Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy

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 [HR adj ] recovery, 1.85; 95% CI, 1.30–2.70; P <0.001; HR adj 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.

Sex disparities in left ventricular assist device implantation outcomes: A systematic review and meta‐analysis of over 50 000 patients

“…Inflammatory markers, which have been linked to cardiovascular morbidity, may be higher in women 49,50 . Women may also be socioeconomically disadvantaged, 51 face disadvantageous gender roles, 18 and have higher rates of depression, all risk factors for cardiovascular morbidity 52 …”

“…Moreover, this disparity poses questions as to whether men may benefit more from LVAD implantation than women. As a caveat, it is worth noting that there may be a bridge‐to‐transplant selection bias; some reports suggest that women on bridge‐to‐transplant receive delayed transplants compared to men, which may contribute to their higher mortality rates post‐LVAD 18 . Also, one study has found that post‐LVAD recovery was better in women, although this was partially due to female‐specific causes of HF that are likely more easily reversed 18 …”

“…48 Inflammatory markers, which have been linked to cardiovascular morbidity, may be higher in women. 49,50 Women may also be socioeconomically disadvantaged, 51 face disadvantageous gender roles, 18 and have higher rates of depression, all risk factors for cardiovascular morbidity. 52 Interestingly, a review by Lam et al, 53 which explored clinical outcomes in the HF population as a whole, reported a lower mortality rate in women than men.…”

Need for Unstructured Preimplantation Data to Predict Myocardial Recovery in Patients With a Left Ventricular Assist Device

“…In this issue of the Journal of the American Heart Association ( JAHA ), Maukel and colleagues 4 reviewed the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database for sex differences in clinical outcomes. From 2006 to 2017, 6771 men and 1690 women underwent cfLVAD implantation in the framework of destination therapy.…”

“…Regardless of demographic and psychosocial characteristics, women experienced significantly more device complications requiring replacement than men. 4 …”