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

Abstract

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.

Gender specific differences in functional capacity in asymptomatic patients with severe aortic stenosis

“…Beside the fact that low-fl ow severe AS has been associated with increased AS-related morbidity and mortality, 20,21 the smaller the LV cavity and the more pronounced the concentric LV remodeling is, the more decreased is exercise capacity. 22 Saeed et al demonstrated in 316 patients with moderate or severe AS that exercise capacity was lower in women than men, and the determinants of exercise capacity differed among genders, 23 with women having smaller LV dimensions in this study. In our study females achieved signifi cantly lower workload during exercise and also had almost all cardiopulmonary parameters worse than males.…”

The five-year outcome of the transcatheter aortic valve replacement in the partner 2A study in patients with intermediate surgical risk—what is clear and what it is unclear

“…On the other hand, they may have less cardiovascular comorbidity, less atherosclerotic disease, and better left ventricular systolic function. Although after TAVR women have more vascular complications and more frequent need for blood transfusion and a higher incidence of stroke, the long-term outcomes appear better than men (20). This gender gap seems to decrease and disappear in lowrisk patients, where the one-year outcomes are similar in both genders.…”

Gender differences in aortic valve replacement: is surgical aortic valve replacement riskier and transcatheter aortic valve replacement safer in women than in men?

“…This is also supported by the PARTNER trial, published in 2010, which showed that women who undergo TAVR are typically older and deemed to be more frail than male counterparts. Conversely, however, women tend to have a higher LVEF and reduced frequency of coronary artery disease (CAD) and prior coronary revascularisation compared to men (38).…”