Long-term outcomes with TAVR in women compared with men - Evidence from a meta-analysis
Selected in the JACC: Cardiovascular Interventions by S. Brugaletta
Saad M, Nairooz R, Pothineni NVK, Almomani A, Kovelamudi S, Sardar P, Katz M, Abdel-Wahab M, Bangalore S, Kleiman NS, Block PC, Abbott JD
JACC Cardiovasc Interv. 2018 Jan 8;11(1):24-35
LinkRead the abstract
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Why this study – the rationale/objective?
Transcatheter aortic valve replacement (TAVR) is the recommended procedure for patients with symptomatic severe aortic stenosis who are at high risk or deemed inoperable for surgical aortic valve replacement (SAVR). More recently, TAVR is being performed in intermediate-risk individuals as an alternative to SAVR. Multiple small observational studies suggested that women have worse short-term outcomes with TAVR; however, conflicting data on sex differences exist. The objective of the present paper was to perform an updated and comprehensive systematic review to examine the difference in short- and long-term clinical outcomes in women compared with men following TAVR.
How was it executed – the methodology?
An electronic search was performed until March 2017 for studies reporting outcomes with TAVR in women versus men. Random effects DerSimonian-Laird risk ratios were calculated. Outcomes included all-cause mortality and major cardiovascular events at short- (30 days) and long-term (>1 year) follow-up.
What is the main result?
Seventeen studies (8 TAVR registries; 47,188 patients; 49.4% women) were analyzed. Women were older but exhibited fewer comorbidities. At 30 days, women had more bleeding (p < 0.001), vascular complications (p < 0.001), and stroke/transient ischemic attack (p= 0.02), without difference in all-cause (p = 0.19) or cardiovascular mortality (p = 0.91) compared with men. However, female sex was associated with lower all-cause mortality at 1 year (risk ratio: 0.85; 95% confidence interval: 0.79 to 0.91; p < 0.001), and longest available follow-up (mean 3.28 years; risk ratio: 0.86; 95% confidence interval: 0.81 to 0.92; p < 0.001), potentially caused by less moderate/severe aortic insufficiency (p =0.001), and lower cardiovascular mortality (p = 0.009). The female survival advantage remained consistent across multiple secondary analyses. The risk of stroke, moderate/severe aortic insufficiency, and all-cause mortality seemed to vary based on the type of valve used; however, without significant subgroup interactions.
Critical reading and the relevance for clinical practice
It is known that women suffering from STEMI exhibit a worse prognosis than men. However, data on sex difference regarding TAVI were contrasting. The present metanalysis tries to shed light on this topic, showing that despite a higher upfront risk of complications, women derive a better long-term survival after TAVR compared with men. Lower incidence of aortic insufficiency post-TAVI, probably related to use of smaller devices, may explain this finding. It should be also noted that women may exhibit fewer co-morbidities and usually live longer than men. A patient-based metanalysis would be needed to clarify all these aspects. In the meanwhile it is interesting to see that eventually, women have a lower cardiovascular mortality than men after that many studies, especially for coronary artery disease, have shown the opposite.