Sex-Based Patterns and Trends in Transcatheter Aortic Valve Implantation

Introduction: Sex Disparities in Aortic Valve Disease

Sex-related differences profoundly impact how aortic valve diseases are diagnosed, referred for treatment, and prognosed. Transcatheter Aortic Valve Implantation (TAVI) has revolutionized care for severe aortic stenosis, yet comprehensive data on sex-specific outcomes has been limited. This study addresses this gap by analyzing decade-long trends among Medicare beneficiaries, revealing critical patterns in treatment utilization and outcomes between women and men.

Study Design and Methodology

Researchers conducted a nationwide retrospective cohort study using Medicare claims data from fee-for-service beneficiaries who underwent TAVI between 2013-2022. After excluding specific cases like valve-in-valve procedures or transapical approaches, the analysis included 314,123 patients with median 2.19-year follow-up. The team compared periprocedural complications and long-term outcomes by sex, adjusting for clinical variables using statistical models that generated odds ratios (AOR) and hazard ratios (AHR) with 95% confidence intervals.

Key Findings: Treatment Trends

Women represented 45% of patients (141,233), with their proportion declining significantly from 47.6% in 2013 to 43.6% in 2022. Female patients were older on average (80.3 vs 79.4 years) and exhibited distinct clinical profiles. This trend suggests potential referral biases or diagnostic disparities in identifying severe aortic stenosis in women, warranting investigation into underlying causes for this treatment gap.

Periprocedural Outcomes Comparison

Women experienced higher rates of critical complications during TAVI procedures compared to men:
– 20% higher mortality risk (2.5% vs 2.2%; AOR 1.20)
– 65% more vascular complications (5.8% vs 3.6%; AOR 1.65)
– 67% increased bleeding events (10.4% vs 6.8%; AOR 1.67)

These differences likely relate to anatomical factors like smaller vessel diameters and more fragile arterial structures in women. However, women required fewer permanent pacemaker implantations (16.9% vs 20.0%; AOR 0.81), possibly due to different calcium distribution patterns in their aortic valves.

Long-Term Survival Paradox

Despite higher immediate risks, women demonstrated 8% better long-term survival (AHR 0.92). This survival advantage persisted throughout the follow-up period, suggesting biological differences in cardiovascular resilience. However, women faced elevated risks for other complications over time, including:
– Heart failure hospitalizations
– Acute myocardial infarction
– Stroke
– Major bleeding events

This paradox highlights the need to separate short-term procedural risks from long-term disease progression factors.

Clinical Implications and Future Directions

The findings necessitate sex-specific clinical approaches in structural heart disease management. Procedural refinements for women could include advanced vascular closure devices and tailored anticoagulation strategies. Addressing the declining treatment rates requires:
– Improved diagnostic protocols for women’s symptoms
– Referral pathway optimization
– Patient education about TAVI safety

Future research should investigate biological mechanisms behind the survival advantage and develop predictive models that account for sex-specific anatomy and physiology.

Conclusion

This landmark study reveals women receive TAVI less frequently over time yet experience higher procedural risks but greater long-term survival. These complex patterns highlight the critical need for sex-informed approaches throughout the treatment pathway—from diagnosis to post-procedural care. As TAVI expands to younger patients, addressing these disparities becomes increasingly vital for achieving equitable outcomes in structural heart disease management.

References

Nicolas J, Gelijns AC, Moskowitz AJ, Leon MB, Mehran R, Chikwe J, Mack MJ, Guerrero ME, Makkar RR, Jessup M, O’Gara PT, Egorova N. Sex-Based Patterns and Trends in Transcatheter Aortic Valve Implantation. JAMA Cardiology. 2026. PMID: 42090130.