Impact of Sex on Mortality in Patients Undergoing Surgical Aortic Valve Replacement
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Patients
2.2. Preoperative Transthoracic Echocardiography
2.3. Outcome and Clinical Data
2.4. Statistical Analysis
3. Results
3.1. Baseline Characteristics According to Sex
3.2. Mortality after SAVR According to Sex
3.3. Subgroup Analysis
4. Discussion
5. Study Limitations
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Osnabrugge, R.L.; Mylotte, D.; Head, S.J.; Van Mieghem, N.M.; Nkomo, V.T.; LeReun, C.M.; Bogers, A.J.; Piazza, N.; Kappetein, A.P. Aortic stenosis in the elderly: Disease prevalence and number of candidates for transcatheter aortic valve replacement: A meta-analysis and modeling study. J. Am. Coll. Cardiol. 2013, 62, 1002–1012. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Ibrahim, M.F.; Paparella, D.; Ivanov, J.; Buchanan, M.R.; Brister, S.J. Gender-related differences in morbidity and mortality during combined valve and coronary surgery. J. Thorac. Cardiovasc. Surg. 2003, 126, 959–964. [Google Scholar] [CrossRef] [Green Version]
- Jang, S.Y.; Park, S.J.; Kim, E.K.; Park, S.W. Temporal trends in incidence, prevalence, and death of aortic stenosis in Korea: A nationwide population-based study. ESC Heart Fail. 2022; Epub ahead of print. [Google Scholar] [CrossRef] [PubMed]
- Joseph, J.; Naqvi, S.Y.; Giri, J.; Goldberg, S. Aortic stenosis: Pathophysiology, diagnosis, and therapy. Am. J. Med. 2017, 130, 253–263. [Google Scholar] [CrossRef]
- Turina, J.; Hess, O.; Sepulcri, F.; Krayenbuehl, H.P. Spontaneous course of aortic valve disease. Eur. Heart J. 1987, 8, 471–483. [Google Scholar] [CrossRef] [Green Version]
- Otto, C.M.; Nishimura, R.A.; Bonow, R.O.; Carabello, B.A.; Erwin, J.P., 3rd; Gentile, F.; Jneid, H.; Krieger, E.V.; Mack, M.; McLeod, C.; et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American college of cardiology/American heart association joint committee on clinical practice guidelines. Circulation 2021, 77, 450–500. [Google Scholar] [CrossRef]
- Shan, Y.; Pellikka, P.A. Aortic stenosis in women. Heart 2020, 106, 970–976. [Google Scholar] [CrossRef]
- Rohde, L.E.; Zhi, G.; Aranki, S.F.; Beckel, N.E.; Lee, R.T.; Reimold, S.C. Gender-associated differences in left ventricular geometry in patients with aortic valve disease and effect of distinct overload subsets. Am. J. Cardiol. 1997, 80, 475–480. [Google Scholar] [CrossRef]
- Dobson, L.E.; Fairbairn, T.A.; Plein, S.; Greenwood, J.P. Sex differences in aortic stenosis and outcome following surgical and transcatheter aortic valve replacement. J. Womens Health 2015, 24, 986–995. [Google Scholar] [CrossRef]
- Hartzell, M.; Malhotra, R.; Yared, K.; Rosenfield, H.R.; Walker, J.D.; Wood, M.J. Effect of gender on treatment and outcomes in severe aortic stenosis. Am. J. Cardiol. 2011, 107, 1681–1686. [Google Scholar] [CrossRef] [Green Version]
- Duncan, A.I.; Lin, J.; Koch, C.G.; Gillinov, A.M.; Xu, M.; Starr, N.J. The impact of gender on in-hospital mortality and morbidity after isolated aortic valve replacement. Anesth. Analg. 2006, 103, 800–808. [Google Scholar] [CrossRef] [PubMed]
- Chaker, Z.; Badhwar, V.; Alqahtani, F.; Aljohani, S.; Zack, C.J.; Holmes, D.R.; Rihal, C.S.; Alkhouli, M. Sex differences in the utilization and outcomes of surgical aortic valve replacement for severe aortic stenosis. J. Am. Heart Assoc. 2017, 6, e006370. [Google Scholar] [CrossRef] [PubMed]
- Kulik, A.; Lam, B.K.; Rubens, F.D.; Hendry, P.J.; Masters, R.G.; Goldstein, W.; Bedard, P.; Mesana, T.G.; Ruel, M. Gender differences in the long-term outcomes after valve replacement surgery. Heart 2009, 95, 318–326. [Google Scholar] [CrossRef] [PubMed]
- Fuchs, C.; Mascherbauer, J.; Rosenhek, R.; Pernicka, E.; Klaar, U.; Scholten, C.; Heger, M.; Wollenek, G.; Czerny, M.; Maurer, G.; et al. Gender differences in clinical presentation and surgical outcome of aortic stenosis. Heart 2010, 96, 539–545. [Google Scholar] [CrossRef]
- Von Elm, E.; Altman, D.G.; Egger, M.; Pocock, S.J.; Gotzsche, P.C.; Vandenbroucke, J.P. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int. J. Surg. 2014, 12, 1495–1499. [Google Scholar] [CrossRef] [Green Version]
- Baumgartner, H.; Hung, J.; Bermejo, J.; Chambers, J.B.; Edvardsen, T.; Goldstein, S.; Lancellotti, P.; LeFevre, M.; Miller, F., Jr.; Otto, C.M. Recommendations on the echocardiographic assessment of aortic valve stenosis: A focused update from the European association of cardiovascular imaging and the American society of echocardiography. J. Am. Soc. Echocardiogr. 2017, 30, 372–392. [Google Scholar] [CrossRef]
- de Simone, G.; Roman, M.J.; Koren, M.J.; Mensah, G.A.; Ganau, A.; Devereux, R.B. Stroke volume/pulse pressure ratio and cardiovascular risk in arterial hypertension. Hypertension 1999, 33, 800–805. [Google Scholar] [CrossRef] [Green Version]
- Namasivayam, M.; He, W.; Churchill, T.W.; Capoulade, R.; Liu, S.; Lee, H.; Danik, J.S.; Picard, M.H.; Pibarot, P.; Levine, R.A.; et al. Transvalvular flow rate determines prognostic value of aortic valve area in aortic stenosis. J. Am. Coll. Cardiol. 2020, 75, 1758–1769. [Google Scholar] [CrossRef]
- Myllykangas, M.E.; Aittokallio, J.; Gunn, J.; Sipila, J.; Rautava, P.; Kyto, V. Sex differences in long-term outcomes after surgical aortic valve replacement: A nationwide propensity-matched study. J. Cardiothorac. Vasc. Anesth. 2020, 34, 932–939. [Google Scholar] [CrossRef]
- Gori, M.; Lam, C.S.; Gupta, D.K.; Santos, A.B.; Cheng, S.; Shah, A.M.; Claggett, B.; Zile, M.R.; Kraigher-Krainer, E.; Pieske, B.; et al. Sex-specific cardiovascular structure and function in heart failure with preserved ejection fraction. Eur. J. Heart Fail. 2014, 16, 535–542. [Google Scholar] [CrossRef]
- Morris, J.J.; Schaff, H.V.; Mullany, C.J.; Morris, P.B.; Frye, R.L.; Orszulak, T.A. Gender differences in left ventricular functional response to aortic valve replacement. Circulation 1994, 90, 183–189. [Google Scholar]
- Doenst, T.; Ivanov, J.; Borger, M.A.; David, T.E.; Brister, S.J. Sex-specific long-term outcomes after combined valve and coronary artery surgery. Ann. Thorac. Surg. 2006, 81, 1632–1636. [Google Scholar] [CrossRef] [PubMed]
- Elhmidi, Y.; Piazza, N.; Mazzitelli, D.; Wottke, M.; Lange, R.; Bleiziffer, S. Sex-related differences in 2197 patients undergoing isolated surgical aortic valve replacement. J. Card. Surg. 2014, 29, 772–778. [Google Scholar] [CrossRef] [PubMed]
- Toumpoulis, I.K.; Anagnostopoulos, C.E.; Balaram, S.K.; Rokkas, C.K.; Swistel, D.G.; Ashton, R.C., Jr.; DeRose, J.J., Jr. Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: Are women different from men? J. Thorac. Cardiovasc. Surg. 2006, 131, 343–351. [Google Scholar] [CrossRef] [Green Version]
- Higgins, J.; Jamieson, W.R.; Benhameid, O.; Ye, J.; Cheung, A.; Skarsgard, P.; Germann, E.; Chan, F.; Lichtenstein, S.V. Influence of patient gender on mortality after aortic valve replacement for aortic stenosis. J. Thorac. Cardiovasc. Surg. 2011, 142, 595–601. [Google Scholar] [CrossRef] [Green Version]
- Toyofuku, M.; Taniguchi, T.; Morimoto, T.; Yamaji, K.; Furukawa, Y.; Takahashi, K.; Tamura, T.; Shiomi, H.; Ando, K.; Kanamori, N.; et al. Sex differences in severe aortic stenosis- clinical presentation and mortality. Circ. J. 2017, 81, 1213–1221. [Google Scholar] [CrossRef] [Green Version]
- Ekblom, O.; Cider, A.; Hambraeus, K.; Back, M.; Leosdottir, M.; Lonn, A.; Borjesson, M. Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: Results from the SWEDEHEART registry. Eur. J. Prev. Cardiol. 2021, 29, 485–492. [Google Scholar] [CrossRef]
Male (n = 493) | Female (n = 424) | p | |
---|---|---|---|
Age (years) | 65.3 ± 9.2 | 67.2 ± 9.4 | 0.003 |
Body mass index (kg/m2) | 24.7 ± 3.0 | 25.0 ± 3.4 | 0.132 |
EuroSCORE II | 0.99 (0.74–1.70) | 1.24 (0.89–2.02) | <0.001 |
Bioprosthetic aortic valve | 218 (44.2%) | 226 (53.3%) | 0.020 |
Comorbidities | |||
Atrial fibrillation | 26 (5.3%) | 13 (3.1%) | 0.099 |
Coronary artery disease | 103 (20.9%) | 49 (11.6%) | <0.001 |
Diabetes mellitus type 2 | 180 (36.5%) | 130 (30.7%) | 0.062 |
Hypertension | 236 (47.9%) | 227 (53.5%) | 0.087 |
Myocardial infarction | 7 (1.4%) | 4 (0.9%) | 0.559 |
Congestive heart failure | 22 (4.5%) | 21 (5.0%) | 0.726 |
Percutaneous coronary intervention | 41 (8.3%) | 13 (3.1%) | 0.001 |
Cerebrovascular disease | 23 (4.7%) | 25 (5.9%) | 0.404 |
Peripheral vascular disease | 25 (5.1%) | 12 (2.8%) | 0.086 |
Chronic obstructive pulmonary disease | 35 (7.1%) | 17 (4.0%) | 0.044 |
Chronic kidney disease | 38 (7.7%) | 26 (6.1%) | 0.350 |
Medications | |||
ACEi or ARB | 150 (30.4%) | 145 (39.2%) | 0.031 |
Beta blocker | 150 (30.4%) | 102 (24.1%) | 0.031 |
Calcium channel blocker | 154 (31.2%) | 153 (36.1%) | 0.121 |
Insulin | 83 (16.8%) | 58 (13.7%) | 0.186 |
Aspirin | 157 (31.8%) | 125 (29.5%) | 0.439 |
Clopidogrel | 64 (13.0%) | 37 (8.7%) | 0.040 |
Diuretics | 145 (29.4%) | 148 (34.9%) | 0.075 |
Laboratory data | |||
Hematocrit | 40.5 ± 4.6 | 36.7 ± 3.6 | <0.001 |
Albumin | 3.81 ± 0.40 | 3.80 ± 0.39 | 0.549 |
Estimated glomerular filtration rate | 80.0 ± 19.4 | 82.3 ± 19.4 | 0.083 |
Brain natriuretic peptide | 82.0 (39.0–210.3) | 82.0 (36.5–240.0) | 0.774 |
Male (n = 493) | Female (n = 424) | p | |
---|---|---|---|
LV end-diastole diameter (mm) | 49.7 ± 5.9 | 46.7 ± 5.4 | <0.001 |
LV end-diastole volume (mL) | 110.0 (90.0–134.0) | 84.0 (69.0–101.0) | <0.001 |
Relative wall thickness a | 0.49 ± 0.09 | 0.48 ± 0.09 | 0.300 |
Relative wall thickness < 0.42 | 121 (24.5%) | 127 (30.0%) | 0.066 |
LV ejection fraction (%) | 63.0 (58.0–66.0) | 64.0 (60.0–67.0) | <0.001 |
LV ejection fraction > 50% | 436 (88.4%) | 387 (91.3%) | 0.158 |
LV mass (g) | 239.7 ± 64.6 | 194.2 ± 53.3 | <0.001 |
LV mass index (g/m2) | 136.5 ± 35.5 | 125.8 ± 33.7 | <0.001 |
LV geometry | <0.001 | ||
Normal | 40 (8.1%) | 42 (9.9%) | |
Concentric remodeling | 104 (21.1%) | 42 (9.9%) | |
Concentric hypertrophy | 268 (54.4%) | 255 (60.1%) | |
Eccentric hypertrophy | 81 (16.4%) | 85 (20.0%) | |
Number of aortic valve cusps | 0.494 | ||
Unicusp | 1 (0.2%) | 1 (0.2%) | |
Bicusp | 297 (60.2%) | 239 (56.4%) | |
Tricusp | 195 (39.6%) | 184 (43.4%) | |
Peak aortic jet velocity (m/s) | 5.11 ± 0.67 | 5.25 ± 0.78 | 0.002 |
Transaortic mean pressure gradient (mmHg) | 64.5 ± 17.8 | 68.7 ± 21.8 | 0.001 |
Aortic valve area (cm2) | 0.62 ± 0.14 | 0.57 ± 0.14 | <0.001 |
LV outflow tract diameter (mm) | 21.4 ± 1.5 | 20.3 ± 1.3 | <0.001 |
Stroke volume (mL) | 75.1 ± 14.0 | 71.2 ± 13.4 | <0.001 |
Stroke volume index (mL/m2) | 42.9 ± 8.2 | 46.2 ± 9.1 | <0.001 |
Stroke volume index < 35 | 79 (16.0%) | 31 (7.3%) | <0.001 |
Transaortic flow rate (mL/s) | 225.8 ± 40.8 | 211.6 ± 39.9 | <0.001 |
Arterial compliance b | 0.67 ± 0.21 | 0.73 ± 0.22 | <0.001 |
Valvuloarterial impedance c | 4.46 ± 1.02 | 4.27 ± 0.94 | 0.014 |
Unadjusted | Model 1 | Model 2 | Model 3 | Model 4 | ||||||
---|---|---|---|---|---|---|---|---|---|---|
HR (95% CI) | p | HR (95% CI) | p | HR (95% CI) | p | HR (95% CI) | p | HR (95% CI) | p | |
Male sex | 1.71 (1.17, 2.50) | 0.006 | 2.12 (1.43, 3.12) | <0.001 | 2.16 (1.46, 3.20) | <0.001 | 1.82 (1.21, 2.73) | 0.004 | 1.93 (1.28, 2.91) | 0.002 |
Age | 1.08 (1.05, 1.10) | <0.001 | 1.06 (1.03, 1.09) | <0.001 | 1.05 (1.03, 1.08) | <0.001 | 1.05 (1.03, 1.08) | <0.001 | ||
Body mass index | 0.91 (0.86, 0.97) | 0.002 | 0.89 (0.84, 0.95) | <0.001 | 0.88 (0.83, 0.94) | <0.001 | 0.88 (0.83, 0.94) | <0.001 | ||
EuroSCORE II | 1.21 (1.05, 1.39) | 0.009 | 1.26 (1.09, 1.45) | 0.002 | 1.15 (0.98, 1.35) | 0.082 | 1.18 (1.00, 1.38) | 0.045 | ||
Tricuspid aortic valve | 2.02 (1.32, 3.09) | 0.001 | 1.69 (1.10, 2.60) | 0.017 | 1.61 (1.04, 2.48) | 0.032 | ||||
Coronary artery disease | 1.02 (0.64, 1.64) | 0.931 | 0.94 (0.58, 1.52) | 0.810 | ||||||
Congestive heart failure | 1.36 (0.69, 2.68) | 0.368 | 1.33 (0.68, 2.61) | 0.413 | ||||||
Cerebrovascular disease | 1.68 (0.94, 2.99) | 0.077 | 1.61 (0.91, 2.88) | 0.104 | ||||||
Chronic kidney disease | 2.16 (1.33, 3.53) | 0.002 | 1.98 (1.21, 3.25) | 0.006 | ||||||
Chronic obstructive pulmonary disease | 1.75 (0.96, 3.16) | 0.065 | 1.68 (0.93, 3.06) | 0.086 | ||||||
Diabetes mellitus type 2 on insulin | 2.04 (1.28, 3.28) | 0.003 | 1.97 (1.23, 3.17) | 0.005 | ||||||
Calcium channel blocker medication | 1.48 (1.00, 2.19) | 0.051 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Kang, H.-U.; Nam, J.-S.; Kim, D.; Kim, K.; Chin, J.-H.; Choi, I.-C. Impact of Sex on Mortality in Patients Undergoing Surgical Aortic Valve Replacement. J. Pers. Med. 2022, 12, 1203. https://doi.org/10.3390/jpm12081203
Kang H-U, Nam J-S, Kim D, Kim K, Chin J-H, Choi I-C. Impact of Sex on Mortality in Patients Undergoing Surgical Aortic Valve Replacement. Journal of Personalized Medicine. 2022; 12(8):1203. https://doi.org/10.3390/jpm12081203
Chicago/Turabian StyleKang, Hyun-Uk, Jae-Sik Nam, Dongho Kim, Kyungmi Kim, Ji-Hyun Chin, and In-Cheol Choi. 2022. "Impact of Sex on Mortality in Patients Undergoing Surgical Aortic Valve Replacement" Journal of Personalized Medicine 12, no. 8: 1203. https://doi.org/10.3390/jpm12081203