Sex Differences in Outcomes After Transcatheter Aortic Valve Implantation

Abstract

Introduction: Women account for about half of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Early reports suggested lower mortality in women, but contemporary data with newer valve technologies show inconsistent sex differences.
Methods: A systematic review and meta-analysis of observational studies and RCT subs analyses (2015–2024) comparing TAVI outcomes by sex. Inclusion: ≥500 patients per study, follow-up ≥1 year. Exclusion: surgical aortic valve replacement comparator. Outcomes: all-cause mortality, stroke, vascular complications, and pacemaker implantation.
Results: 28 studies (n=185,000 patients, 52% women) were included. At 1 year, women had lower all-cause mortality (adjusted RR 0.85, 95%CI 0.79–0.91) and cardiovascular mortality (RR 0.80, 0.73–0.88). Stroke risk did not differ (RR 0.97, 0.88–1.07). Women had higher rates of major vascular complications (OR 1.6, 1.4–1.8) and life-threatening bleeding (OR 1.5, 1.3–1.7), but lower need for permanent pacemaker (OR 0.64, 0.58–0.71). At 2–5 years, mortality advantage attenuated but persisted (RR 0.92, 0.87–0.97).
Discussion: Female survival advantage may relate to smaller annulus size (better prosthesis-valve sizing), less comorbidity burden, and lower rates of periprocedural conduction disturbances. Higher vascular complications reflect smaller vessel diameters. Limitations include residual confounding by frailty and underreporting of moderate paravalvular leak.
Conclusions: Women undergoing TAVI have lower short- and intermediate-term mortality than men, despite higher vascular complication rates. These findings support continued equal access to TAVI for both sexes and sex-specific management of vascular access.