Time course of the survival advantage of transcatheter over surgical aortic valve replacement: Interplay between sex and patient risk profile

Abstract

Objectives The aim of this study was to explore the time course of survival advantage of TAVR over SAVR as function of the patients' risk and sex. Background Women have been reported to have better survival than men undergoing transcatheter aortic valve replacement (TAVR). However, scant data on the sex‐based survival benefit of TAVR over surgical aortic valve replacement (SAVR) are available. Methods A systematic review of studies reporting clinical outcomes of men and women undergoing TAVR or SAVR was performed. Studies were divided into two groups according to average patient's risk score and the interplay of surgical risk and sex on outcomes were analyzed. Results Eight studies involving 6,596 women and 7,204 men patients were extracted. Unlike mens, women patients had survival advantage from TAVR over SAVR that became substantial at 1 year from index procedure and persisted at 2‐year of follow‐up. Moreover, this sex‐based TAVR survival advantage was mainly observed in higher surgical risk patients. Men showed a significantly lower rate of residual paravalvular leak after SAVR. Conclusions Women patients had a selective mortality benefit from TAVR compared to SAVR. This sex‐based TAVR benefit was mainly observed in high surgical risk patients beyond 1 year from procedure.

Transcatheter Versus Surgical Aortic Valve Replacement: An Updated Systematic Review and Meta-Analysis With a Focus on Outcomes by Sex

“…Two (2) previous meta-analyses have investigated sex differences prior to the publication of the newer data, and their findings were similar to ours [16,40]. These two previous reports also demonstrated a mortality benefit at 1-year with TAVI over SAVR in the female cohort, which was not replicated in the male cohort [16,40]. Our results demonstrate that this benefit from TAVI over SAVR amongst women persisted with the inclusion of the recent low-risk randomised trial composite endpoint data, which was largely driven by mortality.…”

“…Our review is the first to investigate differences by sex with the inclusion of the new low-surgical risk randomised controlled data and data out to 5 years. Two (2) previous meta-analyses have investigated sex differences prior to the publication of the newer data, and their findings were similar to ours [16,40]. These two previous reports also demonstrated a mortality benefit at 1-year with TAVI over SAVR in the female cohort, which was not replicated in the male cohort [16,40].…”

“…This finding is potentially related to the more advanced age of women compared to men at baseline [40]. The differing rates of comorbidities between women and men may also play a role, with women undergoing TAVI more likely to have chronic kidney disease, pulmonary hypertension and more severe aortic stenosis at the time of procedure [40]. Given the included RCTs largely examined high-risk surgical patients, we cannot extrapolate these findings to the low-risk surgical patient population who are more likely to survive to 5 years and therefore be affected by these outcomes.…”

“…Interestingly, the selective mortality benefit from TAVI over SAVR amongst women did not persist out to 5 years. This finding is potentially related to the more advanced age of women compared to men at baseline [40]. The differing rates of comorbidities between women and men may also play a role, with women undergoing TAVI more likely to have chronic kidney disease, pulmonary hypertension and more severe aortic stenosis at the time of procedure [40].…”

Why females get better longer‐term outcomes with TAVR

“…Ueshima et al in their paper have extensively analyzed several diverse populations to assess short and long‐term mortality benefit in patients undergoing TAVR versus those who were treated with traditional SAVR . The authors also assessed the data for periprocedural and mid‐term occurrence of stroke, major vascular complications including major bleeding, rate of permanent pacemaker implantation, acute myocardial infarction, acute kidney injury (AKI), and paravalvular leak (PVL).…”