Sex differences in characteristics and outcomes after TAVR-in-TAVR: the PANDORA international registry

As transcatheter aortic valve replacement (TAVR) expands to younger populations with longer life expectancies, a substantial number will require redo-TAVR procedures.

Comprehensive data on sex-specific clinical characteristics and outcomes following redo-TAVR remain scarce.

Patients undergoing redo-TAVR were enrolled in the multicenter PANDORA registry from 19 European centers between 2011 and 2024. Patients were stratified according to sex, and outcomes were assessed using Valve Academic Research Consortium 3 (VARC-3) criteria. The primary endpoint was a composite of all-cause mortality, heart failure hospitalization or aortic valve reintervention.

Out of more than 30,000 TAVR procedures, 172 patients (median age 80 [IQR: 76-85] years; 76 females [44%], 96 males [56%]) underwent redo-TAVR. Females had fewer prior pacemaker (21.3% vs. 38.5%, p=0.025), and lower baseline creatinine levels (0.9 vs. 1.3 mg/dL, p<0.001). Initial valve type differed significantly by sex, with men predominantly receiving self-expandable valves (CoreValve/Evolut: 59.4% vs. 36.8%, p = 0.005) and women predominantly receiving balloon-expandable valves (SAPIEN: 52.6% vs. 21.9%, p < 0.001). Structural valve deterioration was the primary cause of TAVR failure overall (77.9%), with severe stenosis significantly more common among women (61.8% vs. 43.8%, p = 0.027). Procedural success rates were high and similar between sexes. At mid-term follow-up, men demonstrated a significantly higher incidence of the composite primary endpoint compared with women (HR 2.08; 95% CI 1.04–4.15; p = 0.04).

Despite differences in baseline characteristics, valve selection, and modes of failure, redo-TAVR demonstrated comparable procedural success and short-term safety in both sexes. However, male sex was associated with significantly higher mid-term risk of adverse clinical outcomes, highlighting the importance of sex-specific considerations in clinical management and follow-up after redo-TAVR.For image description, please refer to the figure legend and surrounding text.  For image description, please refer to the figure legend and surrounding text.