Author + information
- Received April 15, 2014
- Revision received May 21, 2014
- Accepted June 12, 2014
- Published online November 1, 2014.
- George Petrov, MD, MSc∗,†∗ (, )
- Elke Dworatzek, PhD†,‡,
- Tabea Marie Schulze, MD (cand)∗,
- Michael Dandel, MD∗,†,
- Georgios Kararigas, PhD†,‡,
- Shokufeh Mahmoodzadeh, PhD†,‡,
- Christoph Knosalla, MD∗,†,
- Roland Hetzer, MD∗,† and
- Vera Regitz-Zagrosek, MD∗,†,‡
- ∗Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- †DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- ‡Institute of Gender in Medicine and Center for Cardiovascular Research, Charité Universitaetsmedizin Berlin, Berlin, Germany
- ↵∗Reprint requests and correspondence:
Dr. George Petrov, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, DHZB, Augustenburger Platz 1, 13353 Berlin, Germany.
Objectives The purpose of this study was to test whether adaptive or maladaptive remodeling is associated with survival in women and men after aortic valve replacement (AVR).
Background Women with isolated aortic valve stenosis (AS) develop more concentric left ventricular hypertrophy (LVH) than men in similar disease states. We recently reported less up-regulation of profibrotic genes at AVR and faster LVH regression post-operatively in women than in men, suggesting that there are sex differences in the adaptation to pressure overload and its regression.
Methods The study cohort included 128 patients (age 70.0 ± 9.6 years, 49% women) undergoing AVR for AS. Echocardiography was obtained before and 4.0 ± 1.6 years after surgery. Factor analysis was used to classify LVH as adaptive (combining smaller left ventricular [LV] mass/diameters and greater relative wall thicknesses) or maladaptive. Myocardial tissue samples from the LV septum were obtained during AVR to analyze cardiac fibrosis and associated key molecular regulators.
Results Before AVR, LVH was classified as adaptive in 62% of women and 45% of men (p < 0.050). Four years after AVR, adaptive LVH was observed in 75% of women and 49% of men (p < 0.031). At surgery, more cardiac fibrosis was present in men compared with women (p < 0.05). Higher levels of transforming growth factor beta 1 (p < 0.01), SMAD2 phosphorylation (p < 0.001), and periostin expression (p < 0.05) were found in men than in women. Women with maladaptive LVH had worse survival than women with adaptive LVH (p < 0.050), whereas the pattern of LVH did not affect survival in men (p < 0.307).
Conclusions Women more frequently exhibit adaptive LV remodeling with less fibrosis than men. Maladaptive LVH is associated with worse survival in women. Thus, sex should be considered as a strong modulating factor when management of patients with AS is discussed.
- aortic valve replacement
- aortic valve stenosis
- cardiac fibrosis
- hypertrophy regression
This work was supported by the German Research Foundation (DFG Re662/9-1, FG1054, and DW70/1-1) and DZHK (German Center for Cardiovascular Research). All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Dr. Petrov, Dr. Dworatzek, and Ms. Schulze contributed equally to this work.
- Received April 15, 2014.
- Revision received May 21, 2014.
- Accepted June 12, 2014.
- American College of Cardiology Foundation