After TAVR, Women Show Faster LV Recovery Than Men

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Although women and men appear to achieve similar clinical benefit from transcatheter aortic valve replacement (TAVR) with equivalent rates of procedural success and complications, women show earlier left ventricular recovery compared with their male counterparts, according to a study published online June 4, 2012, ahead of print in the American Journal of Cardiology.

Investigators led by Verena Stangl, MD, of Charité-Humboldt University Medical Center (Berlin, German), examined data on 100 consecutive patients (42 men and 58 women) who underwent transfemoral TAVR at their institution from July 2009 to July 2011. Devices used included the CoreValve (Medtronic, Minneapolis, MN; n = 83%) and Sapien (Edwards Lifesciences, Irvine, CA; n = 17%) postheses.

Apparent Functional Differences

While several factors emerged as independent predictors of procedural complications, including narrow annulus diameter (P = 0.01), low glomerular filtration rate (P = 0.048), low ejection fraction (P = 0.018), and C-reactive protein (CRP; P = 0.032), gender was not a significant factor.

At 3 months, there were no gender-specific differences in short-term outcomes (table 1).

Table 1. Outcomes at 3 Months^a

^a P = NS for comparisons of men vs. women.

In addition, no or minor residual aortic regurgitation was observed in 86%, without relevant gender-specific differences.

However, in terms of left ventricular function and geometry, women showed greater increases in ejection fraction than men. Additionally, the ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E ratio) as an indicator of diastolic function showed a trend toward higher values in women at each time point, including 3 months, but was not statistically significant (table 2).

Table 2. Ejection Fraction Differences

Other functional measures, including septal and posterior wall thickness, left ventricular remodeling, and left ventricular remodeling index decreased without relevant differences between genders. Symptomatic improvement also was similar in men and women, while women experienced a greater decrease in N-terminal pro B-type natriuretic peptide values: from 1,866 ± 2,110 pg/ml at baseline to 1,462 ± 1,522 pg/ml at 3 months for men (P < 0.01) and from 1,907 ± 1,920 pg/ml at baseline to 1,117 ± 1,150 pg/ml at 3 months for women (P < 0.01).

Differential Response Requires More Explanation

In a telephone interview with TCTMD, Ted Feldman, MD, of Evanston Hospital (Evanston, IL), said the study findings are consistent with prior observations regarding differences in presentation for women with aortic stenosis.

“Women tend to present with small hyperdynamic ventricles and men tend to present with large dilated hyperkinetic ventricles,” he said. “We also see in this study that not surprisingly the male to female ratio for TAVR is weighted more toward women, which is in striking contrast to coronary artery disease, where every population that we look at tends to be 60% to 70% male.”

Of interest in the new paper, Dr. Feldman said is “that we get a look at how men and women respond differentially to unloading.” While the difference in ejection fraction recovery is of importance, he said the missing link is why there is variation in the first place.

“This is a clear and consistent observation, but the explanation remains elusive,” Dr. Feldman noted. “The most simplistic speculation is that there is an underlying hormonal difference between men and women that leads to this differential response in the way the left ventricle remodels with aortic stenosis. But we still need to understand whether that is the right explanation or whether maybe there is some entirely different mechanism at work.”

Indeed, the study authors point out that “estrogens limit hypertrophy, and loss of the protective effect of endogenous estrogens after menopause has been associated with steeper increments in LV hypertrophy.”

According to Dr. Feldman, the influence of estrogen on hypertrophy is “completely speculative,” but interesting nonetheless.

“I think it’s helpful for TAVR operators to be aware of this fundamental difference in men and women because the way these procedures are done requires understanding of ventricular function in a given patient,” Dr. Feldman said.

Study Details

Compared with men, women were smaller in height, weight and body surface, and were less likely to have chronic renal insufficiency or to be on chronic dialysis. CAD and diabetes were more frequent in men, whereas COPD was more common in women. Distribution of New York Heart Association classes was comparable, with most patients in class III. Women had higher ejection fractions, smaller end-diastolic and end-systolic diameters, and more concentric hypertrophy.

 

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Source:
Stangl V, Baldenhofer G, Knebel F, et al. Impact of gender on three-month outcome and left ventricular remodeling after transfemoral transcatheter aortic valve implantation. Am J Cardiol. 2012;Epub ahead of print.

 

 

Related Stories:

• TAVR Studies Tease Out Influences on Clinical Outcome
• Women Benefit From TAVR as Much as Men, Maybe More

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