Sex Differences in LV Remodeling and Hemodynamics in Aortic Stenosis: Sex-Specific Criteria for Severe Stenosis?

• Published in: JACC. Cardiovascular imaging 2022-07, Vol.15 (7), p.1175-1189
• Main Authors: Ito, Saki, Miranda, William R, Nkomo, Vuyisile T, Lewis, Bradley R, Oh, Jae K
• Format: Article
• Language: English
• ISSN: 1876-7591
• DOI: 10.1016/j.jcmg.2022.02.007

BACKGROUNDThe current criteria for aortic stenosis (AS) severity have not incorporated sex-related differences. OBJECTIVESThe authors investigated sex-related serial changes in left ventricular (LV) structure/function and hemodynamics in AS. METHODSSerial echocardiograms of patients with severe AS (time 0; aortic valve area [AVA] ≤1 cm2) and ≥1 previous echocardiogram were compared between sexes. RESULTSOf 927 patients (time 0: AVA 0.87 ± 0.11 cm2, peak velocity 4.03 ± 0.65 m/s, mean Doppler systolic pressure gradient [MG] 40.6 ± 13.1 mm Hg), 393 (42%) were women. Women had smaller body surface area (BSA) (1.77 ± 0.22 m2 vs 2.03 ± 0.20 m2; P < 0.001), lower stroke volume (SV) (81.1 ± 17.2 mL vs 88.3 ± 18.6 mL; P < 0.001), and more frequent low-gradient severe AS (n = 196 [50%] vs n = 181 [34%]; P < 0.001). Women consistently had smaller AVA, indexed AVA (AVAi), peak velocity, and MG than men. The difference in aortic valve gradient lessened when AVAi ≤0.6 cm2/m2 was applied as severe AS (n = 694, women 43%, AVA 0.95 ± 0.17 cm2, AVAi 0.50 ± 0.07 cm2/m2). Peak velocity (3.83 ± 0.66 m/s) and MG (36.5 ± 13.2 mm Hg) were lower based on AVAi severity criteria compared to those based on AVA. Men had a lower left ventricular ejection fraction (LVEF) (55.8% ± 14.8% vs 61.1% ± 11.7%; P < 0.001) and greater reduction in SV (-13.3 ± 19.6 mL vs -7.4 ± 16.4 mL; P < 0.001) as AS progressed from moderate to severe. Concentric LV hypertrophy was more common and E/e' higher in women (21.2 ± 10.9 vs 18.8 ± 9.1; P < 0.001). SV, LVEF, AVA, peak velocity, and MG became precipitously worse when AVA reached 1.2 cm2 in both sexes. CONCLUSIONSSmaller BSA in women yields lower SV, resulting in lower aortic valve gradient than men. Indexed parameters by BSA are thus important in sex-related differences of aortic valve hemodynamics, but AVAi ≤0.6 cm2/m2 includes individuals with moderate AS. Elevated filling pressure is more common in women. Men experience a larger reduction in SV and LVEF as AS progresses. The definition of AS severity may require different criteria between sexes.