THE IMPORTANCE OF SEX DIFFERENCES IN LEFT VENTRICULAR REMODELING FOR RISK STRATIFICATION OF PATIENTS WITH AORTIC REGURGITATION

Background: Left ventricular(LV) dilatation is an established prognosticator in aortic regurgitation(AR). Current guidelines recommend using LV end-systolic diameter index (LVESDi) to assess the need for aortic valve surgery(AVS), applying the same threshold of 25 mm/m2 regardless of sex. However, LV volumes have been suggested to better depict LV remodeling in AR.
Purpose:To assess sex differences in LV remodeling using linear and volumetric measurements in patients with moderate-severe AR and their association with outcomes.
Methods:1070 patients(56±18 years, 691 men)with moderate-severe AR were included. The primary outcome was all-cause mortality.
Results:Women were older(58±19 vs. 55±17, p=0.023) and had more advanced HF symptoms than men (NYHA class III-IV 12% vs. 9%, p=0.017).Men showed larger LVESDi (21±5 vs. 20±5 mm/m2, p=0.013) and LV end-systolic volume index (LVESVi 37 ± 28 vs. 26 ± 17 ml/m2 p<0.001).
During a median follow-up of 89 (IQR,54-132) months,168 patients died. Women had lower survival rates at 10 years compared to men (75.3% vs. 84.1%,p=0.005) (Figure 1A). However, sex mortality difference was no longer significant when patients were treated surgically(p=0.705)(Figure 1B).Spline curve analysis revealed that the LVESDi threshold associated with an increased risk of mortality was 20 mm/m2 for both sexes(Figure 2). The LVESVi threshold was 40 ml/m2 for women and 45 ml/m2 for men (Figure 2). LV dilatation defined by these cut-offs remained independently associated with mortality after adjusting for clinical and echocardiographic variables(Table 1A).
Conclusion: In moderate-severe AR, similar LVSEDi thresholds (20 mm/m2) for both sexes, but lower than currently recommended by guidelines, were associated with mortality. For LVESVi, lower thresholds for women compared to men (40 ml/m2 vs. 45 ml/m2) were associated with worse survival.