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Review
. 2022 Oct 4;11(19):e025944.
doi: 10.1161/JAHA.121.025944. Epub 2022 Sep 29.

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

Giulia Masiero  1 , Valeria Paradies  2 , Anna Franzone  3 , Barbara Bellini  4 , Chiara De Biase  5 , Nicole Karam  6 , Francesca Sanguineti  7 , Mamas A Mamas  8   9   10 , Hélène Eltchaninoff  11 , Chiara Fraccaro  1 , Battistina Castiglioni  12 , Tiziana Attisano  13 , Giovanni Esposito  3 , Alaide Chieffo  4
Affiliations
Review

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

Giulia Masiero et al. J Am Heart Assoc. .

Abstract

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.

Keywords: aortic stenosis; clinical management; device selection; sex differences; transcatheter aortic valve implantation.

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Figures

Figure 1
Figure 1. Epidemiological, pathophysiological, and diagnostic peculiarities in female patients affected by degenerative AS.
AS indicates aortic stenosis; AV, aortic valve; AVC, aortic valve calcification; BSA, body surface area; cMR, cardiac magnetic resonance; LF‐LG, low flow–low gradient; LV, left ventricular; LVEF, left ventricular ejection fraction; and MDCT, multidetector computed tomography.
Figure 2
Figure 2. Sex‐tailored TAVI planning and periprocedural management.
3D indicates 3 dimensional; InH, in hospital; LV, left ventricular; MDCT, multidetector computed tomography; PPM, prothesis–patient mismatch; SFAR, sheath‐to‐femoral artery ratio; TAVI, transcatheter aortic valve implantation; THV, transcatheter heart valve; and TTE, transthoracic echocardiogram.
Figure 3
Figure 3. Unfavorable anatomical correlation between THV frame, small aortic root, and coronary ostia, both in native and in bioprosthetic valve TAVI procedures.
A, Possible anatomical relationship between a self‐expandable supra‐annular device and a small annulus and STJ, that may hamper selective coronary artery cannulation because of a high sealing skirt. B, Scenario of a TAVI‐in‐TAVI procedure in case of a small aortic root with a narrow distance between the THV and STJ (<2 mm). Whatever is the first THV (intra‐annular or supra‐annular), if its commissural plane is at the level or even above the STJ, the implantation of a second THV may entail the risk of coronary obstruction because of sinus sequestration., STJ indicates sinotubular junction; TAVI, transcatheter aortic valve implantation; and THV, transcatheter heart valve.
Figure 4
Figure 4. Periprocedural TAVI considerations to address the specific issues associated with the treatment of female patients.
LV indicates left ventricle; PPM, patient–prosthesis mismatch; SFAR, sheath‐to‐femoral artery ratio; TAVI, transcatheter aortic valve implantation; and THV, transcatheter heart valve.
See this image and copyright information in PMC

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