Jérémy Bernard, MSc: No financial relationships to disclose
Background: There is few data on sex-differences in outcomes of degenerative mitral regurgitation (DMR) following surgery. We aimed to assess sex-related differences in presentation, treatment, short- and long-term outcomes of patients undergoing surgery for DMR and to analyze the interaction between sex and type of surgical procedure (i.e., mitral valve replacement [MVR] versus mitral valve repair [MVr]) with regards to postoperative outcomes.
METHODS AND RESULTS: Pre-, intra-, and post-operative clinical and echocardiographic data of consecutive DMR patients treated surgically with MVr or MVR at IUCPQ-UL between 2002 and 2019 were analyzed. To account for differences in baseline characteristics between men and women, an inverse probability weighting (IPW) estimation was used within each type of surgical procedure. The study endpoints were short-term postoperative (i.e., ≤30-days) adverse events and long-term all-cause mortality.
Of the 1,804 patients included in the study, 661 (37%) were women. Women presented more frequent preoperative atrial fibrillation (AF), higher values of brain natriuretic peptides, larger indexed left atrial, left ventricular (LV) end-diastolic and end-systolic dimensions, higher pulmonary pressure, and were more symptomatic (all p≤0.006). Women were however less frequently referred to surgery for Class I guideline-based indications (i.e., symptoms and LV dysfunction/dilation) but more for new onset of AF or pulmonary hypertension and early surgery (all p≤0.03). After IPW adjustment, women were at higher risk of early postoperative stroke (odds ratio [95% confidence interval (CI)]: 2.78 [1.59–4.87], p=0.002). Women presented higher long-term mortality compared to men when treated by MVr (IPW-hazard ratio [95% CI]: 1.68 [1.49-1.90], p< 0.001), but lower mortality (0.74 [0.65-0.84], p< 0.001) when treated by MVR (Figure). Subsequent analyses stratifying patients according to concomitant procedures (e.g., coronary artery bypass grafting) confirmed the higher risk of long-term mortality for women with MVr but not with MVR (all p≤0.03). Independent predictors of long-term mortality were the presence of mitral annulus calcification for men in both MVr and MVR, and DMR severity and LV ejection fraction for women in MVr and MVR, respectively (all p≤0.04).
Conclusion: In this large series of patients with DMR patients treated surgically, women present with a worse preoperative risk profile and display a higher risk of stroke following surgery compared to men. Women were at higher risk of long-term mortality compared to men when treated by MVr, but not when treated by MVR.
