Who Lives Longer After TAVR, Men or Women?

Courtesy of Dr. Carlos Fava.

Currently, some small observational studies and a meta-analysis suggest that women experience more short-term complications after TAVR (due to higher rates of bleeding, vascular complications, and stroke), as well as less 1-year mortality. However, results are still conflicting.

This work analyzed 17 studies including 8 different registries, with a total 23,303 women and 23,885 men.

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Women were older and men exhibited more comorbidities, including higher rates of diabetes, hypertension, atrial fibrillation, coronary disease, peripheral vascular disease, acute myocardial infarction, angioplasty, myocardial revascularization surgery, and stroke. Men featured the highest risk scores. Ejection fraction was higher among women, but they also experienced more heart failure.

Transfemoral access was the one most frequently used, although, among women, transapical access was more common. As regards valves used, women received more balloon-expandable valves.

There were no differences in 30-day all-cause or cardiovascular mortality. However, women experienced higher rates of bleeding (relative risk [RR]: 1.37; 95% confidence interval [CI]: 1.26 to 1.49; p < 0.001), vascular complications (RR: 1.62; 95% CI: 1.35 to 1.95; p > 0.001), transfusions (RR: 1.51; 95% CI: 0.04 to 2.18; p = 0.03), stroke/transient ischemic attack (TIA) (RR: 1.28; 95% CI: 1.04 to 1.57; p = 0.02), and a more pronounced trend towards infarction. Furthermore, they presented less moderate-to-severe leak and prosthesis mismatch when compared to men.

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At one year, women presented lower cardiovascular mortality (RR: 0.80; 95% CI: 0.68 to 0.95; p = 0.009), despite an increased risk for stroke/TIA (RR: 1.23; 95% CI: 1.06 to 0.43; p = 0.006) with similar rates for acute myocardial infarction.

The reduction in all-cause mortality in women was more obvious with balloon-expandable valves, alongside higher rates of stroke when compared to men.

Conclusion

Despite suffering more complications, there is a female survival advantage after TAVR compared with men.

Editorial Comment

In this meta-analysis including 47,188 patients, women exhibited better survival despite mainly vascular complications at 30 days, with higher rates of stroke.

This may be due to the use of first-generation valves (and device caliber may be an influential factor). Furthermore, it agrees with a higher need of using a transapical access.

These vascular and neurological complications may be possibly reduced with second-generation valves, or whatever valves may be available in the near future.

Reduced 1-year mortality may be explained by the fact that, despite being older, women presented much fewer comorbidities and better ventricular function, with a positive impact as regards survival.

Courtesy of Dr. Carlos Fava.

Original title: Long-Term Outcomes with Transcatheter Aortic Valve Replacement in Women Compared with Men. Evidence from a Meta-Analysis.

Reference: Marwna Saad et al. J Am Coll Cardiol Intv 2018;11:24-35.

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