Lévy, Franck

Background Although women represent half of the population burden of aortic stenosis (AS), little is known whether sex affects the presentation, management, and outcome of patients with AS. Methods and Results In a cohort of 2429 patients with severe AS (49.5% women) we aimed to evaluate 5‐year excess mortality and performance of aortic valve replacement (AVR) stratified by sex. At presentation, women were older ( P <0.001), with less comorbidities ( P =0.030) and more often symptomatic ( P =0.007) than men. Women had smaller aortic valve area ( P <0.001) than men but similar mean transaortic pressure gradient ( P =0.18). The 5‐year survival was lower compared with expected survival, especially for women (62±2% versus 71% for women and 69±1% versus 71% for men). Despite longer life expectancy in women than men, women had lower 5‐year survival than men (66±2% [expected‐75%] versus 68±2% [expected‐70%], P <0.001) after matching for age. Overall, 5‐year AVR incidence was 79±2% for men versus 70±2% for women ( P <0.001) with male sex being independently associated with more frequent early AVR performance (odds ratio, 1.49; 1.18–1.97). After age matching, women remained more often symptomatic ( P =0.004) but also displayed lower AVR use (64.4% versus 69.1%; P =0.018). Conclusions Women with severe AS are diagnosed at later ages and have more symptoms than men. Despite prevalent symptoms, AVR is less often performed in women and 5‐year excess mortality is noted in women versus men, even after age matching. These imbalances should be addressed to ensure that both sexes receive equivalent care for severe AS.

Abstract Background Increasing attention has been paid to differences between the sexes in recent studies, but only a few have focused on such differences in aortic stenosis (AS). Purpose We sought to evaluate the differences between genders in AS outcomes and management. Methods We included 2429 patients (51.5% men; 49.5% women) with severe AS. Median follow-up was 42.0 (21–78) months. Results Women were older (p&lt;0.001), more often symptomatic (p=0.007), and presented with smaller aortic valve area (p&lt;0.001), and greater ejection fraction (p&lt;0.001) than men. Despite that women have a longer life expectancy than men in the general population, estimated five-year survival of patients with severe AS was lower for women compared to men (62±2% versus 69±1% respectively, p&lt;0.001). The 5-year survival was lower compared to expected survival, especially for women (62±2% vs. 71% for women and 69±1% vs. 71% for men). The cumulative 5-years incidence of AVR was 79±2% for men, and only 70±2% for women (p&lt;0.001) and, being male was independently predictive of AVR (OR: 1.49 [1.18–1.97]; p=0.011). After propensity matching, when both genders were comparable in terms of characteristics and management (AVR), women, as expected due to their higher life expectancy than men, had better 5-year survival than men (69±2% vs. 62±2%; p=0.023). Conclusion Women with severe AS present at a more advance stage of the disease, at older ages with more symptoms, and incur higher mortality than men. This excess mortality is related to a combination of late diagnosis and a less frequent and later referral for AVR than in men. This justifies appropriate measures to improve the situation and to ensure that both sexes receive equivalent care. Figure 1. (A) Survival curves. (B) Surgery incidence. Funding Acknowledgement Type of funding source: None

Background— Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients. Methods and Results— We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66% [60%–71%]) enrolled in the Mitral Regurgitation International Database (MIDA) registry. With EF <60%, mortality after diagnosis increased precipitously under medical management (adjusted hazard ratio [HR], 1.59 [1.19–2.12]) and during the entire follow-up (adjusted HR, 1.51 [1.22–1.87]). Severe LV dysfunction, if defined by EF <30%, would affect a minuscule number of patients (0.3%). Conversely, EF <45% was more frequent (2.9%) and was associated with considerable mortality under medical management (adjusted HR, 2.43 [1.50–3.95]) and during the entire follow-up (adjusted HR, 2.46 [1.67–3.61]). The group with EF of 45% to 60% represented a large proportion of patients (23%), exhibited rarely overt symptoms, and had higher mortality compared with EF >60%. Above 60%, no EF threshold further determined survival. The benefit of surgery remained considerable in the groups with EF <45% (adjusted HR, 0.28 [0.17–0.56]) and with EF of 45% to 60% (adjusted HR, 0.34 [0.21–0.64]). Conclusions— EF is valuable in defining presence and severity of LV dysfunction in organic mitral regurgitation. Patients with EF <45% have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Although there is no survival gain with EF ranges >60%, with EF dropping <60%, mortality increases precipitously and prompt surgical referral is critical to outcome.