Appleby Clare, Bleiziffer Sabine, Bramlage Peter, Delgado Victoria, Eltchaninoff Helene, Gebhard Catherine, Hengstenberg Christian, Kurucova Jana, Marx Philipp, Rudolph Tanja K, Wojakowski Wojtek
Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK.
Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, University Hospital, Ruhr-University Bochum, Bad Oeynhausen, Germany.
J Thorac Dis. 2024 Sep 30;16(9):6308-6319. doi: 10.21037/jtd-24-406. Epub 2024 Sep 21.
This state-of-the-art review aimed to synthesize evidence from various sex-stratified studies on aortic stenosis (AS), focusing on the difference in clinical presentation, anatomical characteristics, pathophysiology, and management of AS. In comparison to men, women with AS are present at later stages, are older, more symptomatic, frailer, and exhibit higher operative risk [Society of Thoracic Surgeons (STS) score]. Women tend to have smaller aortic valve (AV) areas and left ventricular (LV) outflow tract, leading to lower stroke volumes (SVs) than men and have a higher prevalence of paradoxical, low-flow, low-gradient AS. In women, chronic pressure overload due to AS results in concentric LV remodelling and hypertrophy, characterized by reduced LV cavities, higher filling pressures, lower wall stress, and more diastolic dysfunction. Conversely, men exhibit more dilated eccentric LV remodelling and hypertrophy. AVs in women are less calcified but more fibrotic. Moreover, women are often underdiagnosed, have severity underestimated, and experience delays or receive fewer referrals for AV replacement (AVR). However, women tend to benefit from transcatheter AVR (TAVR) with a long-term survival advantage over men, although the incidence of vascular complications and bleeding events in 30 days after TAVR is higher in women. Surgical AVR (SAVR) in women has high operative risk, is technically demanding and has poorer outcomes with increased mortality at 30 days compared to men. According to the STS score and EuroSCORE, the female sex itself is considered a risk factor for SAVR. Therefore, addressing sex-related disparities in AS and increasing awareness among physicians promises improved diagnosis and treatment, facilitating equitable care and the development of sex-specific personalized medicine.
这篇前沿综述旨在综合来自各种关于主动脉瓣狭窄（AS）的性别分层研究的证据，重点关注AS在临床表现、解剖特征、病理生理学和管理方面的差异。与男性相比，患有AS的女性就诊时病情往往处于较晚期，年龄更大，症状更明显，身体更虚弱，手术风险更高[胸外科医师协会（STS）评分]。女性的主动脉瓣（AV）面积和左心室（LV）流出道往往较小，导致每搏输出量（SVs）低于男性，并且矛盾性、低流量、低梯度AS的患病率更高。在女性中，AS导致的慢性压力超负荷会引起左心室向心性重塑和肥厚，其特征是左心室腔减小、充盈压升高、壁应力降低以及舒张功能障碍更明显。相反，男性表现出更多的扩张性离心性左心室重塑和肥厚。女性的主动脉瓣钙化程度较低，但纤维化程度较高。此外，女性常常未被充分诊断，病情严重程度被低估，在接受主动脉瓣置换术（AVR）时会出现延迟或转诊较少的情况。然而，女性倾向于从经导管主动脉瓣置换术（TAVR）中获益，与男性相比具有长期生存优势，尽管女性在TAVR后30天内血管并发症和出血事件的发生率更高。女性的外科主动脉瓣置换术（SAVR）手术风险高，技术要求高，与男性相比，30天死亡率增加，预后较差。根据STS评分和欧洲心脏手术风险评估系统（EuroSCORE），女性本身被认为是SAVR的一个风险因素。因此，解决AS中与性别相关的差异并提高医生的认识有望改善诊断和治疗，促进公平医疗以及针对性别的个性化医学的发展。
