Sex Matters, But to What Clinical Avail?

Abstract

Despite substantial advances in mechanical circulatory support, cardiac transplantation remains the “gold standard” treatment option for eligible patients with American Heart Association/American College of Cardiology class D end-stage heart failure. Transplant survival rates have progressively improved at all time points, with 55% of recipients now surviving 10 years after transplantation, despite an increase in donor and recipient age and comorbidity and greater recipient urgency. Survival has improved with every 5- to 10-year era, but most of the mortality aversion is in the first 6 to 12 months.1,2 Article see p 401 In this issue of Circulation: Heart Failure , Weiss and colleagues3 from The Johns Hopkins University, evaluated United Network for Organ Sharing data on all first US adult heart transplantations from 1998 to 2007 (n=18,240). The authors show that female recipients had marginally ( P =0.06) worse 5-year survival than male recipients (absolute increase risk of 3.6%; 11% higher risk-adjusted mortality). However, the overall better survival in male recipients was present only in male recipients of a male donor; by using multivariable Cox modeling, they found that male recipients of a female donor (FD/MR) were 15% more likely to die than male recipients of a male donor (MD/MR). Moreover, after the addition of propensity adjustment for the likelihood of receiving a same-sex donor, the FD/MR group was 20% more likely to die than those male recipients who received a same-sex donor. The survivals of donor/recipient sex-matched female (FD/FR) and male (MD/MR) recipients were statistically indistinguishable after multivariable adjustment (with and without propensity adjustment), but when considered together, donor-recipient sex mismatches (FD/MR and MD/FR) were 14% ( P <0.001) more likely to have died at 5 years than the sex-matched group (MD/MR and FD/FR). However, among female recipients alone, the multivariable propensity-adjusted analysis revealed no increase in the risk of …