Influencia del sexo en el pronóstico perioperatorio de pacientes sometidos a sustitución valvular por estenosis aórtica severa

Men are from mars, women are from venus: Factors responsible for gender differences in outcomes after surgical and trans-catheter aortic valve replacement

Females suffer higher operative (30-day) mortality than males after surgical aortic valve replacement (SAVR). In contrast, outcomes after trans-catheter aortic valve replacement (TAVR) seem to favor females, both in terms of procedural mortality, and more prominently, medium to long-term survival. With an ever-greater number of TAVR procedures being performed, an understanding of factors responsible for gender differences in outcomes after the two AVR modalities is critical for better patient selection. Current evidence suggests that this gender difference in outcomes after SAVR and TAVR stems from differences in baseline risk profiles, as well as inherent anatomic/physiological differences between genders. This review attempts to examine these clinical and physiological factors, with a goal of guiding better patient selection for each AVR modality, and to highlight areas that beg further investigation.

Male-female differences in aortic valve and combined aortic valve/coronary surgery: a national cohort study in the Netherlands

Objective

The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery.

Methods

All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included.

Results

In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women.

Conclusions

There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title:

Sex-Related Differences in the Physiology, Risk, and Outcomes of Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a less-invasive alternative to surgical aortic valve replacement (SAVR) for the management of symptomatic severe aortic stenosis in patients with inoperable, high, or intermediate surgical risk. Females undergoing TAVR exhibit distinct physiology and baseline characteristics from their male counterparts. Although rates of procedural complications are higher, medium-term survival appears better for females than males. These sex-based differences are discussed in depth in this review of TAVR in the female population.

Sex, Race, and Socioeconomic Disparities in Patients With Aortic Stenosis (from a Nationwide Inpatient Sample)

Aortic stenosis (AS) is the third most prevalent cardiovascular disease following hypertension and coronary artery disease. The primary objective of this cross-sectional study is to examine gender, racial, and socioeconomic disparities in AS-related health care utilization in patients aged ≥50 years using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AS was identified among inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1. Using stratum-specific weighted totals, means, proportions, and regression models, we examined time trends and disparities for inhospital AS prevalence according to gender, race, and income over the 2002 to 2012 period, predictors of AS (gender, race, income, age, health insurance, co-morbidities, and hospital-level characteristics), and AS's role as a predictor of inhospital death, length of stay, and total charges. Inhospital AS prevalence increased from 2.10% in 2002 to 2.37% in 2012, with similar trends observed within gender, race, and income strata. Women were less likely to have AS compared with men (adjusted odds ratio [ORadj] 0.84; 95% confidence interval [CI] 0.83 to 0.86). Blacks (ORadj 0.68; 95% CI 0.66 to 0.71), Hispanics (ORadj 0.79; 95% CI 0.76 to 0.84), and Asians/Pacific Islanders (ORadj 0.68; 95% CI 0.64 to 0.74) were less likely than whites to have AS diagnosis that was directly associated with income. AS was inversely related to inhospital death but positively linked to total charges overall and longer hospital stays among men, whites, and middle-income patients. However, shorter stays with AS were observed among blacks. In conclusion, among older inpatients, AS prevalence was ∼2% and was higher among males, whites, and higher income groups. Although inhospital death was lower and total charges were higher in AS, length of stay's association with AS varied by gender, race, and income.

Transcatheter aortic valve replacement: focus on sex-related differences in outcomes

Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis for high-risk and inoperable patients. The 10-year experience in Europe has proven the technology to be safe and effective in select populations. The PARTNER trial, the first prospective, randomized, controlled trial for TAVR, showed the technology to be superior to medical management for inoperable patients and equivalent to surgical aortic valve replacement for high-risk patients. Research in cardiovascular medicine has been dominated by studies on the male sex, due to the incidence of the disease process and partly due to historic predominance of male subjects in research studies. Alternatively, TAVR studies focused on high-risk and inoperable patients who are equally distributed by sex. Although sex-related differences are apparent in their baseline characteristics, outcomes have been mixed, with evidence suggesting that female patients may have a mortality advantage with TAVR. Herein we review the TAVR procedure and devices currently available and focus our discussion on outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis.

Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction

INTRODUCTION AND OBJECTIVES

At present, surgery is the only recommended effective treatment for severe aortic stenosis. However, the surgical risk is increased when left ventricular dysfunction is present. The aim of this study was to identify predictors of postoperative and long-term mortality and functional improvement after valve replacement in patients with severe aortic stenosis and left ventricular dysfunction.

METHODS

Between 1996 and 2008, 635 consecutive patients with severe aortic stenosis underwent surgery. Early postoperative mortality in the 82 with an ejection fraction <40% was 19.5%. The following independent predictors of early postoperative mortality were identified: female sex (odds ratio [OR]=2.60; 95% confidence interval [CI], 2.20-89.0; P=.004), mild mitral regurgitation (OR=2.38; 95% CI, 1.40-80.0; P=.020) and coronary artery disease (OR=2.09; 95% CI, 1.26-51.0; P=.027).

RESULTS

During the mean follow-up period of 42.59+/-40.83 months, overall mortality was 18.8% and cardiovascular mortality was 11.3%. The only factor associated with increased mortality during follow-up was a low postoperative cardiac output (OR=4.40; 95% CI, 1.20-15.5; P=.02). In total, 70.5% showed early improvement in ventricular function, the predictors of which were: no improvement following a previous myocardial infarction (P=.04), no revascularized coronary lesions (P=.04), and a low aortic valve pressure gradient (P=.02). Functional class improved significantly during follow-up in 93.4% of patients.

CONCLUSIONS

Despite considerable early postoperative mortality in patients with aortic stenosis and left ventricular dysfunction, over the long term there was evidence of better survival coupled to improved ventricular function and functional class.