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Original research
IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe
  1. Richard Paul Steeds1,
  2. David Messika-Zeitoun2,
  3. Jeetendra Thambyrajah3,
  4. Antonio Serra4,
  5. Eberhard Schulz5,
  6. Jiri Maly6,7,
  7. Marco Aiello8,
  8. Tanja K Rudolph9,
  9. Guy Lloyd10,
  10. Alessandro Santo Bortone11,
  11. Alberto Clerici12,
  12. Georg Delle-Karth13,
  13. Johannes Rieber14,
  14. Ciro Indolfi15,
  15. Massimo Mancone16,
  16. Loic Belle17,
  17. Alexander Lauten18,
  18. Martin Arnold19,
  19. Berto J Bouma20,
  20. Matthias Lutz21,
  21. Cornelia Deutsch22,
  22. Jana Kurucova23,
  23. Martin Thoenes24,
  24. Peter Bramlage22 and
  25. Norbert Frey21
  26. On behalf of the IMPULSE registry group
  1. 1Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
  2. 2University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  3. 3James Cook University Hospital, Middlesbrough, UK
  4. 4Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
  5. 5Cardiology Department, AKH Celle, Celle, Germany
  6. 6Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
  7. 7Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
  8. 8Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
  9. 9Department of Cardiology, Heart and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
  10. 10St Bartholomew's Hospital, London, UK
  11. 11University of Bari, Bari, Italy
  12. 12University of Turin, Turin, Italy
  13. 134th Medical Department, Hietzing Hospital, Vienna, Austria
  14. 14Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Germany
  15. 15Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Italy
  16. 16Sapienza University of Rome, Rome, Italy
  17. 17Centre Hospital d’Annecy, Annecy, France
  18. 18Department for Cardiology, Helios Erfurt Clinic, Erfurt, Germany
  19. 19Department of Cardiology, University of Erlangen, Erlangen, Germany
  20. 20University of Amsterdam, Amsterdam, Netherlands
  21. 21Department of Cardiology and Angiology, University of Kiel, Kiel, Germany
  22. 22Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
  23. 23Edwards Lifesciences, Prague, Czech Republic
  24. 24Edwards Lifesciences, Nyon, Switzerland
  1. Correspondence to Dr Peter Bramlage; peter.bramlage{at}


Aims There is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).

Methods Data from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age.

Results Overall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001).

Conclusions The present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.

  • transcatheter aortic valve replacement
  • aortic valve stenosis
  • endovascular procedures

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  • Contributors All authors have participated in the work. RPS, DM-Z, NF, JK, MT and PB were involved in the conception and design of the project. PB and RPS drafted the manuscript and all other authors revised the article for important intellectual content. All authors gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

  • Funding This work was supported by a research grant from Edwards Lifesciences (Nyon, Switzerland), awarded to the Sponsor, the Institute for Pharmacology and Preventive Medicine (IPPMed, Cloppenburg, Germany).

  • Competing interests PB is the representative of the IPPMed, Cloppenburg, Germany. NF, RPS and DM-Z have received honoraria for advisory board meetings and TKR speakers’ honoraria from Edwards Lifesciences. The institutions of these three and those of the remaining authors representing study centres have received funding for employing a study nurse. JK and MT are employees of the funder of this registry. As this is a disease registry, neither the type of intervention (SAVR, TAVI or medical management) nor on the valves to be used was pre-specified.

  • Patient consent for publication Not required.

  • Ethics approval The study was carried out in accordance with the Declaration of Helsinki and was approved by the independent ethical review board at each participating institution.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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