Comparing access to, and outcomes following, TAVI by biological sex.

INTRODUCTION: European valvular heart disease guidelines define women as a 'special group'. To explore what factors have led us to consider more than 50% of the global population special, we assessed access to transcatheter aortic valve implantation (TAVI) by sex on national and local levels and studied post-TAVI outcomes by sex within our centre. METHODS: Population statistics from census data were compared against British Cardiovascular Intervention Society (BCIS) audit and local data.Using the National Institute for Cardiovascular Outcomes Research TAVI database, a retrospective analysis of 1049 consecutive patients from 2013 to 2023 was conducted at our UK tertiary centre.Primary outcomes were all-cause death, a three-point composite of major adverse cardiac events (MACE) comprising death, non-fatal myocardial infarction and non-fatal stroke during TAVI admission, and post-TAVI survival. RESULTS: Nationally, females comprise 60% of over 75-year-olds; however, TAVI was performed more frequently in males: nationally (55.2% vs 44.8%, p<0.01) and locally (53.2% vs 46.8%, p<0.01). Males were 1.82 times more likely to undergo TAVI.Locally, females undergoing TAVI were older and had worse renal function, higher frailty and greater transvalvular gradients. Males had more cardiovascular comorbidity.In-hospital mortality and MACE did not differ by sex. Median survival was longer in females (1350 days vs 1728 days, p=0.02). Regression analysis demonstrated female sex as a predictor of increased survival (HR 0.73, 95% CI 0.61 to 0.88, p<0.01). Chronic obstructive pulmonary disease, atrial fibrillation, frailty and poor mobility were identified as predictors of reduced survival. CONCLUSION: In this retrospective, observational study, we have demonstrated an under-representation of females undergoing TAVI. This observation is likely of multifactorial cause, including different disease recognition, referral, investigation and treatment practices.We observed no difference in procedural death or MACE, but longer female survival, despite higher baseline age, frailty and renal impairment.