The interrelatedness of sex and age on survival after heart transplantation
T Abdurashidova, B Pitta-Gros, J Asaipillai, M Verdugo Marchese, C Huber, H Skali, V Rancati, P Yerly, P Meyer, M Kirsch, H Lu, R HullinAbstract
Introduction
Heart transplantation (HTx) remains the only choice for successful long-term treatment of patients with advanced heart failure (HF). Female sex is associated with reduced short to medium-term all-cause mortality (ACM) in cardiovascular, renal, or HF disease. In HTx, the effect of sex has been reported with heterogeneous results.
Methods
Of the 498 patients who underwent HTx between 1987 and 2022, this two-center study included 461 adult HTx recipients (86 females). ACM (primary outcome) was evaluated accroding to recipient sex across the spectrum of recipient age, duration of follow-up, the total duration of HTx activity (1987-2022), and the early and late era (1987-1999 vs. 2000-2022; n=202 vs. 259, respectively) which differ in the availablity if guideline-directed HF treatment.
Results
Female patients were younger (48.8 vs. 52.3 years, p=0.014), with lower BMI and eGFR (24.4 vs. 25, p=0.003; 60 vs. 70 ml/min/m² p=0.002; respectively), and less prevalent ischemic cardiomyopathy and dyslipidemia (27.9 vs. 46.7%, p<0.001; 41.6 vs. 57.8%, p=0.01; respectively). Over a median follow-up of 9.4 years (IQR 3.1, 18.5) the primary otucome occured at a rate of 5.0 per 100py among men, and 2.7 per 100 py among women. Compared with men, women experienced a lower risk of ACM (adjusted HR: 0.49; 95%CI: 0.30-0.80), irrespective of age (pinteraction=0.61). This result remained consistent across duration follow-up intervals of 5-, 10-, 15-, and 20-years (adjusted HR and 95%CI: 0.55, 0.27-1.11; 0.55, 0.30-1.01; 0.64, 0.38-1.09; 0.64, 0.39-1.04; respectively). In the early era, the incidence of ACM was lower in female HTx (HR 0.52; 95%CI 0.30-0.91; p=0.022) while in the late era, mortality was not significantly different between the sexes (HR 0.64; 95%CI: 0.64-1.15, p=0.14). The comparison between HTx recipients of the early and late eras showed that the Model of End-stage liver disease excluding INR (MELD-XI) score - a known predictor of survival in HTx patients - did not significantly differ among females (23.4 ± 1.6 vs. 22.9 ± 6.0; p=0.79). In contrast, males had a significantly higher risk profile in the early era, compared to the late era (27.8 ± 5.5 vs. 24.6 ± 6.2; p<0.001).
Conclusion
women presented with better survival. This result was consistent across the spectrum of recipient age, and duration of follow-up. The observation that female sex was associated with similar MELD-XI scores in both the early and late eras, while male HTx recipients haf higher scores in the early era, suggests that variability in disease severity among male canditates may help explain the heterogeneity of sex-related outcomes reported after HTx.All-cause mortality according to sexFor image description, please refer to the figure legend and surrounding text.