Sex Differences and Survival in Adults With Bicuspid Aortic Valves: Verification in 3 Contemporary Echocardiographic Cohorts.
Sex-related differences in morbidity and survival in bicuspid aortic valve (BAV) adults are fundamentally unknown. Contemporary studies portend excellent survival for BAV patients identified at early echocardiographic-clinical stages. Whether BAV adults incur a survival disadvantage throughout subsequent echocardiographic-clinical stages remains undetermined.



Analysis was done of 3 different cohorts of consecutive patients with echocardiographic diagnosis of BAV identified retrospectively: (1) a community cohort of 416 patients with first BAV diagnosis (age 35±21 years, follow-up 16±7 years), (2) a tertiary clinical referral cohort of 2824 BAV adults (age 51±16 years, follow-up 9±6 years), and (3) a surgical referral cohort of 2242 BAV adults referred for aortic valve replacement (AVR) (age 62±14 years, follow-up 6±5 years). For the community cohort, 20-year risks of aortic regurgitation (AR), AVR, and infective endocarditis were higher in men (all P≤0.04); for a total BAV-related morbidity risk of 52±4% vs 35±6% in women (P=0.01). The cohort's 25-year survival was identical to that in the general population (P=0.98). AR independently predicted mortality in women (P=0.001). Baseline AR was more common in men (P≤0.02) in the tertiary cohort, with 20-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.16 (95% confidence interval [CI] 1.05-1.29) for men versus 1.67 (95% CI 1.38-2.03) for women (P=0.001). AR independently predicted mortality in women (P=0.01). Baseline AR and infective endocarditis were higher in men (both ≤0.001) for the surgical referral cohort, with 15-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.34 (95% CI 1.22-1.47) for men versus 1.63 (95% CI 1.40-1.89) for women (P=0.026). AR and NYHA class independently predicted mortality in women (both P≤0.04).



Within evolving echocardiographic-clinical stages, the long-term survival of adults with BAV is not benign, as both men and women incur excess mortality. Although BAV-related morbidity is higher in men in the community, and AR and infective endocarditis are more prevalent in men, women exhibit a significantly higher relative risk of death in tertiary and surgical referral cohorts, which is independently associated with AR.
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN michelena.hector@mayo.edu.
Hector I
HI
Michelena
Division of Cardiovascular Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates.
Rakesh M
RM
Suri
Division of Internal Medicine, Mayo Clinic, Rochester, MN.
Ognjen
O
Katan
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Mackram F
MF
Eleid
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Marie-Annick
MA
Clavel
Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.
Mathew J
MJ
Maurer
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Patricia A
PA
Pellikka
Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.
Douglas
D
Mahoney
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Maurice
M
Enriquez-Sarano
D000293:Adolescent; D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000601:surgery; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D002423:Cause of Death; D015331:Cohort Studies; D004452:Echocardiography; D004696:Endocarditis / Q000000981:diagnostic imaging / Q000453:epidemiology*; D005260:Female; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D012189:Retrospective Studies; D012737:Sex Factors; D015996:Survival Rate; D014481:United States / Q000453:epidemiology; D055815:Young Adult
bicuspid aortic valve; sex‐specific; survival
Ann Epidemiol. 2002 Oct;12(7):462-8
12377423
J Am Coll Cardiol. 1987 Apr;9(4):952-9
3558992
J Am Soc Echocardiogr. 2003 Jul;16(7):777-802
12835667
Eur J Echocardiogr. 2009 Jan;10(1):1-25
19065003
J Am Coll Cardiol. 1999 Sep;34(3):618-20
10483939
J Thorac Cardiovasc Surg. 2011 Sep;142(3):622-9, 629.e1-3
21292285
Clin Infect Dis. 2000 Apr;30(4):633-8
10770721
J Am Coll Cardiol. 2002 Jun 19;39(12):1890-900
12084585
Circulation. 1996 Nov 15;94(10):2472-8
8921790
Am J Cardiol. 2015 Jul 15;116(2):250-5
25983125
Circulation. 2014 Jun 10;129(23):e521-643
24589853
Mayo Clin Proc. 2016 Jan;91(1):122-3
26763517
Heart. 2014 Jan;100(2):126-34
24254191
JAMA. 2008 Sep 17;300(11):1317-25
18799444
Circulation. 1999 Jan 26;99(3):400-5
9918527
Mayo Clin Proc. 1996 Mar;71(3):266-74
8594285
J Am Soc Echocardiogr. 2005 Dec;18(12):1440-63
16376782
J Chronic Dis. 1987;40(5):373-83
3558716
Circulation. 2014 Jun 24;129(25):2691-704
24958752
Circulation. 2008 May 27;117(21):2776-84
18506017
Heart. 2010 Nov;96(21):1723-9
20478858
J Thorac Cardiovasc Surg. 1997 Mar;113(3):476-91; discussion 489-91
9081092
JACC Cardiovasc Imaging. 2013 Dec;6(12):1301-10
24269260
J Thorac Cardiovasc Surg. 2003 Sep;126(3):892-3
14502185
JAMA. 2011 Sep 14;306(10):1104-12
21917581
Ann Thorac Surg. 2015 Oct;100(4):1298-304; discussion 1304
26209480
J Am Coll Cardiol. 1997 Sep;30(3):746-52
9283535