TOPLINE:

Asymptomatic women with moderate-to-severe aortic regurgitation and preserved left ventricular (LV) function managed without surgery had lower survival rates than their male counterparts, although survival after aortic valve surgery was similar for both sexes. Sex-specific thresholds based on LV volume were more strongly associated with mortality than those based on LV diameter.

METHODOLOGY:

• Researchers conducted a multicenter retrospective cohort study to examine whether sex-specific thresholds of LV size more accurately predicted mortality than standard thresholds in asymptomatic patients with moderate-to-severe aortic regurgitation and preserved ejection fraction.
• They included 808 asymptomatic adults with at least moderate-to-severe aortic regurgitation and an LV ejection fraction ≥ 50%, treated between December 2003 and December 2022. The mean age was 56 years, and 320 patients were women.
• Researchers assessed the LV end-systolic diameter index (LVESDi) and LVES volume index (LVESVi) using echocardiography, indexed both measures to body surface area, and compared the values by sex.
• They evaluated the occurrence of all-cause mortality during medical management and after aortic valve surgery. Overall, 323 patients underwent surgery.
• Patients were followed up for a median of 7 years. For postoperative outcome analyses, researchers used echocardiograms obtained within 3 months before surgery.

TAKEAWAY:

• During medical management, women had a lower adjusted 6-year survival rate than men (80% vs 89%; P = .001), with 41 deaths in women and 33 in men.
• Receiver operating characteristic analysis identified LVESDi ≥ 20 mm/m² as the threshold associated with mortality in both sexes. For LVESVi, the threshold was ≥ 40 mL/m² in women and ≥ 45 mL/m² in men. Age-adjusted spline analyses confirmed these cutoffs.
• During medical management, LVESDi ≥ 20 mm/m² was associated with an increased risk for mortality (adjusted hazard ratio [aHR], 1.90; P < .001), with no difference between sexes. LVESVi above the sex-specific thresholds was associated with more than a twofold increased risk for mortality (aHR, 2.43; P < .001), with a significant sex interaction.
• After aortic valve surgery, men and women had similar 6-year survival rates (P = .31). Higher preoperative LVESVi was independently associated with a higher postoperative mortality rate (aHR, 1.14 per 5 mL/m² increase; P = .002; P for sex interaction = .04), whereas LVESDi was not associated with the postoperative mortality rate.

IN PRACTICE:

“Importantly, these data also identify the importance of sex-based analyses of LV remodeling and emphasize that even after adjustment for body surface area, risk thresholds for LVESVi may need to be lowered in women compared with men. These observations provide the basis for further work in understanding sex differences in the LV response to chronic volume overload and its clinical aftermath,” experts wrote in an editor’s note.

SOURCE:

The study was led by Pilar Lopez Santi, MD, of Leiden University Medical Center in Leiden, Netherlands. It was published online on January 21 in JAMA Cardiology.

LIMITATIONS:

The retrospective observational design of the study required confirmation in prospective studies. Specific reasons for aortic valve surgery were not recorded for all patients. Causes of death were not systematically reported.

DISCLOSURES:

One author reported being employed by Abbott Medical Canada. Several authors reported receiving grants (some to their institutions) and/or speaker fees from various cardiovascular, pharmaceutical, medical devices, and other companies, including Edwards Lifesciences, Medtronic, and Novartis.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.