Sex differences in the impact of coronary artery disease on long-term survival after transcatheter aortic valve implantation

Background

It has been suggested that the complexity of coronary artery disease (CAD) is a determinant of worse outcomes after transcatheter aortic valve implantation (TAVI). However, no data is available showing this applies equally to both sexes.

Purpose

Males are usually overrepresented in studies regarding CAD and care should be used when translating these results to the female population. The purpose of this analysis was to compare sex specific clinical outcomes in patients undergoing TAVI with and without coexisting CAD.

Methods

All patients undergoing TAVI at a tertiary referral centre between 2008 and 2020 were included and outcomes up to five years after TAVI were prospectively recorded. Baseline and residual (after revascularization) SYNTAX-scores (SS) were retrospectively calculated to make groups of different CAD complexity.

Results

A total of 605 patients, of whome 284 (46.9%) female patients, underwent TAVI. Five years after TAVI, females and males had similar overall survival (62 vs 59%, p=0.320) and cardiovascular mortality (22% vs 20%, p=0.540), respectively. Females were older (82.7y vs 80.8y, p<0.001), had a higher left ventricular ejection fraction (53.7% vs 49.4%, p<0.001) and higher aortic valve mean gradient (45.7 vs 41.6 mmHg, p=0.002). EuroScore II was comparable between both groups (26.8 vs 27.5, p=0.330). Females had less obstructive CAD (49% vs 64%, p<0.001) and less complex CAD (mean SS: 8.3 vs 12.6, p<0.001), despite reporting similar rates of angina (10% vs 11%, p=0.492). While in males CAD complexity was not predictive of survival (fig 1A) or cardiovascular mortality (fig 2A), females showed worse survival (fig 1B) and cardiovascular mortality (fig 2B) with increasing CAD complexity. This difference seems not to be driven by a lower rate of revascularization since women with CAD received significantly more percutaneous coronary interventions (PCI) (41% vs 24%, p=0.001) and trended towards more complete revascularization (residual SS <8 70% in females vs 52% in males, p=0.054). Background medical therapy with aspirin (70% vs 72%, p=0.710), other antiplatelet agents (61% vs 57%, p=0.390) and statins (71% vs 81%, p=0.065) was not different between both groups. A possible explanation for the similar rates of angina despite less complex CAD in females might be a higher prevalence of underlying microvascular dysfunction, which is also known to be related with an increased rate of cardiovascular events.

Conclusion

We show that in females outcomes after TAVI are significantly influenced by co-existing CAD and its complexity, while in males this is less pronounced. We identified a subgroup of females with a SS >22 that are at particular high risk for fatal cardiovascular events after TAVI. Therefore, awareness for CAD and close follow-up in combination with guideline-directed treatment of complex CAD in females undergoing TAVI is crucial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders

IMR or CFR - Which parameter is better suited to determine microvascular disease in patients with severe aortic stenosis?

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders

Background

Chest pain in patients with severe aortic stenosis (AS) may result from the valve stenosis itself, a coronary atherosclerotic lesion or even microvascular dysfunction (MVD). MVD in severe AS may be purely functional or the consequence of structural left ventricular (LV) remodelling. Unfortunately, there is no data available about invasive quantification of MVD using the index of microvascular resistance (IMR) in this patient group.

Purpose

To study the microcirculation in patients with severe AS by means of IMR and coronary flow reserve (CFR) and to determine the relation between these indices and standard echocardiographic parameters.

Methods

Forty-five patients with severe AS (according to the focused 2017 EACVI/ASE update) were prospectively included and underwent invasive intracoronary hemodynamic assessment and dedicated transthoracic echocardiography (TTE). On TTE we measured LV ejection fraction (EF), diastolic function parameters (E/A, e’ septal and lateral, E/e’, TR velocity), left atrial volume (index) (LAV(I)), aortic valve (AV) pressure gradients, the aortic valve area (index) (AVA(I)) and LV mass (index). The invasive measurements compromised the calculation of the CFR and IMR via thermodilution with the use of an intracoronary guidewire with a dual pressure and temperature sensor and administration of IV adenosine.

Results

Mean IMR and CFR were 22.9 ± 14.2 and 2.5 ± 1.5, respectively (Fig. 1). When using the commonly used cut-offs (increased IMR ≥ 25; impaired CFR < 2.0), 29% of patients had high IMR and 33% had low CFR. Patients with normal and high IMR had similar LV EF (p = 0.54), grade of diastolic dysfunction (DD)(p = 0.18), AV peak (p = 0.80) and mean pressure gradient (p = 0.86), AVA (p= 0.80), AVAI (p = 0.92), E/e’ (p = 0.97), LAVI (p = 0.75), LV mass (p = 0.34) and LV mass index (p = 0.59). In contrast, patients with impaired CFR had significantly lower AVA (0.63 vs 0.80 cm2, p = 0.033) and AVAI (0.32 vs 0.43 cm2/m2, p = 0.035) (Fig. 2A). Moreover there was a significant negative correlation between CFR and LAV (r= -0.354, p= 0.019) as well as LAVI (r= -0.428, p= 0.004)(Fig. 2C). Similarly, patients with different DD grades had no significantly different IMR values (p= 0.71), while there was a significant difference with their CFR values (Grade I: 2.9 ± 1.6; Grade II: 3.1 ± 1.7; Grade III: 1.8 ± 0.6, undetermined DD (due to Atrial Fibrillation): 1.6 ± 0.7, ANOVA p= 0.033) (Fig. 2B).

Conclusion

Approximately 30% of patients with severe AS exhibit MVD as assessed by IMR and CFR. In contrast to CFR, IMR values were not related to the severity of valve disease or systolic and diastolic function of the LV. Interestingly, the IMR was also not related to LV hypertrophy. IMR may therefore be the more objective and independent marker of microvascular disease, better suited to evaluate MVD in severe AS patients with chest pain. Abstract Figure 1  Abstract Figure 2

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