
| | - Iris Parrini
- Cardiology Unity, Umberto I Di Torino Hospital, 10128 Torino, Italy
| | - Annarita Pilleri
- Federico Nardi, Cardiology Unit, Casale Monferrato Hospital, 15033 Casale Monferrato (AL), Italy
| | - Andrea Pozzi
- Cardiology Unity 1, Cardiology 1, Cardiovascular Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano GOM, Reggio Calabria, Via Melacriono, 1, 89129 Reggio, Calabria, Italy
| | - Carmine Riccio
- Post-Acute Patient Follow-up Unit, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | | | | | - Serafina Valente
- Clinical-Surgical Cardiology, A.O.U. Siena, Santa Maria alle Scotte Hospital, 53100 Siena, Italy
| | - Giuseppe Zuccalà
- Department of Geriatrics, Center for Aging Medicine, Catholic University of the Sacred Heart and IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
- Fondazione per il Tuo cuore—Heart Care Foundation, 50121 Firenze, Italy
| | - Massimo Grimaldi
- Cardiology Division, Coronary Intensive Care Unit, Miulli Hospital, 70021 Acquaviva delle Fonti, Italy
| | | | - Fabrizio Oliva
- Cardiology Unit, Cariovascular Department, ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
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Martin CM. Cardiomyopathies in Women. Methodist Debakey Cardiovasc J 2024; 20:59-69. [PMID: 38495661 PMCID: PMC10941701 DOI: 10.14797/mdcvj.1368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Heart failure affects over 2.6 million people in the United States. While women have better overall survival rates, they also suffer from higher morbidity as shown by higher rates of hospitalization and worse quality of life. Several anatomical differences in women's hearts affect both systolic and diastolic cardiac physiology. Despite these findings, women are significantly underrepresented in clinical trials, necessitating extrapolation of data from males. Because women have sex-specific etiologies of heart failure and unique manifestations in genetic-related cardiomyopathies, meaningful sex-related differences affect heart failure outcomes as well as access to and outcomes in advanced heart failure therapies in women. This review explores these gender-specific differences and potential solutions to balance care between women and men.
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Affiliation(s)
- Cindy M. Martin
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
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8
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Imburgio S, Dandu S, Pannu V, Udongwo N, Johal A, Hossain M, Patel P, Sealove B, Almendral J, Heaton J. Sex-based differences in left ventricular assist device clinical outcomes. Catheter Cardiovasc Interv 2024; 103:376-381. [PMID: 37870108 DOI: 10.1002/ccd.30892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/01/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Heart failure (HF) continues to be a significant public health issue, posing a heightened risk of morbidity and mortality for both genders. Despite the widespread use of left ventricular assist device (LVAD), the influence of gender differences on clinical outcomes following implantation remains unclear. OBJECTIVES We investigated the impact of gender differences on readmission rates and other outcomes following LVAD implantation in patients admitted with advanced HF. METHODS We conducted a retrospective study of patients who underwent LVAD implantation for advanced HF between 2014 and 2020, using the Nationwide Readmissions Database. Our study cohort was divided into male and female patients. The primary outcome was 30-day readmission (30-dr), while secondary outcomes were inpatient mortality, length of stay (LOS), procedural complication rates, and periadmission rates. Multivariate linear, Cox, and logistic regression analyses were performed. RESULTS During the study period, 11,492 patients with advanced HF who had LVAD placement were identified. Of these, 22% (n = 2532) were females and 78% (n = 8960) were males. The mean age was 53.9 ± 10.8 years for females and 56.3 ± 10.5 years for males (adjusted Wald test, p < 0.01). Readmissions were higher in females (21% vs. 17%, p = 0.02) when compared to males. Cox regression analysis showed higher readmission events (hazard ratio: 1.24, 95% confidence interval: 1.01-1.52, p = 0.03) in females when compared to males. Inpatient mortality, LOS, and most procedural complication rates were not statistically significantly different between the two groups (p > 0.05, all). CONCLUSION Women experienced higher readmission rates and were more likely to be readmitted multiple times after LVAD implantation when compared to their male counterparts. However, there were no significant sex-based differences in inpatient mortality, LOS, and nearly all procedural complication rates. These findings suggest that female patients may require closer monitoring and targeted interventions to reduce readmission rates.
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Affiliation(s)
- Steven Imburgio
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Sowmya Dandu
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Viraaj Pannu
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Ndausung Udongwo
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Anmol Johal
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Mohammad Hossain
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Palak Patel
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Brett Sealove
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Jesus Almendral
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
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9
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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10
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Chung A, Hartman H, DeFilippis EM. Sex Differences in Cardiac Transplantation. Curr Atheroscler Rep 2023; 25:995-1001. [PMID: 38060058 DOI: 10.1007/s11883-023-01169-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW The goal of this review was to summarize contemporary evidence surrounding sex differences in heart transplantation (HT). RECENT FINDINGS Women have steadily comprised approximately 25% of waitlist candidates and HT recipients. This disparity is likely multifactorial with possible explanations including barriers in referral to advanced heart failure providers, implicit bias, and concerns surrounding sensitization. Women continue to experience higher waitlist mortality at the highest priority tiers. After HT, there are differences in post-transplant complications and outcomes. Future areas of study should include sex differences in noninvasive surveillance, renal outcomes after transplantation, and patient-reported outcomes. There are important sex-specific considerations that impact candidate selection, donor matching, waitlist and post-transplant outcomes. Concerted efforts are needed to improve referral patterns to ensure transplantation is allocated equally.
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Affiliation(s)
- Alice Chung
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Heidi Hartman
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 12-1284, New York, NY, 10032, USA.
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11
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Shetty NS, Parcha V, Abdelmessih P, Patel N, Hasnie AA, Kalra R, Pandey A, Breathett K, Morris AA, Arora G, Arora P. Sex-Associated Differences in the Clinical Outcomes of Left Ventricular Assist Device Recipients: Insights From Interagency Registry for Mechanically Assisted Circulatory Support. Circ Heart Fail 2023; 16:e010189. [PMID: 37232167 PMCID: PMC10421565 DOI: 10.1161/circheartfailure.122.010189] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sex-associated differences in clinical outcomes among left ventricular assist device recipients in the United States have been recognized. However, an investigation of the social and clinical determinants of sex-associated differences is lacking. METHODS Left ventricular assist device receiving patients enrolled in Interagency Registry for Mechanically Assisted Circulatory Support between 2005 and 2017 were included. The primary outcome was all-cause mortality. Secondary outcomes included heart transplantation and postimplantation adverse event rates. The cohort was stratified by the social subgroup of race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic), and clinical subgroups of device strategy (destination therapy, bridge to transplant, and bridge to candidacy), and implantation center volume (low [≤20 implants/y], medium [21-30 implants/y], and high [>30 implants/y]). A multivariable-adjusted Cox proportional hazard model was used to assess the risk of death and heart transplantation with prespecified interaction testing. Poisson regression was used to estimate adverse events by sex across the various subgroups. RESULTS Among 18 525 patients, there were 3968 (21.4%) females. Compared with their male counterparts, Hispanic (adjusted hazard ratio [HRadj], 1.75 [1.23-2.47]) females had the highest risk of death followed by non-Hispanic White females (HRadj, 1.15 [1.07-1.25]; Pinteraction=0.02). Hispanic (HRadj, 0.60 [0.40-0.89]) females had the lowest cumulative incidence of heart transplantation followed by non-Hispanic Black females (HRadj, 0.76 [0.67-0.86]), and non-Hispanic White females (HRadj, 0.88 [0.80-0.96]) compared with their male counterparts (Pinteraction<0.001). Compared with their male counterparts, females on the bridge to candidacy strategy (HRadj, 1.32 [1.18-1.48]) had the highest risk of death (Pinteraction=0.01). The risk of death (Pinteraction=0.44) and cumulative incidence of heart transplantation (Pinteraction=0.40) did not vary by sex in the center volume subgroup. A higher incidence rate of adverse events after left ventricular assist device implantation was also seen in females compared with the males, overall, and across all subgroups. CONCLUSIONS Among left ventricular assist device recipients, the risk of death, the cumulative incidence of heart transplantation, and adverse events differ by sex across the social and clinical subgroups.
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Affiliation(s)
- Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Abdelmessih
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar A. Hasnie
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Khadijah Breathett
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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12
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Fairweather D, Beetler DJ, Musigk N, Heidecker B, Lyle MA, Cooper LT, Bruno KA. Sex and gender differences in myocarditis and dilated cardiomyopathy: An update. Front Cardiovasc Med 2023; 10:1129348. [PMID: 36937911 PMCID: PMC10017519 DOI: 10.3389/fcvm.2023.1129348] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
In the past decade there has been a growing interest in understanding sex and gender differences in myocarditis and dilated cardiomyopathy (DCM), and the purpose of this review is to provide an update on this topic including epidemiology, pathogenesis and clinical presentation, diagnosis and management. Recently, many clinical studies have been conducted examining sex differences in myocarditis. Studies consistently report that myocarditis occurs more often in men than women with a sex ratio ranging from 1:2-4 female to male. Studies reveal that DCM also has a sex ratio of around 1:3 women to men and this is also true for familial/genetic forms of DCM. Animal models have demonstrated that DCM develops after myocarditis in susceptible mouse strains and evidence exists for this progress clinically as well. A consistent finding is that myocarditis occurs primarily in men under 50 years of age, but in women after age 50 or post-menopause. In contrast, DCM typically occurs after age 50, although the age that post-myocarditis DCM occurs has not been investigated. In a small study, more men with myocarditis presented with symptoms of chest pain while women presented with dyspnea. Men with myocarditis have been found to have higher levels of heart failure biomarkers soluble ST2, creatine kinase, myoglobin and T helper 17-associated cytokines while women develop a better regulatory immune response. Studies of the pathogenesis of disease have found that Toll-like receptor (TLR)2 and TLR4 signaling pathways play a central role in increasing inflammation during myocarditis and in promoting remodeling and fibrosis that leads to DCM, and all of these pathways are elevated in males. Management of myocarditis follows heart failure guidelines and there are currently no disease-specific therapies. Research on standard heart failure medications reveal important sex differences. Overall, many advances in our understanding of the effect of biologic sex on myocarditis and DCM have occurred over the past decade, but many gaps in our understanding remain. A better understanding of sex and gender effects are needed to develop disease-targeted and individualized medicine approaches in the future.
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Affiliation(s)
- DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Environmental Health Sciences and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
| | - Danielle J. Beetler
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL, United States
| | - Nicolas Musigk
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bettina Heidecker
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Melissa A. Lyle
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Leslie T. Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Katelyn A. Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
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13
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Sex Differences in Acute Heart Failure Management: Is There a Gap in Treatment Quality? Curr Heart Fail Rep 2023; 20:121-128. [PMID: 36802008 DOI: 10.1007/s11897-023-00593-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE OF REVIEW Differences between men and women in demographics and clinical phenotype of heart failure have previously been described, as well as disparities in management and outcomes. This review summarizes the latest evidence concerning sex-related differences in acute heart failure and its most severe form, cardiogenic shock. RECENT FINDINGS Data from the last 5 years reaffirm the previous observations, with women with acute heart failure being older, more often having preserved ejection fraction and less frequently having an ischemic cause of the acute decompensation. Despite women still receive less invasive procedures and a less optimized medical treatment, the most recent studies find similar outcomes regardless of sex. These disparities persist in the context of cardiogenic shock, where women receive less mechanical circulatory support devices even if they present with more severe forms. This review reveals a different clinical picture of women with acute heart failure and cardiogenic shock compared to men, which translates into disparities in management. More female representation in studies would be needed in order to better understand the physiopathological basis of these differences and minimize inequalities in treatment and outcomes.
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14
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Arjomandi Rad A, Kapadia S, Zubarevich A, Nanchahal S, Van den Eynde J, Vardanyan R, Bareka M, Krasopoulos G, Quarto C, Ruhparwar A, Athanasiou T, Weymann A. Sex disparities in left ventricular assist device implantation outcomes: A systematic review and meta-analysis of over 50 000 patients. Artif Organs 2023; 47:273-289. [PMID: 36461903 DOI: 10.1111/aor.14469] [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: 09/28/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) represent an important therapeutic option for patients progressing to end-stage heart failure. Women have been historically underrepresented in LVAD studies, and have been reported to have worse outcomes despite technological optimisation. We aimed to systematically explore the evidence on sex disparities in the use and outcomes of LVAD implantation. METHODS A systematic database search with meta-analysis was conducted of comparative original articles of men versus women undergoing LVAD implantation, in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to July 2022. Primary outcomes were stroke (haemorrhagic and ischaemic) and early/overall mortality. Secondary outcomes were LVAD thrombosis, right VAD implantation, major bleeding, kidney dysfunction, and device/driveline infection. RESULTS Our search yielded 137 relevant studies, including 22 meeting the inclusion criteria with a total of 53 227 patients (24.2% women). Overall mortality was higher in women (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.05-1.62, p = 0.02), as was overall stroke (OR 1.32, 95%CI 1.06-1.66, p = 0.01), including ischemic (OR 1.80, 95%CI 1.22-2.64, p = 0.003) and haemorrhagic (OR 1.72, 95%CI 1.09-2.70, p = 0.02). Women had more frequent right VAD implantation (OR 2.11, 95%CI 1.24-3.57, p = 0.006) and major bleeding (OR 1.40, 95%CI 1.06-1.85, p = 0.02). Kidney dysfunction, LVAD thrombosis, and device/driveline infections were comparable between sexes. CONCLUSIONS Our analysis suggests that women face a greater risk of adverse events and mortality post-LVAD implantation. Although the mechanisms remain unclear, the difference in outcomes is thought to be multifactorial. Further research, that includes comprehensive pre-operative characteristics and post-operative outcomes, is encouraged.
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Affiliation(s)
- Arian Arjomandi Rad
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Sharan Kapadia
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Sukanya Nanchahal
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | | | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Metaxia Bareka
- Department of Anaesthesiology, University of Laryssa, Laryssa, Greece
| | - George Krasopoulos
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospital NHS Trust, Oxford, UK
| | - Cesare Quarto
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Trust, London, UK
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
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15
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Narang N, Nakamura M, Imamura T. Disparities in mechanical circulatory support utilization post cardiac arrest: An uncomfortable reality. Int J Cardiol 2023; 371:126-127. [PMID: 36216088 DOI: 10.1016/j.ijcard.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
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16
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Cascino TM, Colvin M, Lanfear DE, Richards B, Khalatbari S, Mann DL, Taddei-Peters WC, Jeffries N, Watkins DC, Stewart GC, Aaronson KD. Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study. Circ Heart Fail 2023; 16:e009745. [PMID: 36259388 PMCID: PMC9851944 DOI: 10.1161/circheartfailure.122.009745] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/24/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. METHODS We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. RESULTS The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. CONCLUSIONS Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01369407.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | | | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | | | | | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
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17
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Radhoe SP, Jakus N, Veenis JF, Timmermans P, Pouleur A, Rubís P, Van Craenenbroeck EM, Gaizauskas E, Barge‐Caballero E, Paolillo S, Grundmann S, D'Amario D, Braun OÖ, Gkouziouta A, Planinc I, Macek JL, Meyns B, Droogne W, Wierzbicki K, Holcman K, Flammer AJ, Gasparovic H, Biocina B, Milicic D, Lund LH, Ruschitzka F, Brugts JJ, Cikes M. Sex‐related differences in left ventricular assist device utilization and outcomes: results from the PCHF‐VAD registry. ESC Heart Fail 2022; 10:1054-1065. [PMID: 36547014 PMCID: PMC10053365 DOI: 10.1002/ehf2.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/05/2022] [Accepted: 11/27/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Data on sex and left ventricular assist device (LVAD) utilization and outcomes have been conflicting and mostly confined to US studies incorporating older devices. This study aimed to investigate sex-related differences in LVAD utilization and outcomes in a contemporary European LVAD cohort. METHODS AND RESULTS This analysis is part of the multicentre PCHF-VAD registry studying continuous-flow LVAD patients. The primary outcome was all-cause mortality. Secondary outcomes included ventricular arrhythmias, right ventricular failure, bleeding, thromboembolism, and the haemocompatibility score. Multivariable Cox regression models were used to assess associations between sex and outcomes. Overall, 457 men (81%) and 105 women (19%) were analysed. At LVAD implant, women were more often in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 or 2 (55% vs. 41%, P = 0.009) and more often required temporary mechanical circulatory support (39% vs. 23%, P = 0.001). Mean age was comparable (52.1 vs. 53.4 years, P = 0.33), and median follow-up duration was 344 [range 147-823] days for women and 435 [range 190-816] days for men (P = 0.40). No significant sex-related differences were found in all-cause mortality (hazard ratio [HR] 0.79 for female vs. male sex, 95% confidence interval [CI] [0.50-1.27]). Female LVAD patients had a lower risk of ventricular arrhythmias (HR 0.56, 95% CI [0.33-0.95]) but more often experienced right ventricular failure. No significant sex-related differences were found in other outcomes. CONCLUSIONS In this contemporary European cohort of LVAD patients, far fewer women than men underwent LVAD implantation despite similar clinical outcomes. This is important as the proportion of female LVAD patients (19%) was lower than the proportion of females with advanced HF as reported in previous studies, suggesting underutilization. Also, female patients were remarkably more often in INTERMACS profile 1 or 2, suggesting later referral for LVAD therapy. Additional research in female patients is warranted.
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Affiliation(s)
- Sumant P. Radhoe
- Department of Cardiology, Thorax Center Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Nina Jakus
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Jesse F. Veenis
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | | | - Anne‐Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases Cliniques Universitaires St. Luc Brussels Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Louvain Belgium
| | - Pawel Rubís
- Department of Cardiac and Vascular Diseases Krakow Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | | | - Edvinas Gaizauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine Vilnius University Vilnius Lithuania
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences Federico II University of Naples Naples Italy
| | - Sebastian Grundmann
- Faculty of Medicine Heart Center Freiburg University, University of Freiburg Freiburg Germany
| | - Domenico D'Amario
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Oscar Ö. Braun
- Department of Cardiology, Clinical Sciences Lund University and Skåne University Hospital Lund Sweden
| | | | - Ivo Planinc
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Jana Ljubas Macek
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Bart Meyns
- Department of Cardiac Surgery University Hospital Leuven Leuven Belgium
| | - Walter Droogne
- Department of Cardiology University Hospital Leuven Leuven Belgium
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | - Katarzyna Holcman
- Department of Cardiac and Vascular Diseases Krakow Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | | | - Hrvoje Gasparovic
- Department of Cardiac Surgery University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Davor Milicic
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Lars H. Lund
- Department of Medicine Karolinska Institute Stockholm Sweden
| | - Frank Ruschitzka
- Clinic for Cardiology University Hospital Zurich Zurich Switzerland
| | - Jasper J. Brugts
- Department of Cardiology, Thorax Center Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Maja Cikes
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
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18
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Jones MM, McElroy LM, Mirreh M, Fuller M, Schroeder R, Ghadimi K, DeVore A, Patel CB, Black-Maier E, Bartz R, Thomas K. The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure. J Card Surg 2022; 37:3586-3594. [PMID: 36124416 PMCID: PMC11193413 DOI: 10.1111/jocs.16926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 05/10/2022] [Accepted: 08/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Heart failure affects >6 million people in the United States alone and is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program. METHODS A retrospective single-center cohort study was conducted at a single high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1, 2013 and 12, 2017 with a left ventricular ejection fraction < 30% and inotropic dependence or need for mechanical circulatory support were included. Patients with contraindications to durable LVAD were excluded. An adjusted logistic regression model for durable LVAD implantation within 90 days of the index admission was used to determine the effect of race on durable LVAD implantation. RESULTS Among the 702 study patients (60.9% White, 34.1% Black), durable LVAD implantation was performed within 90 days of the index admission in 183 (26%) of the cohort. After multivariate analysis, Black patients were not found to have a statistically significant difference in durable LVAD implantation rates compared to White patients in our study (OR: 0.68 [95% confidence interval: 0.45-1.04; p: .074]). CONCLUSIONS Black patients in our study did not have a statistically significant difference in the rate of durable LVAD implantation compared with White patients after adjustments were made for age, sex, socioeconomic, and clinical covariates. Larger prospective studies are needed to validate these findings.
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Affiliation(s)
- Mandisa-Maia Jones
- Department of Anesthesiology, Division of Cardiothoracic and Critical Care Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Lisa M. McElroy
- Department of Surgery, Division of Abdominal Transplant Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Manal Mirreh
- Department of Anesthesiology, Division of Pediatric Anesthesiology, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Matthew Fuller
- Department of Anesthesiology, Division of Cardiothoracic and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca Schroeder
- Department of Anesthesiology, Duke University School of Medicine, VAMC, Durham, North Carolina, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Division of Cardiothoracic and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam DeVore
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chetan B. Patel
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric Black-Maier
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Raquel Bartz
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kevin Thomas
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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19
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Cascino TM, McCullough JS, Wu X, Pienta MJ, Stewart JW, Hawkins RB, Brescia AA, Abou el ala A, Zhang M, Noly PE, Haft JW, Cowger JA, Colvin M, Aaronson KD, Pagani FD, Likosky DS. Comparison of Evaluations for Heart Transplant Before Durable Left Ventricular Assist Device and Subsequent Receipt of Transplant at Transplant vs Nontransplant Centers. JAMA Netw Open 2022; 5:e2240646. [PMID: 36342716 PMCID: PMC9641540 DOI: 10.1001/jamanetworkopen.2022.40646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022] Open
Abstract
Importance In 2020, the Centers for Medicare & Medicaid Services revised its national coverage determination, removing the requirement to obtain review from a Medicare-approved heart transplant center to implant a durable left ventricular assist device (LVAD) for bridge-to-transplant (BTT) intent at an LVAD-only center. The association between center-level transplant availability and access to heart transplant, the gold-standard therapy for advanced heart failure (HF), is unknown. Objective To investigate the association of center transplant availability with LVAD implant strategies and subsequent heart transplant following LVAD implant before the Centers for Medicare & Medicaid Services policy change. Design, Setting, and Participants A retrospective cohort study of the Society of Thoracic Surgeons Intermacs multicenter US registry database was conducted from April 1, 2012, to June 30, 2020. The population included patients with HF receiving a primary durable LVAD. Exposures LVAD center transplant availability (LVAD/transplant vs LVAD only). Main Outcomes and Measures The primary outcomes were implant strategy as BTT and subsequent transplant by 2 years. Covariates that might affect listing strategy and outcomes were included (eg, patient demographic characteristics, comorbidities) in multivariable models. Parameters for BTT listing were estimated using logistic regression with center-level random effects and for receipt of a transplant using a Cox proportional hazards regression model with death as a competing event. Results The sample included 22 221 LVAD recipients with a median age of 59.0 (IQR, 50.0-67.0) years, of whom 17 420 (78.4%) were male and 3156 (14.2%) received implants at LVAD-only centers. Receiving an LVAD at an LVAD/transplant center was associated with a 79% increased adjusted odds of BTT LVAD designation (odds ratio, 1.79; 95% CI, 1.35-2.38; P < .001). The 2-year transplant rate following LVAD implant was 25.6% at LVAD/transplant centers and 11.9% at LVAD-only centers. There was an associated 33% increased rate of transplant at LVAD/transplant centers compared with LVAD-only centers (adjusted hazard ratio, 1.33; 95% CI, 1.17-1.51) with a similar hazard for death at 2 years (adjusted hazard ratio, 0.99; 95% CI, 0.90-1.08). Conclusions and Relevance Receiving an LVAD at an LVAD-transplant center was associated with increased odds of BTT intent at implant and subsequent transplant receipt for patients at 2 years. The findings of this study suggest that Centers for Medicare & Medicaid Services policy change may have the unintended consequence of further increasing inequities in access to transplant among patients at LVAD-only centers.
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Affiliation(s)
- Thomas M. Cascino
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Xiaoting Wu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Michael J. Pienta
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - James W. Stewart
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Ashraf Abou el ala
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | | | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Jennifer A. Cowger
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Monica Colvin
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
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20
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Rubinstein G, Lotan D, Moeller CM, DeFilippis EM, Slomovich S, Oren D, Yuzefpolskaya M, Sayer G, Uriel N. Sex differences in patients undergoing heart transplantation and LVAD therapy. Expert Rev Cardiovasc Ther 2022; 20:881-894. [PMID: 36409479 DOI: 10.1080/14779072.2022.2149493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Left ventricular assist device (LVAD) and heart transplantation (HT) are the two life-sustaining therapies that have revolutionized the management of end-stage heart failure (HF). Yet, significant sex differences exist with respect to their use and effects. AREAS COVERED This review summarizes sex differences in the utilization, outcomes, and complications of LVAD and HT. Particular emphasis is placed on leading clinical trials in the field, historical and recent large registries-based analyses, as well as contemporary technological and policy changes affecting these differences. EXPERT OPINION Women with advanced HF remain under-treated with guideline-directed medical therapy and are less likely to be referred for consideration for LVAD and HT. This remains true despite newer LVAD technology and the new heart transplant allocation system. Community outreach, education, as well as increased representation of women in clinical research may reduce inequities.
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Affiliation(s)
- Gal Rubinstein
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Dor Lotan
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Cathrine M Moeller
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Sharon Slomovich
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Daniel Oren
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Gabriel Sayer
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
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21
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Jones-Ungerleider KC, Rose A, Knott K, Comstock S, Haft JW, Pagani FD, Tang PC. Sex-based considerations for implementation of ventricular assist device therapy. Front Cardiovasc Med 2022; 9:1011192. [DOI: 10.3389/fcvm.2022.1011192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Women with advanced heart failure receive advanced surgical therapies such as durable left ventricular assist device (LVAD) implantation or heart transplantation at a rate much lower compared to males. Reasons for this discrepancy remain largely unknown. Much of what is understood reflects outcomes of those patients who ultimately receive device implant or heart transplantation. Females have been shown to have a higher mortality following LVAD implantation and experience higher rates of bleeding and clotting phenomena and right ventricular failure. Beyond outcomes, the literature is limited in the identification of pre-operative factors that drive lower than expected LVAD implant rates in this population. More focused research is needed to define the disparities in advance heart failure therapy delivery in women and other underserved populations.
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22
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Badiwala M, Dvirnik N, Rao V. Durable mechanical circulatory support as bridge to heart transplantation. Curr Opin Organ Transplant 2022; 27:488-494. [PMID: 35950884 DOI: 10.1097/mot.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Durable mechanical circulatory support (MCS) technology has changed over time as devices have evolved from pulsatile to continuous flow support. In this review, we discuss recent data and substantial changes to current practice as it pertains to the subject of current era durable left ventricular assist devices (LVADs) as a bridge to heart transplantation. RECENT FINDINGS The results of heart transplantation in patients bridged with durable LVAD support are satisfactory even after prolonged duration of support. Reports of recent experience with LVAD related infection suggest that this complication has limited impact on post-transplant outcomes. Important sex-related disparities continue to exist following durable LVAD implantation. Recent changes in the United Network for Organ Sharing donor heart allocation policy have resulted in a drastic decline in the use of durable LVAD support for Bridge to Transplant in the United States. SUMMARY Durable MCS in the form of LVAD as a BTT strategy continues to evolve over time. Optimization of its role in the treatment of end-stage heart failure, particularly in females will need to be the focus of future research.
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Affiliation(s)
- Mitesh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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23
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Huang J, McDonnell BJ, Lawley JS, Byrd J, Stöhr EJ, Cornwell WK. Impact of Mechanical Circulatory Support on Exercise Capacity in Patients With Advanced Heart Failure. Exerc Sport Sci Rev 2022; 50:222-229. [PMID: 36095073 PMCID: PMC9475848 DOI: 10.1249/jes.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Approximately 6 million individuals have heart failure in the United States alone and 15 million in Europe. Left ventricular assist devices (LVAD) improve survival in these patients, but functional capacity may not fully improve. This article examines the hypothesis that patients supported by LVAD experience persistent reductions in functional capacity and explores mechanisms accounting for abnormalities in exercise tolerance.
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Affiliation(s)
- Janice Huang
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Barry J. McDonnell
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff UK
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck Austria
| | - Jessica Byrd
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
| | - Eric J. Stöhr
- Faculty of Philosophical Sciences, Institute of Sport Science, Leibniz University Hannover, Hannover, Germany
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - William K. Cornwell
- Department of Medicine-Cardiology. University of Colorado Anschutz Medical Campus, Aurora CO
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
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24
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Reza N, Edwards JJ, Katcoff H, Mondal A, Griffis H, Rossano JW, Lin KY, Holzhauser HL, Wald JW, Owens AT, Cappola TP, Birati EY, Edelson JB. Sex Differences in Left Ventricular Assist Device-related Emergency Department Encounters in the United States. J Card Fail 2022; 28:1445-1455. [PMID: 35644307 PMCID: PMC10066657 DOI: 10.1016/j.cardfail.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a paucity of data regarding sex differences in the profiles and outcomes of ambulatory patients on left ventricular assist device (LVAD) support who present to the emergency department (ED). METHODS AND RESULTS We performed a retrospective analysis of 57,200 LVAD-related ED patient encounters from the 2010 to 2018 Nationwide Emergency Department Sample. International Classification of Diseases Clinical Modification, Ninth Revision and Tenth Revision, codes identified patients aged 18 years or older with LVADs and associated primary and comorbidity diagnoses. Clinical characteristics and outcomes were stratified by sex and compared. Multivariable logistic regression was used to evaluate predictors of hospital admission and death. Female patient encounters comprised 27.2% of ED visits and occurred at younger ages and more frequently with obesity and depression (all P < .01). There were no sex differences in presentation for device complication, stroke, infection, or heart failure (all P > .05); however, female patient encounters were more often respiratory- and genitourinary or gynecological related (both P < .01). After adjustment for age group, diabetes, depression, and hypertension, male patient encounters had a 38% increased odds of hospital admission (95% confidence interval 1.20-1.58), but there was no sex difference in the adjusted odds of death (odds ratio 1.11, 95% confidence interval 0.86-1.45). CONCLUSIONS Patient encounters of females on LVAD support have significantly different comorbidities and outcomes compared with males. Further inquiry into these sex differences is imperative to improve long-term outcomes.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jonathan J Edwards
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Antara Mondal
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather Griffis
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Y Lin
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - H Luise Holzhauser
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anjali T Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas P Cappola
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, and Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Jonathan B Edelson
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Ebong IA, DeFilippis EM, Hamad EA, Hsich EM, Randhawa VK, Billia F, Kassi M, Bhardwaj A, Byku M, Munagala MR, Rao RA, Hackmann AE, Gidea CG, DeMarco T, Hall SA. Special Considerations in the Care of Women With Advanced Heart Failure. Front Cardiovasc Med 2022; 9:890108. [PMID: 35898277 PMCID: PMC9309391 DOI: 10.3389/fcvm.2022.890108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/22/2022] [Indexed: 01/17/2023] Open
Abstract
Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.
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Affiliation(s)
- Imo A. Ebong
- Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
- *Correspondence: Imo A. Ebong
| | - Ersilia M. DeFilippis
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York, NY, United States
| | - Eman A. Hamad
- Division of Cardiovascular Medicine, Temple University Hospital, Philadelphia, PA, United States
| | - Eileen M. Hsich
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Varinder K. Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Filio Billia
- Department of Cardiology, Toronto General Hospital, Toronto, ON, Canada
| | - Mahwash Kassi
- Houston Methodist Debakey Heart & Vascular Center, Houston, TX, United States
| | - Anju Bhardwaj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas-Houston, Houston, TX, United States
| | - Mirnela Byku
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mrudala R. Munagala
- Department of Cardiology, Miami Transplant Institute, University of Miami Miller School of Medicine/Jackson Memorial Hospital, University of Miami, Miami, FL, United States
| | - Roopa A. Rao
- Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, Indianapolis, IN, United States
| | - Amy E. Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas SouthWestern Medical Center, Dallas, TX, United States
| | - Claudia G. Gidea
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, New York, NY, United States
| | - Teresa DeMarco
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States
| | - Shelley A. Hall
- Division of Cardiology, Baylor University Medical Center, Dallas, TX, United States
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Defilippis EM, Truby LK, Clerkin KJ, Donald E, Sinnenberg L, Varshney AS, Cogswell R, Kittleson MM, Haythe JH, Givertz MM, Hsich EM, Agarwal R, Topkara VK, Farr M. Increased Opportunities for Transplantation for Women in the New Heart Allocation System. J Card Fail 2022; 28:1149-1157. [PMID: 35470056 PMCID: PMC10257979 DOI: 10.1016/j.cardfail.2022.03.354] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Historically, women have had less access to advanced heart failure therapies, including temporary and permanent mechanical circulatory support and heart transplantation (HT), with worse waitlist and post-transplant survival compared with men. This study evaluated for improvement in sex differences across all phases of HT in the 2018 allocation system. METHODS AND RESULTS The United Network for Organ Sharing registry was queried to identify adult patients (≥18 years) listed for HT from October 18, 2016, to October 17, 2018 (old allocation), and from October 18, 2018, to October 18, 2020 (new allocation). The outcomes of interest included waitlist survival, pretransplant use of temporary and durable mechanical circulatory support, rates of HT, and post-transplant survival. There were 15,629 patients who were listed for HT and included in this analysis; 7745 (2039 women, 26.3%) in the new and 7875 patients (2074 women, 26.3%) in the old allocation system. When compared with men in the new allocation system, women were more likely to have lower priority United Network for Organ Sharing status at time of transplant, and less likely to be supported by an intra-aortic balloon pump (27.1% vs 32.2%, P < .001), with no difference in the use of venoarterial extracorporeal membrane oxygenation (5.5% vs 6.3%, P = .28). Despite these findings, when transplantation was viewed in the context of risk for death or delisting, the cumulative incidence of transplant within 6 months of listing was higher in women than men in the new allocation system (62.4% vs 54.9%, P < .001) with no differences in post-transplant survival. When comparing women in the old with the new allocation system, the distance traveled for organ procurement was 187.5 ± 207.0 miles vs 272.8 ± 233.7 miles (P < .001). CONCLUSIONS Although the use of temporary mechanical circulatory support in women remains lower than in men in the new allocation system, more women are being transplanted with comparable waitlist and post-transplant outcomes as men. Broader sharing may be making its greatest impact on improving transplant opportunities for women.
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Affiliation(s)
- Ersilia M Defilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lauren K Truby
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Elena Donald
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lauren Sinnenberg
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anubodh S Varshney
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jennifer H Haythe
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Michael M Givertz
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eileen M Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richa Agarwal
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Maryjane Farr
- and the University of Texas Southwestern Medical Center, Dallas, Texas.
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Cascino TM, Somanchi S, Colvin M, Chung GS, Brescia AA, Pienta M, Thompson MP, Stewart JW, Sukul D, Watkins DC, Pagani FD, Likosky DS, Aaronson KD, McCullough JS. Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2223080. [PMID: 35895063 PMCID: PMC9331085 DOI: 10.1001/jamanetworkopen.2022.23080] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
Importance While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. Objectives To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role. Design, Setting, and Participants This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been admitted for heart failure from 2008 to 2014. Data were collected from July 2007 to December 2015 and analyzed from August 23, 2020, to May 15, 2022. Exposures Beneficiary race and sex. Main Outcomes and Measures The propensity for LVAD implantation was based on clinical risk factors from the 6 months preceding HF admission using XGBoost and the synthetic minority oversampling technique. Beneficiaries with a 5% or greater probability of receiving an LVAD were included. Logistic regression models were estimated to measure associations of race and sex with LVAD receipt adjusting for clinical characteristics and social determinants of health (eg, distance from LVAD center, Medicare low-income subsidy, neighborhood deprivation). Next, 1-year mortality after LVAD was examined. Results The analytic sample included 12 310 beneficiaries, of whom 22.9% (n = 2819) were Black and 23.7% (n = 2920) were women. In multivariable models, Black beneficiaries were 3.0% (0.2% to 5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (5.6% to 10.2%) less likely to receive LVAD than men. Individual poverty and worse neighborhood deprivation were associated with reduced use, 2.9% (0.4% to 5.3%) and 6.7% (2.9% to 10.5%), respectively, but these measures did little to explain observed disparities. The racial disparity was concentrated among patients with a low propensity score (propensity score <0.52). One-year survival by race and sex were similar on average, but Black patients with a low propensity score experienced improved survival (7.2% [95% CI, 0.9% to 13.5%]). Conclusions and Relevance In this cohort study of Medicare beneficiaries hospitalized for HF, disparities in LVAD use by race and sex existed and were not explained by clinical characteristics or social determinants of health. The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates. However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients. Inequity in LVAD access may have resulted from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Sriram Somanchi
- University of Notre Dame, Mendoza College of Business, Department of IT Analytics and Operations, Notre Dame, Indiana
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Grace S. Chung
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
| | | | - Michael Pienta
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | | | - James W. Stewart
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | - Devraj Sukul
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | | | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Jeffrey S. McCullough
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
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Li T, Mariani S, Bounader K, Boethig D, Schöde A, Homann K, Hanke JS, Napp LC, Merzah AS, Dogan G, Haverich A, Schmitto JD. Is There a Sex Gap in Outcomes of Comparable Patients Supported with Left Ventricular Assist Devices? Artif Organs 2022; 46:2293-2303. [PMID: 35686944 DOI: 10.1111/aor.14333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Historically, females were described as suffering from worse outcomes after left ventricular assist device (LVAD) implantation. However, females' preoperative conditions are unique, making direct comparisons with males challenging. This study aimed to select through propensity score (PS) matching two preoperatively comparable populations of females and males and test if any real sex-related difference exists regarding survival and adverse events after LVAD implantation. METHODS This retrospective single-center observational study investigated patients who received LVAD implantation between 2010 and 2018. PS matching was applied to balance preoperative heterogeneity between males and females. Primary endpoint was survival at follow-up. Secondary endpoints included perioperative outcomes and LVAD-related adverse events. RESULTS 92 fully comparable females(n=46) and males(n=46) were selected after PS matching (median age:57 years, min-max:18-75). 26.1% of patients required preoperative mechanical circulatory support. Females needed more intraoperative fresh frozen plasma (p<0.001) and platelets transfusions (p=0.008) compared to males, but postoperative outcomes were comparable between groups. In-hospital, 1-year and 2-year survival were 78.3%, 69.6% and 65.2%, respectively, with no differences between groups. Survival probability remained comparable up to 8 years of follow-up(p=0.35). Overall, females showed a higher rate of strokes(p=0.039) compared to males in the follow-up time. CONCLUSIONS After reducing preoperative heterogeneity between females and males, survival after LVAD implantation does not differ based on sex. However, differences might exist in terms of higher transfusions and strokes in females. Reducing preoperative sex disparities and developing intraoperative and anticoagulation strategies which acknowledge sex-related variations might help abolishing differences in LVAD outcomes.
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Affiliation(s)
- Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastrichts, Netherlands
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexandra Schöde
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Katharina Homann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ali Saad Merzah
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Kislitsina ON, D Rich J, Wilcox JE, E Vorovich E, Wu T, Churyla A, S Harap R, Andrei AC, McCarthy PM, Yancy CW, Pham DT. Propensity Score-Matched Comparison of Right Ventricular Strain in Women and Men Before and After Left Ventricular Assist Device Implantation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:102-110. [PMID: 35275496 DOI: 10.1177/15569845221081937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Adverse events following left ventricular assist device (LVAD) implantation are more common in women than in men, but the impact of gender differences on right ventricular (RV) failure is not well defined. Therefore, we calculated RV strain before and after LVAD implantation in matched groups of men and women to determine if gender differences in RV failure after LVAD might account for the gender differences in overall outcomes. Methods: RV free wall longitudinal strain (FWS) and fractional area change were calculated preoperatively and 3 months postoperatively using speckle-tracking echocardiography analysis. A total of 172 patients (86 women, 86 men) were then propensity score matched (1:1) for comparison. Results: Although women had higher preoperative CHA2DS2-VASc scores and more frequent moderate mitral regurgitation than men (P = 0.018), the preoperative hemodynamic parameters were similar. Preoperative RV-FWS was -6.7% in women and -6.0% in men (P = 0.65). Postoperatively, women had more progression to severe tricuspid regurgitation (TR) than men (15% vs 7%, P = 0.06). At 3 months the RV-FWS was -7.7% in women and -7.0% in men (P = 0.59). Postoperative TR was moderate-severe in 20% of women and in 9% of men (P = 0.001). Women had a higher incidence of venous thromboembolism, cardiac arrhythmias, and bleeding compared with men. Women also had higher mortality rates at discharge and 30 days after surgery, but the survival rates at 5 years were similar. Conclusions: RV strain measurements track standard hemodynamic and echocardiographic parameters and confirm that gender differences in outcomes following LVAD implantation are not related to gender differences in RV failure rates.
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Affiliation(s)
- Olga N Kislitsina
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA.,Division of Cardiac Surgery, Feinberg School of Medicine, 3270Northwestern University, Chicago, IL, USA
| | - Jonathan D Rich
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Jane E Wilcox
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Esther E Vorovich
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Tingqing Wu
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Feinberg School of Medicine, 3270Northwestern University, Chicago, IL, USA
| | - Rebecca S Harap
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Adin-Christian Andrei
- Division of Cardiac Surgery, Feinberg School of Medicine, 3270Northwestern University, Chicago, IL, USA
| | - Patrick M McCarthy
- Division of Cardiac Surgery, Feinberg School of Medicine, 3270Northwestern University, Chicago, IL, USA
| | - Clyde W Yancy
- Division of Cardiology, Feinberg School of Medicine, 12244Northwestern University, Chicago, IL, USA
| | - Duc Thin Pham
- Division of Cardiac Surgery, Feinberg School of Medicine, 3270Northwestern University, Chicago, IL, USA
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Maukel L, Weidner G, Beyersmann J, Spaderna H. Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy. J Am Heart Assoc 2022; 11:e023294. [PMID: 35191318 PMCID: PMC9075087 DOI: 10.1161/jaha.121.023294] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The relevance of sex and preimplant factors for clinical outcomes among patients with left ventricular assist devices intended for destination therapy is unclear. Methods and Results INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) data (2006-2017) from 6771 men and 1690 women with left ventricular assist devices as destination therapy were analyzed to evaluate the contribution of preimplant clinical, demographic, and clinically judged psychosocial characteristics to time until death, heart transplant, device explant due to recovery, or complication-related device replacement. Associations of sex with time until each competing outcome were evaluated using cumulative incidence functions and event-specific Cox proportional hazards models. Women were younger, more likely to have nonischemic diagnoses, and reported less substance abuse but were more likely to be unmarried, not working for an income, overweight, and depressed than men. After 2 years, women had higher probabilities for recovery (3.7% versus 1.6%, P<0.001) and device replacement (12.1% versus 10%, P=0.019) than men but not for death and transplant (P>0.12). The sex differences remained after controlling for covariates (adjusted hazard ratio [HRadj] recovery, 1.85; 95% CI, 1.30-2.70; P<0.001; HRadj device replacement, 1.22; 95% CI, 1.04-1.33; P=0.015). Female-specific diagnoses (eg, postpartum heart failure) contributed to women's enhanced rate of recovery. Demographic and psychosocial factors were unrelated to women's increased event rates. Conclusions In destination therapy, women have higher rates of device replacement and recovery than men. The latter was partly explained by female-specific diagnoses. Standardized assessments of psychosocial characteristics are needed to elucidate their association with sex differences in outcomes.
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Affiliation(s)
| | - Gerdi Weidner
- Biology, San Francisco State UniversitySan FranciscoCA
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31
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DeFilippis EM, Beale A, Martin T, Agarwal A, Elkayam U, Lam CSP, Hsich E. Heart Failure Subtypes and Cardiomyopathies in Women. Circ Res 2022; 130:436-454. [PMID: 35175847 PMCID: PMC10361647 DOI: 10.1161/circresaha.121.319900] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure affects over 2.6 million women and 3.4 million men in the United States with known sex differences in epidemiology, management, response to treatment, and outcomes across a wide spectrum of cardiomyopathies that include peripartum cardiomyopathy, hypertrophic cardiomyopathy, stress cardiomyopathy, cardiac amyloidosis, and sarcoidosis. Some of these sex-specific considerations are driven by the cellular effects of sex hormones on the renin-angiotensin-aldosterone system, endothelial response to injury, vascular aging, and left ventricular remodeling. Other sex differences are perpetuated by implicit bias leading to undertreatment and underrepresentation in clinical trials. The goal of this narrative review is to comprehensively examine the existing literature over the last decade regarding sex differences in various heart failure syndromes from pathophysiological insights to clinical practice.
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Affiliation(s)
| | - Anna Beale
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (A.B.)
| | - Trejeeve Martin
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
| | - Anubha Agarwal
- Northwestern University Feinberg School of Medicine (A.A.)
| | - Uri Elkayam
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California (U.E.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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Anne Dual S, Nayak A, Hu Y, Schmid Daners M, Morris AA, Cowger J. Does Size Matter for Female Continuous-flow LVAD Recipients? A Translational Approach to a Decade Long Question. ASAIO J 2022; 68:21-27. [PMID: 34156789 DOI: 10.1097/mat.0000000000001443] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Females have increased risk of right-ventricular failure (RVF) and 3 month mortality after left-ventricular assist device (LVAD) implantation. In this translational study, we tested the hypothesis that sex differences in outcomes are driven by pump-induced LV size-volume mismatch, due to a negative impact on interventricular septal (IVS) interdependence. Adult continuous-flow LVAD recipients from the International Society For Heart And Lung Transplantation Mechanically Assisted Circulatory Support registry (n = 15,498) were studied to determine association of female sex with outcomes of 3 month mortality and RVF. Female sex was associated with smaller preimplant left-ventricular end-diastolic diameter (6.5 vs. 6.9 cm, p < 0.001), increased 3 month mortality (odds ratio [OR]: 1.42, p < 0.001) and RVF (OR: 1.18, p = 0.005). Smaller left-ventricular end-diastolic diameter was associated with worse outcomes after LVAD implantation (OR for mortality: 1.20, p < 0.001; RVF: 1.09, p < 0.001), and attenuated the association of female sex with these outcomes. In test bench heart phantoms (n = 4), the IVSs of smaller hearts demonstrated abnormal leftward shift earlier than larger hearts (volume change at IVS shift: 40 [95% confidence interval: 30-52] vs. 50 [95% confidence interval: 48-69] ml). Smaller LV size partially mediates worse post-LVAD outcomes for female patients, due to lower volume thresholds for adverse IVS shifting.
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Affiliation(s)
- Seraina Anne Dual
- From the Product Development Group Zurich, ETH Zurich, Zurich, Switzerland
- Department of Radiology, Stanford University, Stanford, California
- Cardiovascular Institute, Stanford University, Stanford, California
| | - Aditi Nayak
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Alanna A Morris
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Cowger
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6527516. [DOI: 10.1093/ejcts/ezac032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/06/2021] [Accepted: 01/11/2022] [Indexed: 11/14/2022] Open
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Lala A, Tayal U, Hamo CE, Youmans Q, Al-Khatib SM, Bozkurt B, Davis MB, Januzzi J, Mentz R, Sauer A, Walsh MN, Yancy C, Gulati M. Sex Differences in Heart Failure. J Card Fail 2021; 28:477-498. [PMID: 34774749 DOI: 10.1016/j.cardfail.2021.10.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) continues to be a major contributor of morbidity and mortality for men and women alike, yet how the predisposition for, course and management of HF differ between men and women remains underexplored. Sex differences in traditional risk factors as well as sex-specific risk factors influence the prevalence and manifestation of HF in unique ways. The pathophysiology of HF differs between men and women and may explain sex-specific differences in clinical presentation and diagnosis. This in turn contributes to variation in response to both pharmacologic and device/surgical therapy. This review examines sex-specific differences in HF spanning prevalence, risk factors, pathophysiology, presentation, and therapies with a specific focus on highlighting gaps in knowledge with calls to action for future research efforts.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute & Department of Population Health Science & Policy at Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Upasana Tayal
- National Heart Lung Institute, Imperial College London, UK, Royal Brompton Hospital, London, UK
| | - Carine E Hamo
- Zena and Michael A. Wiener Cardiovascular Institute & Department of Population Health Science & Policy at Icahn School of Medicine at Mount Sinai, New York, NY
| | - Quentin Youmans
- Northwestern University, Department of Medicine, Chicago, IL
| | - Sana M Al-Khatib
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Cardiology, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - James Januzzi
- Cardiology Division, Massachusetts General Hospital; Trial Design, Baim Institute for Clinical Research
| | - Robert Mentz
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Andrew Sauer
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Clyde Yancy
- Northwestern University, Department of Medicine, Chicago, IL
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Abstract
PURPOSE OF REVIEW Cardiothoracic transplantation is the definitive therapy for end-stage heart and lung disease. In service to this population, disparities in access and care must be simultaneously understood and addressed. RECENT FINDINGS There are sex, race, geographic, age, and underlying disease disparities in both heart and lung transplantation. Women have reduced waitlist survival but improved posttransplant survival when compared with men for both heart and lung transplantation. Black patients have worse outcome compared with other races postheart transplant. Geographic disparities impact the likelihood of receiving heart or lung transplant and the growing number of patients with advanced age seeking transplant complicates discussions on survival benefit. Finally, underlying disease has affected outcomes for both heart and lung transplant and now are incorporated into the allocation system. SUMMARY Though heart and lung transplantation have several existing disparities, it remains to be seen how advancements in medical technology, changes in donor organ allocation policies, and growing experience in patient selection will impact these concerns.
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Affiliation(s)
- Wayne Tsuang
- Respiratory Institute
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | - Eileen Hsich
- Heart and Vascular Institute
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Risk factors of gynecological bleeding in female patients with left-ventricular assist device. J Artif Organs 2021; 25:110-116. [PMID: 34581883 DOI: 10.1007/s10047-021-01292-2] [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: 07/06/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Women with implantable left-ventricular assist devices (LVADs) experience gynecological bleeding (GYN-bleeding). However, a few studies have investigated female-specific problems. Therefore, this study aimed to identify the risk factors for adverse GYN-bleeding after LVAD implantation. We retrospectively analyzed 59 women (mean age: 41 ± 15 years) with long-term implantable LVAD support (≥ 6 months) at our institution between 2005 and 2018. The history of GYN-bleeding before implantation was defined as abnormal utero-ovarian bleeding, excessive menstruation, uterine fibroids, and endometrial lesions. GYN-bleeding after implantation was defined as a requirement of emergency outpatient visits and/or hospitalization, blood transfusions, hormonal therapy, and/or surgery. Additionally, risk factors for GYN-bleeding were identified using the Cox regression model. Twenty-four GYN-bleeding cases were seen in 15 patients (two times: five patients, three times: two patients, 0.18 events per patient-year). The 1- and 2-year GYN-bleeding-free rates were 84% and 73%, respectively. Twelve patients (17 events) required RBC ≥ 4 units, and five patients (7 events) required FFP ≥ 4 units. Seven patients required pseudomenopausal treatment after blood transfusion, and four patients required surgical treatment. Fifteen patients with GYN-bleeding after implantation were significantly younger than the remaining 44 patients without GYN-bleeding (34 ± 12 years vs. 43 ± 16 years, P = 0.02). Multivariable risk analysis showed a history of GYN-bleeding before implantation was a significant risk factor (hazard ratio 3.7 [1.2-10.6], P = 0.004). Patients with a history of GYN-bleeding before LVAD implantation have a high risk of developing GYN-bleeding after implantation. We should identify the high-risk population and prepare for the management of GYN-bleeding.
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Darma A, Bertagnolli L, Torri F, Lurz JA, König S, Ueberham L, Bollmann A, Dagres N, Hindricks G, Dinov B, Arya A. Gender differences in patients with structural heart disease undergoing VT ablation. J Cardiovasc Electrophysiol 2021; 32:2675-2683. [PMID: 34411387 DOI: 10.1111/jce.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/20/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study sought to examine gender differences in patients with structural heart disease (SHD) referred for ablation of ventricular tachycardia (VT). BACKGROUND Female patients are often underrepresented in large studies. Significant differences in the clinical presentation, treatment, and prognosis of female patients have been described in previous studies. METHODS AND RESULTS We investigated 88 female patients with SHD undergoing VT ablation (mean age 59 years, 56% nonischemic cardiomyopathy, mean left ventricular ejection fraction 35%, 82% in electrical storm). A case-control study with 88 male patients was performed and the results regarding clinical and procedural characteristics, acute and long-term results of the two groups were compared. The female patients had more arrhythmogenic substrate, as they more commonly presented with electrical storm (p = .016) and had a higher number of inducible VT morphologies during the procedure (p = .018). Moreover, the female patients were less likely to have an optimized heart failure medical treatment at baseline (p = .030) and required more time from the first manifestation of the VT to ablation referral (p = .034). Although fewer epicardial ablations were performed in female patients (p = .019), the two groups showed similar results regarding VT noninducibility as ablation endpoint (p = .844), major procedure-related complications (p = .719) and freedom from VT during follow-up (p = .268). Moreover, the overall mortality in the two groups was similar (p = .176). Advanced NYHA class was associated with worse transplant and assist-device-free survival in the female group. CONCLUSION Female patients presenting for VT ablation had more arrhythmogenic substrate and were less likely to have an optimized heart failure medical treatment. Nevertheless, the procedural acute and long-term outcomes between the two genders were similar.
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Affiliation(s)
- Angeliki Darma
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Livio Bertagnolli
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Federica Torri
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Julia A Lurz
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Sebastian König
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Laura Ueberham
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Cardiac Electrophysiology, Heart Centre of Leipzig, Leipzig, Germany
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Yarboro LT, Mehaffey JH, Cantor R, Deng L, Teman NR, Yount KW, Kern JA, Kirklin JK, Bergin JD. Progression to Transplant under New Heart Allocation System: The Society of Thoracic Surgeons Intermacs Database. Ann Thorac Surg 2021; 113:1926-1934. [PMID: 34389303 DOI: 10.1016/j.athoracsur.2021.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Under the new heart allocation policy, durable left ventricular assist devices receive lower priority on the transplant list. We sought to identify predictors of successful heart transplant after durable device implant as a means to inform patient care in the current era. METHODS All patients (n=25,164) undergoing primary durable left ventricular device implant in the Society of Thoracic Surgeons Intermacs database (2010-2019) were evaluated. Patients identified as bridge to transplant (BTT, n=5242) or bridge to candidacy (BTC, n=6248) were analyzed with the endpoint of transplant before (n=10,588) and after (n=902) the change in the heart allocation system on October 18, 2018. Multivariable hazard modeling was used to assess risk-adjusted time to event associations. RESULTS Of 11,490 patients, 45.5% progressed to transplant, (BTT 53.0%, BTC 36.6%), most by 14 months post LVAD. Under the new allocation system, progression to transplant was significantly lower at 14 months (18.6% vs. 34.8%, p<0.001). Factors associated with successful bridge to transplant before the allocation change included BTT status, white race and married. Under the new allocation system, BTT status (HR 1.79 95% CI 1.19-2.69, p<0.0054) remained a positive predictor, while blood type O (HR 0.43, 95% CI 0.28-0.65, p<0.0001) remained a negative predictor. CONCLUSIONS Despite having priority in the previous allocation system, less than half of BTT/BTC patients progressed to transplant. Under the current system, these numbers are further reduced. Heart teams should consider the implications of longer wait times with a durable left ventricular assist device when determining the optimal bridging strategy.
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Affiliation(s)
- Leora T Yarboro
- Division of Cardiac Surgery, University of Virginia, Charlottesville, VA.
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, University of Virginia, Charlottesville, VA
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama Birmingham AL
| | - Luqin Deng
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama Birmingham AL
| | - Nicholas R Teman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, VA
| | - Kenan W Yount
- Division of Cardiac Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Division of Cardiac Surgery, University of Virginia, Charlottesville, VA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama Birmingham AL
| | - James D Bergin
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA
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Löchel S, Maukel LM, Weidner G, de By TMMH, Spaderna H. Gender differences in psychosocial and clinical characteristics in the European Registry for Patients with Mechanical Circulatory Support. Heart Lung 2021; 50:845-852. [PMID: 34325182 DOI: 10.1016/j.hrtlng.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 06/11/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Not much is known about psychosocial characteristics of men and women receiving continuous flow left ventricular assist devices (CF LVAD). OBJECTIVE To investigate gender differences in clinical and psychosocial (demographic, behavioral, psychological) characteristics in CF LVAD recipients. METHODS We analyzed European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data (N=2395, 16.8% women; 2011 to 2017) and compared pre-implant characteristics in men and women intended for bridge-to-transplant (BTT) or destination therapy (DT). RESULTS Women were underrepresented [DT (n=61): 13.4%; BTT (n=341): 17.6%]. They were more likely to be divorced/separated, widowed, in unstable clinical condition, and non-working (DT only), but less likely to be smokers, to have ischemic cardiomyopathy or diabetes, and younger (BTT only) than men. Missing data were abundant, especially those that reflect psychological characteristics (>87%). CONCLUSION Gender differences were noted, some specific to device strategy. Improved collection of psychosocial characteristics is warranted to elucidate their relationship to future prognosis.
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Affiliation(s)
- Sarah Löchel
- Department of Nursing Science, Section Health Psychology, Trier University, Trier, Germany
| | - Lisa-Marie Maukel
- Department of Nursing Science, Section Health Psychology, Trier University, Trier, Germany
| | - Gerdi Weidner
- Department of Biology - EOS Center, San Francisco State University, San Francisco, CA, USA
| | - Theo M M H de By
- European Association for Cardio-Thoracic Surgery, EACTS House, Windsor, UK
| | - Heike Spaderna
- Department of Nursing Science, Section Health Psychology, Trier University, Trier, Germany.
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Gender Differences in Mortality After Left Ventricular Assist Device Implant: A Causal Mediation Analysis Approach. ASAIO J 2021; 67:614-621. [PMID: 33060408 DOI: 10.1097/mat.0000000000001288] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We used the International Society for Heart and Lung Transplantation (ISHLT) Registry for Mechanically Assisted Circulatory Support (IMACS) database to examine 1) gender differences in post-left ventricular assist device (LVAD) mortality in the contemporary era and 2) preimplant clinical factors that might mediate any observed differences. Adults who received continuous-flow (CF)-LVAD from January 2013 to September 2017 (n = 9,565, age: 56.2 ± 13.2 years, 21.6% female, 31.1% centrifugal pumps) were analyzed. An inverse probability weighted Cox proportional hazards model was used to estimate association of female gender with all-cause mortality, adjusting for known covariates. Causal mediation analysis was performed to test plausible preimplant mediators mechanistically underlying any association between female gender and mortality. Females had higher mortality after LVAD (adjusted hazard ratio [HR]: 1.36; p < 0.0001), with significant gender × time interaction (p = 0.02). An early period of increased risk was identified, with females experiencing a higher risk of mortality during the first 4 months after implant (adjusted HR: 1.74; p < 0.0001), but not after (adjusted HR: 1.18; p = 0.16). More severe tricuspid regurgitation and smaller left ventricular end-diastolic diameter at baseline mediated ≈21.9% of the increased early hazard of death in females; however, most of the underlying mechanisms remain unexplained. Therefore, females have increased mortality only in the first 4 months after LVAD implantation, partially driven by worsening right ventricular dysfunction and LV-LVAD size mismatch.
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Modi K, Pannu AK, Modi RJ, Shah SD, Bhandari R, Pereira KN, Kubra KT, Raval MR, Ajibawo T. Utilization of Left Ventricular Assist Device for Congestive Heart Failure: Inputs on Demographic and Hospital Characterization From Nationwide Inpatient Sample. Cureus 2021; 13:e16094. [PMID: 34367750 PMCID: PMC8330485 DOI: 10.7759/cureus.16094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives The first goal of the study is to provide a descriptive overview of the utilization of left ventricular assist device (LVAD) for the treatment of congestive heart failure (CHF) and determine the rates of LVAD use stratified by patients' demographic and hospitals' characteristics in the United States. Next, is to measure the hospitalization outcomes of length of stay (LOS) and cost in inpatients managed with LVAD. Methods We conducted a cross-sectional study using the nationwide inpatient sample and included 184,115 patients (age ≥65 years) with a primary discharge diagnosis of hypertensive and non-hypertensive CHF and was further classified by inpatients who were managed with LVAD. We compared the distributions of demographic and hospital characteristics in CHF inpatients with versus without LVAD by performing Pearson's chi-square test for categorical variables, and independent sample t-test for continuous variables. Results The inpatient utilization of LVAD was 0.93% (1690 out of 184,115) in CHF patients. The LVAD cohort were younger compared to non-LVAD group (mean age, 69.9 years vs. 79.4 years). The utilization rate of LVAD was also almost four times higher in males (1.50%) compared to females (0.36%). Although whites (78.5%) accounted for majority of LVAD recipients, the rate of LVAD utilization was highest in blacks (1.04%) and lowest in Hispanics (0.58%) with whites having utilization rate of 0.89%. Medicare was the dominant primary payer to cover the LVAD inpatients (91.1%), though the rate of LVAD utilization is highest in private (2.22%) and lowest in those covered by public insurance (medicaid/medicare). CHF patients in public hospitals (1.79%) were more than twice more likely to receive LVAD than in private hospitals (0.83%) due to higher utilization rate. LVAD utilization rate was approximately 55 times higher in teaching hospitals (1.67%) compared to non-teaching hospitals (0.03%), and 20 times higher in large bed hospitals (1.41%) compared to small bed-size hospitals (0.07%). CHF patients that received LVAD had a significantly longer LOS (34.6 days vs 9.8 days) and higher inpatient treatment costs ($802,118 vs. $86,302) compared to non-LVAD group. Conclusion The inpatient utilization of LVAD was in CHF patients is higher in males, blacks and private health insurance beneficiaries. In terms of hospital characteristics, the utilization of LVAD for CHF management was higher in large bed sized, and public type and teaching hospitals compared to their counterparts. This data will allow us to devise strategies to improve LVAD utilization and increase its outreach for heart failure patients, especially those on the transplant waiting list. Despite its effectiveness, aggressive usage of LVAD is restricted due to cost-effectiveness and lack of technical confidence among medical professional due to complications.
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Affiliation(s)
- Karnav Modi
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Amanpreet K Pannu
- Medicine, Sri Guru Ram Das University of Health Sciences, Amritsar, IND
| | - Ronak J Modi
- Cardiology, Bankers Heart Institute, Vadodara, IND
| | - Suchi D Shah
- Internal Medicine, Ahmedabad Municipal Corporation's Medical Education Trust Medical College, Ahmedabad, IND
| | - Renu Bhandari
- Medicine, Manipal College of Medical Sciences, Kaski, NPL
| | | | | | - Maharshi R Raval
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
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Sullivan K, Doumouras BS, Santema BT, Walsh MN, Douglas PS, Voors AA, Van Spall HG. Sex-Specific Differences in Heart Failure: Pathophysiology, Risk Factors, Management, and Outcomes. Can J Cardiol 2021; 37:560-571. [DOI: 10.1016/j.cjca.2020.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
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Nayak A, Hu Y, Ko YA, Steinberg R, Das S, Mehta A, Liu C, Pennington J, Xie R, Kirklin JK, Kormos RL, Cowger J, Simon MA, Morris AA. Creation and Validation of a Novel Sex-Specific Mortality Risk Score in LVAD Recipients. J Am Heart Assoc 2021; 10:e020019. [PMID: 33764158 PMCID: PMC8174331 DOI: 10.1161/jaha.120.020019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Prior studies have shown that women have worse 3‐month survival after receiving a left ventricular assist device compared with men. Currently used prognostic scores, including the Heartmate II Risk Score, do not account for the increased residual risk in women. We used the IMACS (International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support) registry to create and validate a sex‐specific risk score for early mortality in left ventricular assist device recipients. Methods and Results Adult patients with a continuous‐flow LVAD from the IMACS registry were randomly divided into a derivation cohort (DC; n=9113; 21% female) and a validation cohort (VC; n=6074; 21% female). The IMACS Risk Score was developed in the DC to predict 3‐month mortality, from preoperative candidate predictors selected using the Akaike information criterion, or significant sex × variable interaction. In the DC, age, cardiogenic shock at implantation, body mass index, blood urea nitrogen, bilirubin, hemoglobin, albumin, platelet count, left ventricular end‐diastolic diameter, tricuspid regurgitation, dialysis, and major infection before implantation were retained as significant predictors of 3‐month mortality. There was significant ischemic heart failure × sex and platelet count × sex interaction. For each quartile increase in IMACS risk score, men (odds ratio [OR], 1.86; 95% CI, 1.74–2.00; P<0.0001), and women (OR, 1.93; 95% CI, 1.47–2.59; P<0.0001) had higher odds of 3‐month mortality. The IMACS risk score represented a significant improvement over Heartmate II Risk Score (IMACS risk score area under the receiver operating characteristic curve: men: DC, 0.71; 95% CI, 0.69–0.73; VC, 0.69; 95% CI, 0.66–0.72; women: DC, 0.73; 95% CI, 0.70–0.77; VC, 0.71 [95% CI, 0.66–0.76; P<0.01 for improvement in receiver operating characteristic) and provided excellent risk calibration in both sexes. Removal of sex‐specific interaction terms resulted in significant loss of model fit. Conclusions A sex‐specific risk score provides excellent risk prediction in LVAD recipients.
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Affiliation(s)
- Aditi Nayak
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Yingtian Hu
- Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Yi-An Ko
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA.,Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Rebecca Steinberg
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Subrat Das
- Icahn School of Medicine at Mount Sinai New York City NY
| | - Anurag Mehta
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
| | - Chang Liu
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA.,Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - John Pennington
- Department of Surgery University of Alabama at Birmingham AL
| | - Rongbing Xie
- Department of Surgery University of Alabama at Birmingham AL
| | - James K Kirklin
- Department of Surgery University of Alabama at Birmingham AL
| | - Robert L Kormos
- Department of Cardiothoracic Surgery University of Pittsburgh PA
| | - Jennifer Cowger
- Division of Cardiovascular Medicine Department of Medicine Henry Ford Hospital Detroit MI.,Department of Internal Medicine Wayne State University Detroit MI
| | - Marc A Simon
- Departments of Medicine (Division of Cardiology) and Bioengineering Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute McGowan Institute for Regenerative MedicineClinical and Translational Science InstituteUniversity of Pittsburgh PA.,Heart and Vascular Institute University of Pittsburgh Medical Center (UPMC) Pittsburgh PA
| | - Alanna A Morris
- Division of Cardiology Department of Medicine Emory Clinical Cardiovascular Research InstituteEmory University School of Medicine Atlanta GA
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Mariani S, Li T, Bounader K, Boethig D, Schöde A, Hanke JS, Michaelis J, Napp LC, Berliner D, Dogan G, Lorusso R, Haverich A, Schmitto JD. Sex differences in outcomes following less-invasive left ventricular assist device implantation. Ann Cardiothorac Surg 2021; 10:255-267. [PMID: 33842220 DOI: 10.21037/acs-2020-cfmcs-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Worse outcomes in women compared to men undergoing left ventricular assist device (LVAD) implantation remain an underestimated problem in heart failure (HF) patients. With device miniaturization, less-invasive LVAD implantation techniques have gained relevance, but their impact on outcomes in women is unknown. This study investigates sex-related differences in patients undergoing LVAD implantation through less-invasive procedures. Methods This retrospective single-center cohort study included patients who underwent isolated LVAD implantation between 2011 and 2018 through less-invasive techniques. Propensity score matching (PSM) was utilized to balance preoperative heterogeneity. Primary endpoint was two-year survival, and secondary endpoints included long-term survival, surgical outcomes and postoperative adverse events. Results Baseline analysis of 191 patients (females 18.3%) showed differences in terms of age [female (median, 52; IQR, 47-61); male (median, 58.5; IQR, 49-66); P=0.005], underlying diagnosis (P<0.001), INTERMACS profile (P=0.009), history of previous cardiac surgery (P=0.049) and preoperative creatinine values [female (median, 110; IQR, 71-146); male (median, 126; IQR, 9-168); P=0.049]. Over a follow-up of 460.68 patient-years, Kaplan-Meyer analysis showed better survival in females (P=0.027) and a similar probability of cardiac transplantation (P=0.288). After PSM, females showed higher needs for intraoperative fresh frozen plasma (P=0.044) and platelets (P=0.001) but comparable postoperative outcomes. No sex-related differences were noticed regarding two-year outcomes, long-term survival and adverse events. LVAD-related infections remained the most common complication with males experiencing more pump infections than women (P=0.050). Conclusions Patients receiving less-invasive LVAD implantation do not show significant sex-related differences in short and long-term outcomes and survival. Prospective studies are needed to evaluate the role of less-invasive techniques in reducing sex-based disparities after LVAD implantation.
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Affiliation(s)
- Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Karl Bounader
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexandra Schöde
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jana Michaelis
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Guenes Dogan
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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García-Cosío MD, González-Vilchez F, López-Vilella R, Barge-Caballero E, Gómez Bueno M, Martínez-Selles M, María Arizón J, Rangel Sousa D, González-Costello J, Mirabet S, Pérez-Villa F, Molina BD, Rábago G, Portolés Ocampo A, de la Fuente Galán L, Garrido I, Delgado JF. Influence of Gender in Advanced Heart Failure Therapies and Outcome Following Transplantation. Front Cardiovasc Med 2021; 8:630113. [PMID: 33718453 PMCID: PMC7946818 DOI: 10.3389/fcvm.2021.630113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/12/2021] [Indexed: 11/13/2022] Open
Abstract
Biological differences between males and females change the course of different diseases and affect therapeutic measures' responses. Heart failure is not an exception to these differences. Women account for a minority of patients on the waiting list for heart transplantation or other advanced heart failure therapies. The reason for this under-representation is unknown. Men have a worse cardiovascular risk profile and suffer more often from ischemic heart disease. Conversely, transplanted women are younger and more frequently have non-ischemic cardiac disorders. Women's poorer survival on the waiting list for heart transplantation has been previously described, but this trend has been corrected in recent years. The use of ventricular assist devices in women is progressively increasing, with comparable results than in men. The indication rate for a heart transplant in women (number of women on the waiting list for millions of habitants) has remained unchanged over the past 25 years. Long-term results of heart transplants are equal for both men and women. We have analyzed the data of a national registry of heart transplant patients to look for possible future directions for a more in-depth study of sex differences in this area. We have analyzed 1-year outcomes of heart transplant recipients. We found similar results in men and women and no sex-related interactions with any of the factors related to survival or differences in death causes between men and women. We should keep trying to approach sex differences in prospective studies to confirm if they deserve a different approach, which is not supported by current evidence.
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Affiliation(s)
- María Dolores García-Cosío
- Servicio de Cardiología, Hospital 12 de Octubre Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | | | - Raquel López-Vilella
- Servicio de Cardiología, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Eduardo Barge-Caballero
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Manuel Gómez Bueno
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Manuel Martínez-Selles
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Jose María Arizón
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Diego Rangel Sousa
- Servicio de Cardiología, Hospital Universitario Virgen Del Rocío, Seville, Spain
| | - José González-Costello
- Servicio de Cardiología, Hospital Universitari De Bellvitge, Hospitalet de Llobregat, Spain
| | - Sonia Mirabet
- Servicio de Cardiología, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Félix Pérez-Villa
- Servicio de Cardiología, Hospital Clínic i Provincial, Barcelona, Spain
| | - Beatriz Díaz Molina
- Servicio de Cardiología, Hospital Universitario Central De Asturias, Oviedo, Spain
| | - Gregorio Rábago
- Servicio de Cirugía Cardiaca, Clínica Universidad De Navarra, Navarra, Spain
| | - Ana Portolés Ocampo
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Iris Garrido
- Servicio de Cardiología, Hospital Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Juan F. Delgado
- Servicio de Cardiología, Hospital 12 de Octubre Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Gonzalez MH, Wang Q, Yaranov DM, Albert C, Wolski K, Wagener J, Aggarwal A, Menon V, Jacob M, Tang W, Hsich E, Taylor D, Tong M, Soltesz E, Estep JD, Starling RC, Joyce E. Dynamic Assessment of Pulmonary Artery Pulsatility Index Provides Incremental Risk Assessment for Early Right Ventricular Failure After Left Ventricular Assist Device. J Card Fail 2021; 27:777-785. [PMID: 33640481 DOI: 10.1016/j.cardfail.2021.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The pulmonary artery pulsatility index (PAPi) has been studied to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation, but only as a single time point before LVAD implantation. Multiple clinical factors and therapies impact RV function in pre-LVAD patients. Thus, we hypothesized that serial PAPi measurements during cardiac intensive care unit (CICU) optimization before LVAD implantation would provide incremental risk stratification for early RVF after LVAD implantation. METHODS AND RESULTS Consecutive patients who underwent sequential pulmonary artery catherization with cardiac intensive care optimization before durable LVAD implantation were included. Serial hemodynamics were reviewed retrospectively across the optimization period. The optimal PAPi was defined by the initial PAPi + the PAPi at optimized hemodynamics. RVF was defined as need for a right ventricular assist device or prolonged inotrope use (>14 days postoperatively). Patients with early RVF had significantly lower mean optimal PAPi (3.5 vs 7.5, P < .001) compared with those who did not develop RVF. After adjusting for established risk factors of early RVF after LVAD implantation, the optimal PAPi was independently and incrementally associated with early RVF after LVAD implantation (odds ratio 0.64, 95% confidence interval 0.532-0.765, P < .0001). CONCLUSIONS Optimal PAPi achieved during medical optimization before LVAD implantation provides independent and incremental risk stratification for early RVF, likely identifying dynamic RV reserve.
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Affiliation(s)
- Matthew H Gonzalez
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Spectrum Health Medical Group, Grand Rapids, Michigan.
| | - Qiuqing Wang
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Chony Albert
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kathy Wolski
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Wagener
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Appas Aggarwal
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Miriam Jacob
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Tang
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eileen Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Taylor
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jerry D Estep
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emer Joyce
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
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DeFilippis EM, Givertz MM, Blankstein R. Letter by DeFilippis et al Regarding Article, "Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young". Circ Heart Fail 2021; 14:e008033. [PMID: 33486970 DOI: 10.1161/circheartfailure.120.008033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiovascular Medicine, Department of Medicine (E.M.D., M.M.G., R.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,New York Presbyterian-Columbia University Irving Medical Center, New York, NY (E.M.D.)
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Department of Medicine (E.M.D., M.M.G., R.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine (E.M.D., M.M.G., R.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology (R.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Immohr MB, Boeken U, Mueller F, Prashovikj E, Morshuis M, Böttger C, Aubin H, Gummert J, Akhyari P, Lichtenberg A, Schramm R. Complications of left ventricular assist devices causing high urgency status on waiting list: impact on outcome after heart transplantation. ESC Heart Fail 2021; 8:1253-1262. [PMID: 33480186 PMCID: PMC8006689 DOI: 10.1002/ehf2.13188] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/19/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023] Open
Abstract
Aims Heart transplantation (HTx) represents optimal care for advanced heart failure. Left ventricular assist devices (LVADs) are often needed as a bridge‐to‐transplant (BTT) therapy to support patients during the wait for a donor organ. Prolonged support increases the risk for LVAD complications that may affect the outcome after HTx. Methods and results A total of 342 patients undergoing HTx after LVAD as BTT in a 10‐year period in two German high‐volume HTx centres were retrospectively analysed. While 73 patients were transplanted without LVAD complications and with regular waiting list status (T, n = 73), the remaining 269 patients were transplanted with high urgency status (HU) and further divided with regard to the observed leading LVAD complications (infection: HU1, n = 91; thrombosis: HU2, n = 32; stroke: HU3, n = 38; right heart failure: HU4, n = 41; arrhythmia: HU5, n = 23; bleeding: HU6, n = 18; device malfunction: HU7, n = 26). Postoperative hospitalization was prolonged in patients with LVAD complications. Analyses of perioperative morbidity revealed no differences regarding primary graft dysfunction, renal failure, and neurological events except postoperative infections. Short‐term survival, as well as Kaplan–Meier survival analysis, indicated comparable results between the different study groups without disadvantages for patients with LVAD complications. Conclusions Left ventricular assist device therapy can impair the outcome after HTx. However, the occurrence of LVAD complications may not impact on outcome after HTx. Thus, we cannot support the prioritization or discrimination of HTx candidates according to distinct mechanical circulatory support‐associated complications. Future allocation strategies have to respect that device‐related complications may define urgency but do not impact on the outcome after HTx.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Franziska Mueller
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Emir Prashovikj
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, Duesseldorf, 40225, Germany
| | - René Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Georgstrasse 11, Bad Oeynhausen, 32545, Germany
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Sex differences in patients with cardiogenic shock requiring extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2020; 164:960-969.e6. [DOI: 10.1016/j.jtcvs.2020.12.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 12/13/2022]
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