Sex Disparities in the Treatment of Aortic Stenosis and Related Outcomes: An Analysis of the National Inpatient Sample

Abstract

Introduction The impact of transcatheter aortic valve replacement (TAVR) on sex disparities has not been well established. This study sought to examine the impact of sex on outcomes following aortic valve replacement (AVR) for aortic stenosis (AS) in the era of routine TAVR. Methods We performed a cross-sectional analysis of the National Inpatient Sample (2009-18) to study AS visits for all AVR, and in-hospital outcomes as a function of sex. Survey estimation commands were used to provide national estimates. Results There were an estimated 431,344 surgical aortic valve replacement (SAVR) and 189,137 TAVR inpatient visits. Mortality was higher in women after SAVR (3.8%±0.1 vs 2.7%±0.07, p<0.001) and TAVR (2.4%±0.1 vs 1.7%±0.1, p<0.001) compared to men. Female patients undergoing SAVR had higher rates of permanent pacemaker (PPM) implantation, stroke, and bleeding (5.9%±0.1 vs 5%±0.1, 2.8%±0.1 vs 2.3%±0.07, and 37.8%±0.8 vs 29.8%±0.6; p<0.001, respectively) but lower rates of acute kidney injury (AKI) (16.4%±0.3 vs 20.3%±0.3, p<0.001). Women undergoing TAVR had higher rates of stroke and bleeding (2.4%±0.1 vs 1.6%±0.09 and 28.7%±0.6 vs 22%±0.5; p<0.001 respectively) but lower rates of PPM and AKI (9.5%±0.3 vs 10.7%±0.2 and 11.3%±0.3 vs 13.4%±0.3; p<0.001, respectively). Compared with isolated SAVR, isolated TAVR was associated with lower mortality in women during 2016-18, both after multivariable adjustment (OR = 0.40, 95% CI 0.27-0.60) and propensity matching (mean difference 0.66%±0.2), however there was no difference in men. Conclusion Although women continue to have higher in-hospital mortality following both TAVR and SAVR as compared to men, TAVR is associated with a lower in-hospital mortality in women compared to SAVR. Thus, TAVR may represent a potential intervention to narrow the sex-based disparities in the management of AS.

Transcatheter or Surgical Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial

“…21,22 Indeed, some studies including a recent meta-analysis showed improved outcomes with TAVR (vs. SAVR) at early and midterm follow-up among women. 23-25 The results of the VIVA trial showed similar clinical outcomes in TAVR and SAVR groups after a median follow-up of 2 years, with all-cause mortality and cardiac rehospitalization rates of 8.6% and 20.2%, respectively, in the overall cohort. The 2-year mortality rate appears to be slightly higher than the <5% reported in the PARTNER 3 and Evolut Low Risk trials.…”

“…21,22 Indeed, some studies including a recent meta-analysis showed improved outcomes with TAVR (vs. SAVR) at early and midterm follow-up among women. 23-25…”

“…21,22 Indeed, some studies including a recent meta-analysis showed improved outcomes with TAVR (vs. SAVR) at early and midterm follow-up among women. [23][24][25] Limitations. Although the study is a prospective, randomized trial, the sample size of the study was limited and the possibility of a type II error for some clinical variables cannot be excluded.…”

Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial

“…21,22 Indeed, some studies including a recent meta-analysis showed improved outcomes with TAVR (versus SAVR) at early and midterm follow-up among women. [23][24][25] The results of the VIVA trial showed the lack of significant differences in clinical outcomes in TAVR and SAVR groups after a median follow-up of 2 years, with allcause mortality and cardiac rehospitalization rates of 8.6% and 20.2%, respectively, in the overall cohort. The 2-year mortality rate appears to be slightly higher than the <5% reported in the PARTNER 3 and Evolut Low Risk trials.…”