Gender differences in patients undergoing TAVI: a multicentre study

Sex differences in transcatheter aortic valve replacement outcomes among patients with bicuspid aortic stenosis

BACKGROUND

Despite comprising almost half of all patients undergoing valvular repair, data on transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (BAS) are limited.

OBJECTIVE

We aimed to evaluate whether there are any sex differences in trends and outcomes of TAVR in this population.

METHODS

We utilized the National Inpatient Sample from 2012 to 2020 to identify admissions with BAS who underwent TAVR and analyzed trends and outcomes. Our primary outcome was in-hospital mortality and secondary outcomes were in-hospital complications. We used two models to adjust for demographics (A) and interventions (B).

RESULTS

Between 2012 to 2020, there were 76,540 hospitalizations for BAS patients who underwent AVR, among which 6,010 (7.9 %) underwent TAVR. There was an overall increasing trend in number of TAVR cases with a decreasing trend in mortality (2013: 8.7 %, 2020: 1.3 %). TAVR was performed more in males (61.1% vs 38.9 %). Despite the worse baseline characteristics in males, in-hospital mortality (2.4% vs. 1.5 %; OR: 1.584; 95 % CI: 0.621-4.038; p = 0.335) and secondary outcomes were similar across both sexes, even after adjusting for demographics and interventions.

CONCLUSION

TAVR in BAS has grown rapidly in the last decade. Males comprised the majority and had more comorbidities, but mortality and complications were similar in both sexes. Despite the increasing number of cases, a decreasing trend in mortality was observed for both sexes ultimately approaching that of SAVR, suggesting that TAVR may be a safe alternative among eligible males and females with bicuspid AS.

The influence of gender on outcomes following transcatheter aortic valve implantation

Objectives

This study aimed to compare gender-related differences in short- and long-term outcomes after transcatheter aortic valve implantation.

Methods

Patients who underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) from September 2017 to December 2022 were enrolled. The primary endpoint was 5-year all-cause mortality. The secondary endpoints were 30-day mortality and the incidence of post-procedural complication. Patients were separated according to gender before statistical analysis. To compare patients with similar baseline characteristics, we performed a propensity matching.

Results

A total of 704 patients [females, 361 (51.3%); males, 343 (48.7%)] were enrolled. Compared to women, men had a higher incidence of smoking (40.5% vs. 14.7%, p < 0.001), diabetes (32.9% vs. 25.1%, p < 0.025), peripheral artery disease (35.8% vs. 18.3%, p < 0.001), and previous cardiac surgery (13.7% vs. 7.2%, p = 0.006) and a lower ejection fraction [56.6 (9.3) vs. 59.8 (7.5), p = 0.046]. Female patients were frailer at the time of the procedure [poor mobility rate, 26% vs. 11.7%, p < 0.001; CCI (Charlson comorbidity index) 2.4 (0.67) vs. 2.32 (0.63), p = 0.04]. Despite these different risk profiles, no significant differences were reported in terms of post-procedural outcomes and long-term survival. Propensity score matching resulted in a good match of 204 patients in each group (57.9% of the entire study population). In the matched cohort, men had a significantly higher incidence of new pacemaker implantation compared to women [33 (16.2%) vs. 18 (8.8%)]. The Kaplan-Meier 5-year survival estimate was 82.4% for women and 72.1% for men, p = 0.038.

Conclusions

Female gender could be considered as a predictor of better outcomes after TAVI.

The impact of gender on outcomes of transcatheter aortic valve implantation between self-expanding valve and balloon-expandable valve

BACKGROUND

While females have been found to have a higher rate of procedural complications with transcatheter aortic valve implantation (TAVI) than males, the effect of valve choice has not been fully elucidated. This study aimed to investigate the impact of gender and choice of balloon or self-expanding valve on TAVI complications.

METHODS

Data from patients who received a TAVI in our institution from January 2016 to September 2021 were retrospectively analyzed. A total of 971 patients were included and divided into self-expanding valve (n = 315) and balloon-expandable valve (n = 656) groups. The endpoints were 30-day mortality, need for a new pacemaker, and major adverse cardiovascular events (MACE) which is defined as cardiac arrest, stroke, myocardial infarction, major bleeding, and unplanned vascular surgery/intervention.

RESULTS

There were more females in the self-expanding valve group than in the balloon-expandable valve group (64.1 % vs. 43.6 %: p < 0.0001). There is no significant difference in the prevalence of hypertension, diabetes mellitus, current smoker, hemodialysis, and the STS risk score between the 2 groups. Females had a higher rate of major adverse cardiovascular events (3.7 % in men vs. 6.8 % in women; p = 0.043), which was driven mostly by vascular complications. This difference was particularly observed in the self-expanding valve group (2.7 % in men vs. 9.4 % in women; p = 0.036).

CONCLUSIONS

TAVI complications were more common in females than males, driven mostly by vascular complications. This difference was particularly observed in woman treated with a self-expanding valve. Particular attention should be given to access choices in females undergoing TAVI.

Sex-Related Outcomes of Transcatheter Aortic Valve Implantation With Self-Expanding or Balloon-Expandable Valves: Insights from the OPERA-TAVI Registry

Evidence regarding gender-related differences in response to transcatheter aortic valve implantation according to the valve type is lacking. This study aimed to evaluate the impact of gender on the treatment effect of Evolut PRO/PRO+ (PRO) or SAPIEN 3 Ultra (ULTRA) devices on clinical outcomes. The Comparative Analysis of Evolut PRO vs SAPIEN 3 Ultra Valves for Transfemoral Transcatheter Aortic Valve Implantation (OPERA-TAVI) is a multicenter, multinational registry including patients who underwent the latest-iteration PRO or ULTRA implantation. Overall, 1,174 of 1,897 patients were matched based on valve type and compared according to gender, whereas 470 men and 630 women were matched and compared according to valve type. The 30-day and 1-year outcomes were evaluated. In the PRO and ULTRA groups, men had a higher co-morbidity burden, whereas women had smaller aortic root. The 30-day (device success [DS], early safety outcome, permanent pacemaker implantation, patient-prosthesis mismatch, paravalvular regurgitation, bleedings, vascular complications, and all-cause death) and 1-year outcomes (all-cause death, stroke, and heart failure hospitalization) did not differ according to gender in both valve groups. However, the male gender decreased the likelihood of 30-day DS with ULTRA versus PRO (p for interaction = 0.047). A higher risk of 30-day permanent pacemaker implantation and 1-year stroke and a lower risk of patient-prosthesis mismatch was observed in PRO versus ULTRA, regardless of gender. In conclusion, gender did not modify the treatment effect of PRO versus ULTRA on clinical outcomes, except for 30-day DS, which was decreased in men (vs women) who received ULTRA (vs PRO).

Transcatheter aortic valve replacement: Past, present, and future

Transcatheter aortic valve replacement (TAVR) has emerged as a ground-breaking, minimally invasive alternative to traditional open-heart surgery, primarily designed for elderly patients initially considered unsuitable for surgical intervention due to severe aortic stenosis. As a result of successful large-scale trials, TAVR is now being routinely applied to a broader spectrum of patients. In deciding between TAVR and surgical aortic valve replacement, clinicians evaluate various factors, including patient suitability and anatomy through preprocedural imaging, which guides prosthetic valve sizing and access site selection. Patient surgical risk is a pivotal consideration, with a multidisciplinary team making the ultimate decision in the patient's best interest. Periprocedural imaging aids real-time visualization but is influenced by anaesthesia choices. A comprehensive postprocedural assessment is critical due to potential TAVR-related complications. Numerous trials have demonstrated that TAVR matches or surpasses surgery for patients with diverse surgical risk profiles, ranging from extreme to low risk. However, long-term follow-up data, particularly in low-risk cases, remains limited, and the applicability of published results to younger patients is uncertain. This review delves into key TAVR studies, pinpointing areas for potential improvement while delving into the future of this innovative procedure. Furthermore, it explores the expanding role of TAVR technology in addressing other heart valve replacement procedures.

Sex-related differences in outcome after left atrial appendage occlusion: Insights from Europe and the EWOLUTION registry

BACKGROUND

Women with atrial fibrillation (AF) generally experience worse symptoms, poorer quality of life, and have a higher risk of stroke and death. There is limited availability of sex-related differences regarding left atrial appendage occlusion (LAAO).

AIMS

The aim of this study was to evaluate the sex-related differences in patients undergoing LAAO in EWOLUTION.

METHODS

A total of 1025 patients scheduled for elective LAAO therapy employing the WATCHMAN Gen 2.5 prospectively consented for participation; 1005 patients received a successful implant and were followed for 2 years. As we detected sex-related differences in baseline data we performed a propensity score matching. The primary endpoint is a combined endpoint of survival free from mortality, major bleeding, ischemic stroke, transitory ischemic attack (TIA) and systemic embolization (SE) up to 2-year clinical follow-up. Secondary Endpoints were periprocedural data and overall 2-year survival.

RESULTS

Women were older but had less often vascular disease and hemorrhagic stroke. There was no sex-related significant difference after LAAO at 2 years in the combined endpoint of survival free from mortality, major bleeding, ischemic stroke, TIA, and SE (female vs. male: 79% vs.76%, p = 0.24) or in overall survival (female vs. male: 85% vs. 82%, p = 0.16). Procedural data showed a higher sealing rate after the implantation in women (complete sealing female 94% vs. male 90%, p = 0.033), significantly more pericardial effusions (female 1.2% vs. male 0.2%, p = 0.031) and a similar periprocedural risk profile.

CONCLUSIONS

Females undergoing LAAO differ in various baseline variables, but after adjustment, we observed similar safety and efficacy of LAAO with no significant difference in long-term outcomes between women and men.

Sex-Based Outcomes in Patients Undergoing WATCHMAN Device Implantation

Sex-based disparities in outcomes are reported for various cardiovascular procedures. This study aimed to assess the difference in outcomes in patients who underwent WATCHMAN device implant based on sex. Patients who underwent WATCHMAN device placement, from 2016 to 2018, were identified from the National Inpatient Sample database. The primary outcome was inpatient mortality, and the secondary outcomes were the length of stay (LOS), hospitalization cost (HOC), and periprocedural complications. A logistic regression model was built to perform an adjusted analysis for the outcomes. A total of 12,327 patients underwent WATCHMAN device placement. Female patients were older and more likely to have hypertension (p <0.01) and less likely to have peripheral arterial disease (5.6 vs 7.2, p <0.01), chronic kidney disease (21% vs 26%, p <0.01), and diabetes (18% vs 20%, p = 0.03) and were also at a higher risk for certain periprocedural complications, including pericardiocentesis and anemia requiring blood transfusion (p <0.01 for all). In the unadjusted analysis, the female sex was associated with longer LOS (1.5 vs 1.3 days, p <0.01) and inpatient mortality (0.23 vs 0.10, p = 0.05). The HOC was numerically higher in women but statistically nonsignificant ($120,791 vs $118,554, p = 0.1). In the stepwise, backward, multivariate regression analysis, the female sex  was an independent risk factor for higher LOS (1.5 vs 1.3 days, p <0.01, 95% confidence interval 1.3 to 1.4) after adjusting for potential confounders. The inpatient mortality and HOC were similar between 2 groups after adjusting for potential cofounders in the multivariate regression analysis. Our study suggests that the female sex is an independent risk factor for longer LOS among patients hospitalized for WATCHMAN device placement.

Sex difference and outcome trends following transcatheter aortic valve replacement

Background

Based on worldwide registries, approximately 50% of patients who underwent transcatheter aortic valve replacement (TAVR) are female patients. Although TAVR procedures have improved tremendously in recent years, differences in outcome including mortality between sexes remain. We aimed to investigate the trends in TAVR in the early and new eras of utilization and to assess TAVR outcomes in female patients vs. male patients.

Methods

Using the 2011–2017 National Inpatient Sample (NIS) database, we identified hospitalizations for patients with the diagnosis of aortic stenosis during which a TAVR was performed. Patients' sociodemographic and clinical characteristics, procedure complications, and mortality were analyzed. Piecewise regression analyses were performed to assess temporal trends in TAVR utilization in female patients and in male patients. Multivariable analysis was performed to identify predictors of in-hospital mortality.

Results

A total of 150,647 hospitalizations for TAVR across the United States were analyzed during 2011–2017. During the study period, a steady upward trend was observed for TAVR procedures in both sexes. From 2011 to 2017, there were significantly more TAVR procedures performed in men [80,477 (53.4%)] than in women [70,170 (46.6%)]. Male patients had significantly higher Deyo-CCI score and comorbidities. Differences in mortality rates among sexes were observed, presenting with higher in-hospital mortality in women than in men, OR 1.26 [95% CI 1.18–1.35], p < 0.001.

Conclusion

Utilization of TAVR demonstrated a steady upward trend during 2011–2017, and a similar trend was presented for both sexes. Higher in-hospital mortality was recorded in female patients compared to male patients. Complication rates decreased over the years but without effect on mortality differences between the sex groups.

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.

The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience

Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.

Gender difference in left atrial appendage occlusion outcomes: Results from the Amplatzer™ Amulet™ Observational Study

Background

Percutaneous LAAO represents an alternative for stroke prevention in patients not tolerating anticoagulation. While women are at higher risk of complications during percutaneous coronary or valvular interventions, the impact of gender on LAAO outcomes is not well characterized. The current study assessed potential gender-related differences in procedural and long-term outcomes following left atrial appendage occlusion (LAAO).

Methods

1088 AF patients were enrolled in the prospective, multicenter, Amplatzer™ Amulet™ Observational Study and followed for 2 years with scheduled adverse event assessments. The prespecified primary outcome was ischemic stroke, systemic embolism or cardiovascular (CV) death at 2 years. We also compared the rate of procedural success, device-related thrombus (DRT) and major bleeding between genders.

Results

702 men and 386 women underwent LAAO. Implant successwas high, and similar between men and women (98.9 vs 99.5%, p = 0.58). Similarly, no difference was observed in the primary outcome (12.0 vs 12.5%, p = 0.82). Compared to the CHA₂DS₂-VASc predicted rate, we observed a numerically greater absolute risk reduction of ischemic stroke in women (from 7.6 to 2.1%/year) than men (from 6.2 to 2.2%/year). DRT through 2 years was similar between groups (1.6%, p = 0.96). We found no significant gender difference in terms of periprocedural or long-term (7.1 vs 7.6%/year) major bleeding.

Conclusions

In this large group of patients undergoing LAAO using the Amplatzer™ Amulet™ device we found no significant gender difference in terms of procedural or long-term clinical outcomes. Similarly to oral anticoagulation, device-based LAA occlusion renders AF-related stroke risk similar in women and men.

Clinical trial registration

Clinicaltrials.gov Identifier: NCT02447081.

https://clinicaltrials.gov/ct2/show/NCT02447081.

Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis

Background

As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower‐risk populations, the burden and predictors of procedure‐related complications including the need for permanent pacemaker (PPM) implantation needs to be identified.

Methods and Results

Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random‐ and fixed‐effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random‐effects model indicated significantly higher odds of post‐TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04–1.28); for patients with baseline mobitz type‐1 second‐degree atrioventricular block (OR, 3.13; 95% CI, 1.64–5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09–1.86), bifascicular block (OR, 2.59; 95% CI, 1.52–4.42), right bundle‐branch block (OR, 2.48; 95% CI, 2.17–2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69–6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18–1.76), while self‐expandable valves had 1.93 (95% CI, 1.42–2.63) fold higher odds of PPM requirement compared with self‐expandable and balloon‐expandable valves, respectively.

Conclusions

Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self‐expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.

Sex differences in patients undergoing transcatheter aortic valve replacement in Asia

Objectives

Transcatheter aortic valve replacement (TAVR) is increasingly performed. Physically small Asians have smaller aortic root and peripheral vessel anatomy. The influence of gender of Asian patients undergoing TAVR is unknown and may affect outcomes. The aim of this study was to assess sex differences in Asian patients undergoing TAVR.

Methods

Patients undergoing TAVR from eight countries were enrolled. In this retrospective analysis, we examined differences in characteristics, 30-day clinical outcomes and 1-year survival between female and male Asian patients.

Results

Eight hundred and seventy-three patients (54.4% women) were included. Women were older, smaller and had less coronary artery and lung disease but tended to have higher logistic EuroSCOREs. Smaller prostheses were used more often in women. Major vascular complications occurred more frequently in women (5.5% vs 1.8%, p<0.01); however, 30-day stroke and mortality (women vs men: 1.5% vs 1.6%, p=0.95% and 4.3% vs 3.4%, p=0.48) were similar. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements (11.2% vs 9.0%, p=0.52) were also similar as was 1-year survival (women vs men: 85.6% vs 88.2%, p=0.25). The only predictors of 30-day mortality were major vascular injury in women and age in men.

Conclusions

Asian women had significantly smaller stature and anatomy with some differences in clinical profiles. Despite more frequent major vascular complications, women had similar 30-day stroke or mortality rates. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements were similar as was 1-year survival.

Simultaneous Estimation of Gender Male and Atrial Fibrillation as Risk Factors for Adverse Outcomes Following Transcatheter Aortic Valve Implantation

Accurate outcome prediction following transcatheter aortic valve implantation (TAVI) has gained further importance along with expanding its indication to patients with a lower surgical risk. Although previous studies have evaluated the prognostic impacts of gender and atrial fibrillation (AF) in TAVI patients, these two factors have rarely been addressed simultaneously. This retrospective observational study based on a multicenter TAVI registry involved 1088 patients who underwent TAVI between May, 2010 and February, 2020 at 3 hospitals in Japan. Participants were divided into 4 groups by gender and pre-existing AF, such as Female AF(-) (n = 559), Male AF(-) (n = 266), Female AF(+) (n = 187) and Male AF(+) (n = 76). Primary and secondary endpoints were death due to any and cardiovascular cause, and the composite of all-cause death and heart failure hospitalization, respectively. The median follow-up period was 538 days. Cumulative incidences of primary and secondary endpoints were lower in the Female AF(-) group compared to the other 3 groups. Adjusted multivariate Cox proportional hazard analyses showed an independent association of either or both of male gender and AF with adverse outcomes, when compared to the group with none of these (hazard ratios and 95% confidence intervals vs. Female AF(-) (reference) for all-cause death of Male AF(-): 2.7, 1.6-4.6, p < 0.001, Female AF(+): 3.5, 2.1-6.0, p < 0.001, and Male AF(+): 3.9, 1.9-7.8, p < 0.001), while there was no evidence of their synergistic prognostic impact. Male gender and being complicated by AF independently, but not synergistically, predicted poor long-term outcomes in patients undergoing TAVI.

Sex Differences in In-Hospital Outcomes of Transcatheter Aortic Valve Replacement

Since the introduction of transcatheter aortic valve replacement (TAVR), there has been a paradigm shift in the management of severe aortic stenosis. While women represent almost half of the patients undergoing TAVR, there are limited data on sex-based comparisons in hospital outcomes and predictors of mortality in women and men. The National Inpatient Sample database from 2012 to 2015 was used to identify TAVR using international classification of diseases-9 clinical modification procedure codes 35.05 and 35.06. We identified 61,239 patients who underwent TAVR between 2012 and 2015. After adjusting for potential confounders, women had higher odds of all-cause mortality as compared to men [odds ratio (OR) 1.25, 95% confidence interval (CI): 1.01-1.54; P = 0.036]. Moreover, women had significantly increased odds of cardiac complications [OR 2.41, 95% CI: 1.67-3.49; P ≤ 0.01], respiratory complications [OR 1.20 95% CI: 1.07-1.34; P = 0.001], major hemorrhage requiring transfusion [OR 1.51, 95% CI: 1.37-1.67; P ≤ 0.001], neurological complications [OR 1.38, 95% CI: 0.95-1.99; P = 0.08], need for vasopressor treatment [OR 1.33, 95% CI: 1.01-1.75; P = 0.04], and vascular complications [OR 1.73, 95% CI: 1.19-2.52; P = 0.004]. On the contrary, the odds of pacemaker requirement [OR 0.85, 95% CI: 0.75-0.97; P = 0.02], and acute kidney injury [OR 0.80, 95% CI: 0.71-0.91; P = 0.001] were significantly lower in women. Among patients undergoing TAVR, women were more likely to have in-hospital complications and mortality as compared with men. Further studies are needed to identify the discrepancy in in-hospital outcomes with sex-specific factors being considered.

Sex difference in the prognostic role of body composition parameters in Taiwanese patients undergoing transcatheter aortic valve implantation

Background

Evidence on association between body composition and outcomes of transcatheter aortic valve implantation (TAVI) is limited for Asian patients. This study investigated the prognostic role of body composition parameters in Taiwanese patients undergoing TAVI.

Materials and methods

Data of consecutive patients undergoing TAVI for severe aortic stenosis between May 1, 2010 and August 31, 2019 were prospectively collected in this observational study. The association between body composition parameters (body mass index [BMI], body surface area [BSA], lean body mass [LBM], and LBM index) and cumulative mortality was analyzed using Cox proportional hazard regression model.

Results

A total of 221 patients (mean age 81.4 years), including 125 (56.6%) males, were included with median follow-up duration of 23.8 months. In males, multivariate analysis revealed that higher BMI (P = 0.035), BMI ≥ 20 kg/m² (P = 0.026), and higher LBM index (P = 0.023) significantly predicted lower overall all-cause cumulative mortality. In females, none of the body composition parameters was significantly associated with all-cause cumulative mortality. Paradoxical association between BMI and estimated all-cause cumulative mortality was only significant among male patients.

Conclusion

In Taiwanese TAVI patients, the prognostic effects of BMI and LBM index on cumulative mortality were only observed in males, not in females. Sex differences must be considered when stratifying risk among patients undergoing TAVI.

Long-Term Follow-Up of Transcatheter Aortic Valve Implantation With Portico Versus Evolut Devices

New-generation devices such as Evolut and Portico have provided favorable results in patients who underwent transcatheter aortic valve implantation (TAVI) for aortic stenosis, but their comparative effectiveness remains debated, despite its relevance when envisioning TAVI in low-risk patients. We evaluated the safety and efficacy of 2 leading TAVI devices (Evolut and Portico) used by the same team of experienced TAVI operators, focusing on long-term outcomes, including major adverse events (i.e., the composite of death, stroke, myocardial infarction, major vascular complication, or major bleeding). Unadjusted and propensity score-adjusted analyses were carried out. A total of 233 patients were included, 119 (51.1%) receiving Evolut and 114 (49%) Portico. Baseline and procedural data showed significant between-device differences, including functional class, surgical risk, chronic obstructive pulmonary disease, renal function, transesophageal guidance, device size, postdilation, and procedural time (all p <0.05). Yet, acute and in-hospital outcomes were not significantly different (all p >0.05). Follow-up status was ascertained in 228 (98%) patients after 15.0 ± 7.6 months. Unadjusted analysis showed similar rates of major adverse events, as well as the individual risk of death, stroke, myocardial infarction, major vascular complication, major bleeding, and pacemaker implantation (all p >0.05). Even at propensity score-adjusted analysis outcomes were not significantly different with Evolut and Portico (all p >0.05). In conclusion, Evolut and Portico devices yield similarly favorable results at long-term follow-up when used by experienced TAVI operators.

Impact of transcatheter aortic valve implantation on mechanical dispersion

Objectives

The physiological determinants of left ventricular (LV) mechanical dispersion (MD) are not fully explored. We aimed to investigate the impact of afterload reduction and changes in ventricular conduction on LV MD after transcatheter aortic valve implantation (TAVI).

Methods

Patients with severe aortic stenosis (AS) were examined in a prospective, repeated measures observational cohort study before and after an uncomplicated transfemoral TAVI in a single tertiary centre. LV MD was assessed by speckle tracking echocardiography. Valvulo-arterial impedance (ZVA) was used as a measure of global afterload.

Results

We included 140 consecutive patients (83±8 years old, 49% women, logistic EuroSCORE 16±10) with severe AS (valve area 0.7±0.2 cm², mean transvalvular gradient 54±18 mm Hg) and a relatively preserved LV ejection fraction (52%±11%). After TAVI, we observed favourable changes in transvalvular gradients and ZVA in all patients. Compared with baseline, postprocedural MD was significantly lower in 108 patients with unchanged ventricular conduction (55±17 ms vs 51±17 ms, p=0.02) and higher in 28 patients with TAVI-induced left bundle branch block (51±13 ms vs 62±19 ms, p≤0.001). During 22±9 months observation, 22 patients died. Postprocedural MD was associated with mortality in a univariate Cox regression model (HR=1.24 (1.01-1.52), p<0.04, per 10 ms increase).

Conclusions

Isolated afterload reduction was associated with reduction of MD, while concomitant impairment of ventricular conduction resulted in a more pronounced MD after TAVI, indicating that loading conditions and conduction should be considered when evaluating MD. A pronounced postprocedural LV MD was associated with mortality.

Is oral anticoagulation effective in preventing transcatheter aortic valve implantation failure? A propensity matched analysis of the Italian Transcatheter balloon-Expandable valve Registry study

BACKGROUND

Early hypo-attenuated leaflet thickening after transcatheter aortic valve implantation (TAVI) has been recently described presumably reflecting thrombus apposition. Although its clinical relevance is still unknown, oral anticoagulant therapy (OAT) led to almost complete resolution.

METHODS

The retrospecitve Italian Transcatheter balloon-Expandable valve registry that included all patients undergoing balloon-expandable TAVI in 33 Italian centers. Patients discharged after TAVI with aspirin alone were compared with those assuming aspirin and OAT before and after propensity score with matching. Prosthetic heart valve dysfunction at follow-up was the primary end point. All-cause death, cardiovascular death, bleeding, vascular complications and cerebrovascular accidents at 30 days and at follow-up were the secondary ones.

RESULTS

Among the 1904 patients enrolled in the Italian Transcatheter balloon-Expandable valve registry, 716 patients on OAT and aspirin or aspirin alone were identified and analyzed: 555 were on aspirin alone and 161 on OAT and aspirin. The median follow-up was 44.0 ± 12 months. After matching, risk of prosthetic valve dysfunction at follow-up did not differ between the two groups: 3.1% in patients treated with aspirin alone vs. 1.9% in those treated with OAT and aspirin, (P = 0.72). Nevertheless patients treated with aspirin alone at follow-up had a significantly lower risk of death (21 vs. 33%, P = 0.03) and major bleeding (4 vs. 14%, P = 0.04) with a similar rate of stroke/transient ischemic attack (TIA) (1.2 vs. 3.1%, P = 0.45). At 30 days rates of Valve Academic Research Consortium death were similar in both groups (0.6 vs. 3.7%, P = 0.12) with higher risk of life threatening bleeding and minor vascular complications in patients on OAT and aspirin.

CONCLUSION

After TAVI with Edwards Sapien valve OAT did not reduce the incidence of valve dysfunction and stroke but was responsible for mortality and bleeding increases.

Gender Disparities in Management and Outcomes Following Transcatheter Aortic Valve Implantation With Newer Generation Transcatheter Valves

The impact of gender on management and early outcomes after transcatheter aortic valve implantation (TAVI) in the setting of newer generation transcatheter heart valves (THVs) is not well known. We evaluated gender-specific differences on clinical management and in-hospital outcomes in adults who underwent TAVI with newer generation THVs. The study population included 298 consecutive patients who underwent TAVI and received a newer generation THV (Sapien 3 [Edwards Lifesciences, Irvine, California] or Corevalve Evolut R or Evolut Pro [Medtronic, Minneapolis, Minnesota]) from December 2015 to June 2018 at an academic tertiary medical center. Of the 298 patients, 154 (52%) were men and 144 (48%) were women. Compared with men, women were older, had lower serum creatinine, higher left ventricular ejection fraction, and lower rates of multiple co-morbidities, including previous coronary artery bypass graft surgery, previous myocardial infarction, and atrial fibrillation. Women were noted to have smaller aortic annular area and perimeter and underwent implantation of smaller THVs than men. At the time of discharge, women were more frequently prescribed a P2Y12 inhibitor (primarily clopidogrel) and less frequently prescribed oral anticoagulation (namely warfarin). Hospital length of stay and in-hospital rates of mortality, disabling stroke, and pacemaker were similar in men and women. In conclusion, in this observational prospective study of adults who underwent TAVI with newer generation THVs, while gender-related disparities in clinical presentation and procedural management were observed, no significant difference in clinical outcomes were noted in men and women. Further studies examining gender-related differences in procedural and postprocedural care after TAVI in the contemporary era are warranted to better understand and optimize clinical outcomes in both men and women.

Sex-Specific Outcomes After Transcatheter Aortic Valve Replacement: A Review of the Literature

Transcatheter aortic valve replacement (TAVR) is a safe and effective therapy for aortic valve replacement in patients ineligible for or at high risk for surgery. However, outcomes after TAVR based on an individual's sex remain to be fully elucidated. We searched PUBMED and EMBASE using the keywords: "transcatheter aortic valve replacement," "transcatheter aortic valve implantation," "sex differences," "gender," "sex characteristics" and collected information on baseline features, procedural characteristics, and postprocedural outcomes in women. Inclusion/exclusion resulted in 23 publications. Women had less preexisting comorbidities than men. Most studies reported better survival in women (range of hazard ratio [95% CI] = 0.27 [0.09-0.84] to 0.91 [0.75-1.10]). At 30 days, women also had more vascular complications (6-20% vs 2-14%) and higher bleeding rates (10-44% vs 8-25%). Stroke rates were similar at 30 days (women, 1-7%; men, 1-5%). This literature review showed better survival in women than men after TAVR. However, women had more vascular complications and bleeding; stroke rates were similar. These findings may partly be explained by fewer baseline comorbidities in women. These results should be interpreted with caution as most measures only include unadjusted percentages.

Impact of gender on outcomes after transcatheter aortic valve implantation

Backgound

The influence of gender on clinical outcomes following transcatheter aortic valve implantation (TAVI) was considerably discrepant in previous studies. We aimed to investigate the impact of gender in our registry.

Methods

The study is a retrospective observational analysis of a prospectively designed cohort (546 consecutive patients treated at the University Hospital Zurich who were enrolled in Swiss TAVI Cohort from May 2008 to April 2014). The Study took place in University Heart Centre at University Hospital Zurich, Switzerland.

Results

Both genders were equally represented with 51.5 % (n = 281) of the populations being females, who were significantly older and had a more pronounced history of hypertension (P < 0.001). Males on the other hand showed a higher incidence of diabetes (P = 0.004), coronary artery disease (P < 0.001), chronic obstructive pulmonary disease (P < 0.001) and renal failure requiring renal replacement therapy (P = 0.018). Patients were followed up for a median of 391 days with a 100% complete follow-up at one year. The primary outcome (all-cause mortality) occurred in 6.8% (n = 37) and 15% (n = 82) of patients at 30 days and one year, respectively. The 30-day all-cause mortality outcome did not significantly differ between females (7.5%) and males (6.0%) (P = 0.619), but one year all-cause mortality occurred significantly more in males than in females (18.7% vs. 11.7%, P < 0.037).

Conclusion

After TAVI implantation for severe aortic stenosis, males have a less favorable long-term (one year) mortality outcome than females.

Female-specific survival advantage from transcatheter aortic valve implantation over surgical aortic valve replacement: Meta-analysis of the gender subgroups of randomised controlled trials including 3758 patients

Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is the first area of interventional cardiology where women are treated as often as men. In this analysis of the gender specific results of randomised controlled trials (RCTs) comparing TAVI with surgical aortic valve replacement (SAVR) we aimed to determine whether gender affects the survival comparison between TAVI and SAVR. We identified all RCTs comparing TAVI versus SAVR for severe AS and reporting 1 and/or 2year survival. Summary odds ratios (ORs) were obtained using a random-effects model. Heterogeneity was assessed using the Q statistic and I². Four RCTs met the criteria, totalling 3758 patients, 1706 women and 2052 men. Amongst females, TAVI recipients had a significantly lower mortality than SAVR recipients, at 1year (OR 0.68; 95%CI 0.50 to 0.94) and at 2years (OR 0.74; 95%CI 0.58 to 0.95). Amongst males there was no difference in mortality between TAVI and SAVR, at 1year (OR 1.09; 95%CI 0.86 to 1.39) or 2years (OR 1.05; 95%CI 0.85 to 1.3). The difference in treatment effect between genders was significant at both 1year (p_interaction=0.02) and 2years (p_interaction=0.04). In women TAVI has a 26 to 31% lower mortality odds than SAVR. In men, there is no difference in mortality between TAVI and SAVR.

Sex-Specific Considerations in Women with Aortic Stenosis and Outcomes After Transcatheter Aortic Valve Replacement

Aortic stenosis (AS) is the most common valvular disease in the elderly and is associated with poor outcomes. Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) in high-risk patients. Herein, we describe the gender-related differences in baseline characteristics and pathophysiologic response to severe AS, imaging considerations unique to females, and short- and long-term outcomes after TAVR. Women undergoing TAVR are older and frailer, have less cardiovascular comorbidities, smaller femoral artery size, better left ventricular systolic function, hypertrophied and small left ventricles leading to a higher incidence of paradoxical low-flow low-gradient AS, and a greater prevalence of porcelain aorta, smaller aortic annulus size, and lower coronary ostia heights. Imaging and histopathological data also suggests a sex-related myocardial response to pressure overload from AS. Women experience more vascular complications and blood transfusion requirements, serious procedural complications, and a greater incidence of stroke, but have better long-term outcomes than men. Patient-prosthesis mismatch, which is a concern in patients with a small aortic annulus size undergoing SAVR, has not been problematic with TAVR. The aforementioned findings suggest that TAVR may be preferable for women with severe AS. Further studies are warranted to directly compare TAVR with SAVR in women.

Comparison of Outcomes and Complications of Transcatheter Aortic Valve Implantation in Women Versus Men (from the National Inpatient Sample)

Transcatheter aortic valve implantation (TAVI) is a rapidly emerging procedure for the treatment of intermediate and high-surgical-risk patients with severe aortic stenosis. The impact of gender on in-hospital outcomes has not been studied on a large scale. The aim of this study was to examine gender differences in in-hospital outcomes after TAVI. The National Inpatient Sample (2012 to 2014) using the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for TAVI (35.05 and 35.06) were used to form this database. Propensity score matching (1:1) was performed and in-hospital outcomes were compared. The primary outcome was in-hospital mortality. Statistical analysis was performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina). A total of 41,050 (weighted) patients were included in our study. Women accounted for 47.7% (n = 19,570) in our study and presented with older age (81.7 years vs 80.5 years, p ≤ 0.0001). The population was predominantly white (87.4%). After performing propensity score-matched analysis (1:1), no difference in the primary outcome was noted between men and women. The secondary outcomes including stroke, hemorrhage requiring transfusion, and pericardial complications were higher in women. The composite end point of death and stroke occurred more frequently in women than in men. Acute renal failure was higher in men. The post-TAVI length of stay was higher in women (8.3 days vs 7.7 days, p = 0.0007). In conclusion, this large, retrospective registry analysis of patients with severe aortic stenosis who underwent TAVI suggests women may experience higher rates of in-hospital morbidity compared with men.

Sex-related differences in clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic stenosis

Introduction

There are inconsistent data on the sex-related differences in clinical outcomes and quality of life (QoL) after transcatheter aortic valve implantation (TAVI).

Aim

We sought to investigate sex-related differences in procedural, clinical and QoL outcomes of TAVI.

Material and methods

A total of 101 consecutive patients undergoing TAVI were enrolled. Patients were stratified by gender. Baseline characteristics, procedural and long-term clinical outcomes as well as frailty and QoL indices (EQ-5D-3L questionnaire) were compared between women and men.

Results

Women represented 60.4% of the study population. Periprocedural risk measured with the Logistic EuroSCORE and STS scale was similar for women and men. There were no differences in 30-day or 12-month all-cause mortality between groups (women vs. men: 9.8% vs. 12.5%; age-adjusted odds ratio (OR) (95% CI): 1.38 (0.39–4.94); 13.1% vs. 25.0%; age-adjusted OR (95% CI): 2.51 (0.87–7.25)). Men were at higher risk of new onset atrial fibrillation at follow-up (1.6% vs. 17.5%; age-adjusted OR (95% CI): 14.61 (1.68–127.37)). In multivariable Cox regression analysis, a history of stroke/transient ischemic attack (TIA) (hazard ratio (HR)) (95% CI): 3.93 (1.39–11.07) and blood transfusion (HR (95% CI): 2.84 (1.06–7.63)) were identified as independent factors affecting 12-month mortality. No differences in QoL parameters were noted.

Conclusions

The TAVI can be considered as an effective and safe treatment in high-risk patients with severe aortic stenosis, regardless of gender.

Comparison in Men Versus Women of Co-morbidities, Complications, and Outcomes After Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

Transcatheter aortic valve implantation (TAVI) decreases mortality in high-risk patients with severe aortic stenosis, but it remains unclear if female gender is associated with more favorable outcomes after TAVI. All patients who underwent TAVI at a single institution were retrospectively analyzed and stratified by gender. Procedural, in-hospital, 30-day, and 1-year outcomes were defined according to the second Valve Academic Research Consortium. The primary end point was all-cause mortality at 1 year. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression were conducted. Overall, 755 patients underwent TAVI and were included in the study; 50.7% were women. Average age was 83.0 ± 7.7 years, with a mean Society of Thoracic Surgeons score of 8.9 ± 4.6. Women were older than men and more likely to be black. Most co-morbidities were less common among women, and they were more likely than men to suffer both in-hospital (8.4% vs 4.3%, p = 0.021) and 30-day (9.4% vs 5.4%, p = 0.035) all-cause mortality. Life-threatening bleeding, transfusion, and iliofemoral dissection or perforation were more common among women. There was no difference in mortality between women and men at 1 year (20.6% vs 21.5%, log-rank p = 0.87). After multivariable adjustment, however, female gender was independently associated with lower mortality at 1 year after TAVI. In conclusion, despite higher rates of major bleeding, vascular complications, and 30-day mortality, female gender was independently associated with improved survival at 1 year after TAVI.

Antithrombotic therapy following transcatheter aortic valve implantation: what challenge do we face?

The issue of stroke and bleeding events following transcatheter aortic valve implantation (TAVI) and its relation with antithrombotic regimens before, during and after the procedure is increasingly recognized as an important issue. While dedicated trials are ongoing, there is no clear evidence at present on the best antithrombotic regimen in the context of TAVI. In this article, we will go through the mechanisms involved in embolic and bleeding complications of TAVI, and we will discuss the key aspects of antithrombotic treatment in patients undergoing TAVI.

Meta-analysis of comparison between self-expandable and balloon-expandable valves for patients having transcatheter aortic valve implantation

Two different devices, 1 self-expanding and 1 balloon-expandable, have been developed for patients who underwent transcatheter aortic valve implantation with contrasting data about efficacy and safety. Pubmed, Medline, and Google Scholar were systematically searched for studies of these different devices, with data derived from randomized controlled trial or registries with multivariate analysis. All-cause death at 30 days and at follow-up were the primary end points, whereas postprocedural moderate or severe aortic regurgitation (AR), stroke, major vascular complications, bleedings, and pacemaker implantation the secondary ones. Six studies with 957 self-expanding and 947 balloon-expandable valves were included: 1 randomized controlled trial and 5 observational studies. At 30 days follow-up, rates of death did not differ between self-expanding and balloon-expandable valves (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.47 to 1.17), whereas balloon expandable reduced rates of moderate or severe AR (OR 0.51, 95% CI 0.27 to 0.99) and of pacemaker implantation (OR 0.28, 95% CI 0.17 to 0.47). After a follow-up of 360 days (300 to 390), rates of all-cause death did not differ between the 2 groups. In conclusion, risks of moderate or severe AR and pacemaker implantation were lower with the balloon-expandable devices without an impact on 30 days and midterm mortality.

Sex Differences in Aortic Stenosis and Outcome Following Surgical and Transcatheter Aortic Valve Replacement

Aortic stenosis is the commonest valve defect in the developed world and is associated with a high mortality once symptomatic. There is a difference in the way that male and female hearts remodel in the face of chronic pressure overload: women develop a concentrically hypertrophied, small cavity left ventricle (LV), whereas men are more prone to the development of eccentric hypertrophy. At a cellular level, there is an increase in collagen and metalloproteinase gene expression in males suggesting a different regulation of extracellular volume composition according to sex. Male hearts with aortic stenosis appear to have more fibrosis than their female comparators. The trigger for this appears to be in part related to estrogen receptor signaling, but other factors such as renin-angiotensin activation, nitric oxide, and circulating noradrenaline levels may also be implicated. Treatment options include surgical valve replacement (SAVR) and more recently transcatheter aortic valve replacement (TAVR). Female sex may be a risk factor for adverse outcome following SAVR and conversely appears to confer a survival advantage when undergoing TAVR. Whether the lower mortality seen following TAVR in women compared with men (despite their increased age and frailty) reflects their longer life expectancy, smaller annular size (and less post-TAVR aortic regurgitation), more favorable LV reverse remodeling, or more likely, a combination of these factors remains to be established.

Effect of gender after transcatheter aortic valve implantation: a meta-analysis

BACKGROUND

The effect of gender on patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains to be defined.

METHODS

MEDLINE, Cochrane Library, and Scopus databases were searched for articles describing sex differences in baseline characteristics, procedures, and outcomes. All-cause death at follow-up of at least 1 year was the primary end point, and the independent effect of female gender was evaluated with pooled analysis using a random-effect model and with meta-regression.

RESULTS

Six studies with 6,645 patients were included, half of them being women presenting with lower European System for Cardiac Operative Risk Evaluation (EuroSCORE) compared with men. At 30 days, more frequent major vascular complications and major and life-threatening bleeding occurred in women, with lower rates of moderate to severe aortic regurgitation, whereas 30-day mortality was similar. After a median follow-up of 365 days (range, 365 to 730 days) all-cause mortality was 24.0% in women and 34.0% in men. A pooled analysis of the multivariable approach found female gender was significantly related to a lower risk of death (odds ratio, 0.82; 95% CI, confidence interval, 0.73 to 0.93; I(2) = 0%). A meta-regression analysis showed age, ejection fraction, previous cardiovascular accident, renal insufficiency, and access site did not influence these data.

CONCLUSIONS

Female patients undergoing TAVI present with a lower burden of comorbidities. The counterbalance between higher rates of vascular complications but lower of valve regurgitation may explain the reduced risk for women after TAVI, independently from baseline features and access site.

Meta-analysis of predictors of all-cause mortality after transcatheter aortic valve implantation

The aim of this study was to identify predictors of 30-day and midterm mortality after transcatheter aortic valve implantation (TAVI) by means of a systemic review. TAVI was demonstrated to be safe and efficacious in patients with severe aortic stenosis. An accurate estimation of procedural risk of these patients represents an actual challenge. The PubMed and Cochrane Collaboration databases were systematically searched for studies reporting on the incidence and independent predictors of 30-day and midterm mortality. Adverse events were pooled with random effect, whereas independent predictors are reported as odds ratios (ORs) with 95% confidence intervals (CIs). A total of 25 studies with 8,874 patients were included (median age 82.5 ± 1.5 years, 54.6% women). At 30 days, 7.5% of patients (n = 663) died. At midterm follow-up (median 365 days, interquartile range 267 to 365 days), the cumulative mortality rate was 21.6% (n = 1,917). Acute kidney injury (AKI) stage ≥2 (OR 18.0, 95% CI 6.3 to 52), preprocedural hospitalization for heart failure (OR 9.4, 95% CI 2.6 to 35), periprocedural acute myocardial infarction (OR 8.5, 95% CI 2.6 to 33.5), and increased pro-brain natriuretic peptide (pro-BNP) levels (OR 5.4, 95% CI 1.7 to 16.5) were the most important independent predictors of 30-day mortality. Increased pro-BNP levels (OR 11, 95% CI 1.5 to 81), AKI stage 3 (OR 6.8, 95% CI 2.6 to 15.7), left ventricular ejection fraction <30% (OR 6.7, 95% CI 3.5 to 12.7), and periprocedural acute myocardial infarction (OR 6.5, 95% CI 2.3 to 18.1) represented the predictors of midterm mortality. In conclusion, in this large meta-analysis of patients undergoing TAVI, we found that high pro-BNP levels and postprocedural AKI were the strongest independent predictors of both 30-day and 1-year mortality. These findings may contribute to a better understanding of the risk assessment process of patients undergoing TAVI.

A gender based analysis of predictors of all cause death after transcatheter aortic valve implantation

The impact of gender-related pathophysiologic features of severe aortic stenosis on transcatheter aortic valve implantation (TAVI) outcomes remains to be determined, as does the consistency of predictors of mortality between the genders. All consecutive patients who underwent TAVI at 6 institutions were enrolled in this study and stratified according to gender. Midterm all-cause mortality was the primary end point, with events at 30 days and at midterm as secondary end points. All events were adjudicated according to Valve Academic Research Consortium definitions. Eight hundred thirty-six patients were enrolled, 464 (55.5%) of whom were female. At midterm follow-up (median 365 days, interquartile range 100 to 516) women had similar rates of all-cause mortality compared with men (18.1% vs 22.6%, p = 0.11) and similar incidence of myocardial infarction and cerebrovascular accident. Gender did not affect mortality also on multivariate analysis. Among clinical and procedural features, glomerular filtration rate <30 ml/min/1.73 m(2) (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.36 to 4.79) and systolic pulmonary arterial pressure >50 mm Hg (HR 2.26, 95% CI 1.26 to 4.02) independently predicted mortality in women, while insulin-treated diabetes (HR 3.45, 95% CI 1.47 to 8.09), previous stroke (HR 3.42, 95% CI 1.43 to 8.18), and an ejection fraction <30% (HR 3.82, 95% CI 1.41 to 10.37) were related to mortality in men. Postprocedural aortic regurgitation was independently related to midterm mortality in the 2 groups (HR 11.19, 95% CI 3.3 to 37.9). In conclusion, women and men had the same life expectancy after TAVI, but different predictors of adverse events stratified by gender were demonstrated. These findings underline the importance of a gender-tailored clinical risk assessment in TAVI patients.

Impact of access on TAVI procedural and midterm follow-up: a meta-analysis of 13 studies and 10,468 patients

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) may be performed using the transfemoral (TF) or transapical (TA) approach in most patients with aortic stenosis. The impact of access choice on peri-procedural and midterm results remains to be defined.

METHODS

Medline and Cochrane Library were searched for articles describing differences in baseline, peri-procedural, and midterm outcomes among patients undergoing TF or TA TAVI. The primary end-point was all-cause mortality after at least 1-year follow-up, while secondary end-points were 30 days mortality and in-hospital complications (bleeding and cerebrovascular events). The independent impact of access choice was evaluated with pooled analysis using a random-effect model.

RESULTS

Thirteen studies with 10,468 patients were included. TF was the most exploited strategy (69.5% vs. 30.5%). After adjusting for confounding variables, 30-day and midterm follow-up mortality (median 365 days, range 222-400) were lower in TF patients with a pooled adjusted odds ratio of 0.81 (0.68-0.97 I(2) 99%) and 0.85 (0.80-0.90 I(2) 96%), respectively. Regarding periprocedural outcomes, TF reduced risk of bleedings and strokes (OR of 0.74 [0.66-0.82 I(2) 95%] and 0.91 [0.83-0.99] I(2) 86%, respectively).

CONCLUSIONS

The TF approach reduces mortality in TAVI patients, due to lower rates of periprocedural bleedings and strokes.

Worldwide TAVI registries: what have we learned?

With a rapidly aging society, the number of patients with cardiovascular disease-in particular aortic stenosis-is progressively increasing. Although conventional aortic valve replacement remains the only treatment known to improve prognosis and symptoms in symptomatic patients with aortic stenosis, about one-third are still withhold from the life-saving therapy. Based on the compelling evidence of the randomized Placement of Aortic transcatheter valves (PARTNER) A and B cohort, TAVI is now considered standard of care for extreme risk and inoperable patients and is an alternative to surgery for high-risk patients with symptomatic aortic stenosis. However, these patients were super-selected, which does not reflect a clinical real-world situation. TAVI registries represent a real-world scenario, and therefore provide the evidence for the treatment of high-risk patients (regarding comorbidities and anatomical factors) in daily clinical life. The review will focus on the recently published Edwards SAPIEN, Medtronic CoreValve and mixed (national) registries with the focus on short- and midterm outcome. These registries suggest that the growing experience of the operators with regard to patient selection, prevention, recognition and treatment of procedural complications together with the developments in valve design will improve the short-term results of TAVI. However, randomized trials in intermediate risk patients and data on long-term valve durability are a prerequisite before indications can be expanded to younger and lower risk patient population.

Influence of gender on clinical outcomes following transcatheter aortic valve implantation from the UK transcatheter aortic valve implantation registry and the National Institute for Cardiovascular Outcomes Research

Gender differences exist in outcomes after percutaneous coronary intervention and coronary artery bypass graft surgery but have yet to be fully explored after transcatheter aortic valve implantation. We aimed to investigate gender differences after transcatheter aortic valve implantation in the UK National Institute for Cardiovascular Outcomes Research registry. A retrospective analysis was performed of Medtronic CoreValve and Edwards SAPIEN implantation in 1,627 patients (756 women) from January 2007 to December 2010. Men had more risk factors: poor left ventricular systolic function (11.9% vs 5.5%, p <0.001), 3-vessel disease (19.4% vs 9.2%, p <0.001), previous myocardial infarction (29.5% vs 13.0%, p <0.001), peripheral vascular disease (32.4% vs 23.3%, p <0.001), and higher logistic EuroSCORE (21.8 ± 14.2% vs 21.0 ± 13.4%, p = 0.046). Thirty-day mortality was 6.3% (confidence interval 4.3% to 7.9%) in women and 7.4% (5.6% to 9.2%) in men and at 1 year, 21.9% (18.7% to 25.1%) and 22.4% (19.4% to 25.4%), respectively. There was no mortality difference: p = 0.331 by log-rank test; hazard ratio for women 0.91 (0.75 to 1.10). Procedural success (96.6% in women vs 96.4% in men, p = 0.889) and 30-day cerebrovascular event rates (3.8% vs 3.7%, p = 0.962) did not differ. Women had more major vascular complications (7.5% vs 4.2%, p = 0.004) and less moderate or severe postprocedural aortic regurgitation (7.5% vs 12.5%, p = 0.001). In conclusion, despite a higher risk profile in men, there was no gender-related mortality difference; however, women had more major vascular complications and less postprocedural moderate or severe aortic regurgitation.