Sex-based differences in baseline characteristics, periprocedural outcomes and long-term survival following transcatheter aortic valve implantation

Background Sex-related differences in outcomes after transcatheter aortic valve implantation (TAVI) remain debated. Women referred for TAVI tend to be older, have smaller aortic annuli, and present with more comorbidities, yet some studies suggest a long-term survival advantage over men. Understanding sex-specific outcome patterns is essential for refining patient selection and periprocedural management. Purpose To evaluate sex-based differences in baseline characteristics, procedural data, in-hospital complications, and long-term all-cause mortality following TAVI in a large cohort. Methods We analysed consecutive patients (who underwent TAVI in a prospective registry of two tertiary centers. Baseline characteristics, procedural data, and in-hospital outcomes were compared between sexes using chi-square/Fisher’s exact tests for categorical and Mann-Whitney U tests for continuous variables. The primary endpoint was all-cause mortality. Long-term survival was assessed using Kaplan-Meier analysis with log-rank testing. Outcomes were reported according to the Valve Academic Research Consortium-3 (VARC-3) criteria. Results We analysed 4,331 consecutive patients (2,299 males [53.1%]; 2,032 females [46.9%]). Women were older (83 vs 82 years; p<0.001) and had higher pre-procedural transvalvular gradients (mean gradient 45 vs 43 mmHg; p<0.001), smaller aortic valve area (0.66 vs 0.70 cm²; p<0.001), and better preserved left ventricular function (LVEF ≥50%: 78.8% vs 64.5%; p<0.001). Men had a significantly higher burden of coronary artery disease (prior MI: 17.7% vs 9.2%; prior PCI: 31.7% vs 19.4%; prior CABG: 25.9% vs 14.9%; all p<0.001), diabetes (27.6% vs 23.1%; p<0.001), and atrial fibrillation (28.1% vs 22.3%; p<0.001). Women experienced significantly higher rates of cardiac tamponade (2.2% vs 0.8%; p<0.001), vascular access-site complications (14.4% vs 9.2%; p<0.001), any bleeding (15.0% vs 8.8%; p<0.001), in-hospital cerebrovascular accident (4.0% vs 2.6%; p=0.011), conversion to sternotomy (1.0% vs 0.3%; p=0.010), and in-hospital mortality (3.2% vs 2.0%; p=0.018). Conversely, men had a higher rate of new permanent pacemaker implantation (17.5% vs 13.2%; p<0.001). VARC-3 technical success was achieved in 97.3% of males vs 96.0% of females (p=0.021). Over a median follow-up of 6.4 years, 1,594 deaths occurred (890 males, 704 females). Kaplan-Meier analysis demonstrated significantly better long-term survival for women (median survival: 7.1 vs 6.0 years; log-rank p<0.001). Conclusions Despite a higher incidence of periprocedural complications, including vascular injury, bleeding, tamponade, and in-hospital mortality, women undergoing TAVI demonstrated significantly higher long-term survival compared to men. These findings underscore the need for sex-specific risk stratification, tailored periprocedural management to mitigate the higher early risks in women, and long-term outcome assessment beyond the index hospitalisation.Kaplan Meier analysis