2022, Number S5
Valve disease in women
Full text
10.35366/108059
Language: English
References: 10
Page: s480-483
PDF size: 171.13 Kb.
INTRODUCTION
Valvular disease (VD) has a prevalence of 2.5% in the population, with an increase in degenerative etiologies and in older adults.1 Women and men are equally likely to develop VD, with some sex-specific differences. In general, women suffer more mitral valve diseases, especially mitral valve prolapse (MVP) and rheumatic valve disease (RVD), and men have more aortic valve diseases, such as aortic insufficiency (AI) and aortic stenosis (AS).
AORTIC VALVE DISEASE (
Men are at higher risk of developing AS; it is more common in the elderly, mostly women. Women have less valvular calcium but more fibrosis. At presentation, they are older, hypertensive, with worse functional class but better left ventricular ejection fraction (LVEF) with hypertrophic ventricles. Greater low-flow, low-gradient paradoxical AS and less amyloidosis.1,2 Aortic insufficiency is more frequent in men associated with bicuspids (BAV), with a 2% male/female ratio of 3:1. Women will develop more AS and men AI aneurysms, aortic dissection, and endocarditis.2
MITRAL VALVE DISEASE (
RVD is responsible for the most significant global burden of VMD and is more common among women in all age groups.1 New mechanisms for the pathogenesis of VRD suggest that Prothymosin alpha, associated with Estrogen Receptor alpha activity, would have a role in the sexual predisposition of RVD, perhaps explaining the higher incidence of rheumatic valve disease in women.3
Mitral valve insufficiency (MVI) is women's most common valve pathology. It can be primary: rheumatic, valve prolapse (myxomatous degeneration, thickening of the leaflets), or secondary: due to alteration in the geometry of the left ventricle, due to ischemic heart disease, or other dilated heart diseases. Women have more symptoms of heart failure (CHF), their condition is underestimated, and fewer are referred for intervention.1,2
Mitral stenosis (MS) is more common in women; its etiology is rheumatic or degenerative, associated with calcification of the mitral annulus at an advanced age. Some cases are related to chest radiation, carcinoid heart disease, or inherited metabolic disorders. It is classified as severe when the mitral valve area is ≤ 1.5 cm2.1,3
TRICUSPID VALVE DISEASE (
Tricuspid regurgitation (TR) can be due to primary causes (congenital, genetic, endocarditis, rheumatic compromise, or device-related anomalies) or secondary causes (right ventricular dilatation and dysfunction). TR is more common in women/men in a 1.6:1 ratio. Once it develops in them, it progresses more rapidly, possibly due to anatomical differences in the annulus more elastic, cellular, and smaller1 than in men, that have myocardium fibers in the annulus.
In women, secondary TR occurs at an older age than in men (72 [62-79] years vs 70 [61-77] years; p = 0.003) and is more symptomatic. The most common etiology in women is isolated TR or is related to left-sided valvular disease.1 In the imaging evaluation of the severity of TR, the quantification of the size of the cardiac cavities, according to sex and body surface, must be considered. Sex-specific dimension data now exist for different cardiac imaging modalities.4,5
VALVE INTERVENTIONISM
AVD. Women treated with surgical aortic valve replacement (SAVR) are older than men, with more advanced disease and higher operative mortality. Female gender is considered an independent predictor of post-SAVR operative mortality and morbidity.6 Transcatheter aortic valve implantation (TAVI) results by gender show no differences in implant success; the female sex was associated with increased vascular complications and major bleeding but a lower incidence of paravalvular leak, pacemaker, and better medium-term survival.7
MVD. The registries show that the women were taken significantly less or later to mitral surgery (repair/replacement). In degenerative MI, women are less frequently taken to repair (44 vs 31.9%, p = 0.001), with slightly lower long-term survival.1
In percutaneous therapy in severe functional MR with TEER (Transcatheter Edge-to-Edge Repair) with more MitraClip evidence, women represented only 36% of patients in the COAPT study and 25% in MITRA-FR, being younger, but with worse quality of life and functional capacity. TEER resulted in better clinical outcomes vs. medical therapy, regardless of gender; the reduction in CHF hospitalizations was less pronounced in women. Female gender was independently associated with a lower adjusted risk of death at two years (HR, 0.64; 95% CI, 0.46-0.90; p = 0.011).1
In RVD, the treatment of choice is mitral valvuloplasty with a catheter and a balloon, followed by valve surgery.8
TVD. Regarding the surgical results in tricuspid insufficiency (TI), the repair has higher survival, and there is no difference by sex in terms of results.1
PREGNANCY AND STROKE
Moderate or severe EV in pregnancy is complex and requires an experienced cardio-obstetric multidisciplinary team. Significant MS and symptomatic severe AS are poorly tolerated. Percutaneous commissurotomy should be considered in MS with severe symptoms (NYHA III-IV) or pulmonary artery systolic pressure > 50 mmHg and unresponsive to medical treatment. Aortic balloon valvuloplasty can be regarded as salvage therapy in AS with severe symptoms despite medical treatment, and definitive interventions will be defined after delivery. Valvular insufficiencies are usually better tolerated, except when there is associated ventricular dysfunction.9
If valve surgery is required and the fetus is viable, a cesarean section will be performed, followed by valve surgery. Valve surgery with extracorporeal circulation with a fetus in utero has fetal mortality of 15-56%. Therefore, it should be restricted to situations with life-threatening risk for the mother and no percutaneous management option.
Pregnant women with mechanical prostheses are very complex since there is no ideal anticoagulant regimen, so it is necessary to weigh the risks for the mother and the fetus (Warfarin according to the dose or low molecular weight heparin but always with monitoring of antifactory Xa levels)9,10 (Table 1).
Women with VD have been underrepresented in studies and tend to be diagnosed and referred for interventions later, leading to adverse outcomes1,2 summarizes the complex relationship between pregnancy and valvular heart disease.
REFERENCES
Petersen SE, Khanji MY, Plein S, Lancellotti P, Bucciarelli-Ducci C. European Association of Cardiovascular Imaging expert consensus paper: a comprehensive review of cardiovascular magnetic resonance normal values of cardiac chamber size and aortic root in adults and recommendations for grading severity. Eur Heart J Cardiovasc Imaging. 2019; 20: 1321-1331.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28: 1-39. e14.
Onorati F, D'Errigo P, Barbanti M, Rosato S, Covello RD, Maraschini A et al. Different impact of sex on baseline characteristics and major periprocedural outcomes of transcatheter and surgical aortic valve interventions: results of the multicenter Italian OBSERVANT Registry. J Thorac Cardiovasc Surg. 2014; 147: 1529-1539.
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022; 43: 561-632.
Regitz-Zagrosek V, Roos-Hesselink JW, Baursachs J, Blomstrom-Lundqvist C, Cifkova R, De Bonis M et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy: the task force for the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39: 3165-3241.
AFFILIATIONS
1 Clinical Cardiology of Valvular Diseases. Children's Cardio Foundation. Bogota Colombia.
2 Sociedad Colombiana de Cardiología y Cirugía Cardiovascular, SIAC COMUNIDAD.
3 Leader of the Cardiovascular and Pulmonary Unit and the Cardio-Obstetric Clinic of the Hospital Universitario San Vicente Fundación. Medellin Colombia. Colombian Society of Cardiology and Cardiovascular Surgery.
4 IPEMED Faculty of Medical Sciences. Physician at the valvular heart disease outpatient clinic of the UFMG School of Medicine.
5 Professor of Medicine, Mayo Clinic Health System. Department of Cardiovascular Medicine, Mayo Clinic. Rochester, Minnesota, USA.
CORRESPONDENCE
Karen Dueñas C. E-mail: kduenas@lacardio.org