Sex-related differences in survival and safety outcomes after transcatheter aortic valve replacement: a meta-analysis of reconstructed time-to-event data

Aims The impact of sex-related differences on outcomes following transcatheter aortic valve replacement (TAVR) remains inconclusive. This study investigates sex-related differences in survival and safety outcomes in patients with aortic stenosis undergoing TAVR. Methods and results We systematically searched PubMed, Embase, Scopus, and Cochrane Library until November 2024. Individual patient data (IPD) were reconstructed from published Kaplan-Meier curves and compared using Cox-proportional hazards model for overall survival and cardiovascular mortality. Pooled risk ratios (RR) for safety outcomes at 30-days and 1 year were estimated using a random-effects model. A total of 48 studies (69 355 women and 65 580 men) were included. Meta-analysis of reconstructed IPD showed that men were at higher risk of all-cause mortality at 5 years [hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.20-1.28, P < 0.001] and cardiovascular mortality at 4 years (HR: 1.34, 95% CI: 1.21-1.49, P < 0.001) compared with women. In random-effects meta-analysis, men faced a higher risk of permanent pacemaker implantation (RR: 1.29, 95% CI: 1.16-1.44, P < 0.001) during the first year. Men experienced a lower risk of stroke (RR: 0.75, 95% CI: 0.64-0.87, P < 0.001) and major vascular complications (RR: 0.58, 95% CI: 0.49-0.69, P < 0.001) at 30 days, and a lower risk of major bleeding (RR: 0.77, 95% CI: 0.70-0.84, P < 0.001) as well as major vascular complications (RR: 0.54, 95% CI: 0.43-0.68, P < 0.001) within the first year. Conclusion Men demonstrated poorer 5-year overall survival and 4-year cardiovascular survival following TAVR compared with women. Future research with extended follow-up is needed to understand the mechanism underlying sex-specific TAVR outcomes.