Mitral Valve Surgery in Women: Another Target for Eradicating Sex Inequality

Sex-Related Differences in Patients with Mitral Regurgitation Undergoing Mitral Valve Surgery: A Propensity Score-Matched Study

Background/Objectives: Sex-related differences in the presentation and outcomes of patients with mitral regurgitation (MR) undergoing mitral valve (MV) surgery remain unclear. We aimed to identify these differences to inform personalized management. Methods: A total of 143 consecutive patients undergoing surgery for MR between 2017 and 2018 were stratified by sex and assessed for differences in characteristics. We performed 1:1 propensity score matching (PSM) by sex, with baseline characteristics as covariates, yielding 38 comparable pairs which were analyzed for differences in all-cause mortality and post-operative length of stay (LOS). Results: Females (n = 67) were more symptomatic (NYHA Class ≥ 3: 73% vs. 45%, p < 0.001), had higher logistic EuroSCORE (5.5 vs. 3.9, p = 0.006), had more urgent operations (25% vs. 11%, p = 0.020), MV replacements (28% vs. 11%, p = 0.007), and secondary MR (43% vs. 16%, p < 0.001). Females had significantly smaller end-diastolic and end-systolic left ventricular (LV) diameters, though indexed diameters showed no significant differences. After PSM, females had significantly longer LOS (7 days vs. 9 days, p = 0.033) and no differences in long-term mortality (hazard ratio [HR]: 1.25, 95% confidence interval [CI]: 0.34-4.76, p = 0.7, median follow-up: 6.67 years). An indexed LV end-systolic diameter (LVESDi) > 19 mm/m2 yielded greater specificity (46.0% vs. 26.7%) and comparable sensitivity (69.4% vs. 69.2%) to LVESD > 40 mm. In subgroup analyses, female patients undergoing concomitant tricuspid intervention (HR: 6.80 [1.63-37.92], p < 0.01) or urgent operation (HR: 4.85 [1.08-21.06], p = 0.04) had worse prognoses than males. Conclusions: Females undergoing MV surgery for MR had more symptoms, higher surgical risk, and longer LOS, but similar mortality compared to males. However, concomitant tricuspid intervention and urgent operations were associated with higher mortality. Our results add to the growing body of evidence that current non-indexed LV diameter thresholds may not adequately account for sex differences.

Degenerative mitral regurgitation due to flail leaflet: sex-related differences in presentation, management, and outcomes

BACKGROUND AND AIMS

Presentation, outcome, and management of females with degenerative mitral regurgitation (DMR) are undefined. We analysed sex-specific baseline clinical and echocardiographic characteristics at referral for DMR due to flail leaflets and subsequent management and outcomes.

METHODS

In the Mitral Regurgitation International Database (MIDA) international registry, females were compared with males regarding presentation at referral, management, and outcome (survival/heart failure), under medical treatment, post-operatively, and encompassing all follow-up.

RESULTS

At referral, females (n = 650) vs. males (n = 1660) were older with more severe symptoms and higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality vs. expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27-1.65), P < .001] but was higher in females [SMR 2.00 (1.67-2.38), P < .001]. Female sex was independently associated with mortality [adjusted hazard ratio (HR) 1.29 (1.04-1.61), P = .02], cardiovascular mortality [adjusted HR 1.58 (1.14-2.18), P = .007], and heart failure [adjusted HR 1.36 (1.02-1.81), P = .04] under medical management. Females vs. males were less offered surgical correction (72% vs. 80%, P < .001); however, surgical outcome, adjusted for more severe presentation in females, was similar (P ≥ .09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality vs. expected [SMR 1.31 (1.16-1.47), P < .001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85-0.99), P = .036].

CONCLUSIONS

Females with severe DMR were referred to tertiary centers at a more advanced stage, incurred higher mortality and morbidity under conservative management, and were offered surgery less and later after referral. Ultimately, these sex-related differences yielded persistent excess mortality despite surgery in females with DMR, while males enjoyed restoration of life expectancy, warranting imperative re-evaluation of sex-specific DMR management.

Gender and Sex Differences in the Management, Intervention, and Outcomes of Patients With Severe Primary Mitral Regurgitation

BACKGROUND

Gender- and sex-based disparities in mitral valve disease exist; however the factors associated with these differences are unknown. Identifying these differences is essential in devising mitigating strategies. We evaluated gender and sex differences among patients with severe primary mitral regurgitation (MR) across treatment phases.

METHODS AND RESULTS

We conducted a retrospective cohort study of patients with new diagnoses of severe primary MR between 2016 and 2020. We compared multidisciplinary evaluation incidence and 2-year survival between men and women. We analyzed a subgroup meeting class 1 indications for intervention, which includes severe symptomatic MR or severe asymptomatic MR with ejection fraction <60% or left ventricular end-systolic diameter >40 mm. Logistic regression models identified predictors associated with the likelihood of multidisciplinary evaluation. Among 330 patients meeting class 1 indications, women were older (79 versus 76 years, P=0.01) and had higher Society of Thoracic Surgeons risk scores for mitral valve repair than men (2.5% versus 1.4%, P=0.003). Women were less likely to undergo multidisciplinary evaluation (57% versus 84%, P<0.001) and intervention (47% versus 69%, P<0.001) than men. Median days to intervention for women and men were 77 and 43, respectively. Women had a higher 2-year mortality rate than men (31% versus 21%, P=0.035). On a multivariable model, female sex and older age were associated with lower odds of undergoing multidisciplinary evaluation (odds ratio, 0.26; P<0.001; odds ratio, 0.95; P<0.001, respectively).

CONCLUSIONS

Women with severe primary MR with class 1 indication for intervention were less likely to undergo multidisciplinary evaluation and intervention and had a longer interval to intervention than men. Survival was comparable after accounting for age and comorbidity differences.

Sex Differences in Epidemiological Distribution and Outcomes of Surgical Mitral Valve Disease

BACKGROUND

Mitral valve (MV) disease is the most common form of valvular heart disease. Findings that indicate women have a higher risk for unfavorable outcomes than men remain controversial. This study aimed to determine the sex-based differences in epidemiological distributions and outcomes of surgery for MV disease.

METHODS AND RESULTS

Overall, 18,572 patients (45.3% women) who underwent MV surgery between 2001 and 2018 were included. Outcomes included in-hospital death and all-cause mortality during follow up. Subgroup analysis was conducted across different etiologies, including infective endocarditis (IE), degenerative, ischemic, and rheumatic mitral pathology. The overall MV repair rate was lower in women than in men (20.5% vs. 30.6%). After matching, 6,362 pairs (woman : man=1 : 1) of patients were analyzed. Women had a slightly higher risk for in-hospital death than men (10.8% vs. 9.8%; odds ratio [OR]: 1.11, 95% confidence interval [CI]: 0.99-1.24; P=0.075). Women tended to have a higher incidence of de novo dialysis (9.8% vs. 8.6%; P=0.022) and longer intensive care unit stay (8 days vs. 7.1 days; P<0.001). Women with IE had poorer in-hospital outcomes than men; however, there were no sex differences in terms of all-cause mortality.

CONCLUSIONS

Sex-based differences of MV intervention still persist. Although long-term outcomes were comparable between sexes, women, especially those with IE, had worse perioperative outcomes than men.

Considerations & challenges of mitral valve repair in females: diagnosis, pathology, and intervention

PURPOSE OF REVIEW

Disparities in mitral valve (MV) repair outcomes exist between men and women. This review highlights sex-specific differences in MV disease aetiology, diagnosis, as well as timing and type of intervention.

RECENT FINDINGS

Females present with more complicated disease: anterior or bileaflet prolapse, leaflet dysplasia/thickening, mitral annular calcification, and mixed mitral lesions. The absence of indexed echocardiographic mitral regurgitation (MR) severity parameters contributes to delayed intervention in women, resulting in more severe symptom burden at time of surgery. The sequelae of chronic MR also necessitate concomitant procedures (e.g. tricuspid repair, arrhythmia surgery) at the time of mitral surgery. Complex MV pathology, greater patient acuity, and more complicated procedures collectively pose challenges to successful MV repair and postoperative recovery. As a consequence, women receive disproportionately more MV replacement than men. In-hospital mortality after MV repair is also greater in women than men. Long-term outcomes of MV repair are comparable after risk-adjustment for preoperative status; however, women experience a greater incidence of postoperative heart failure.

SUMMARY

To address the inequity in MV repair outcomes between sexes, indexed diagnostic measurements, diligent surveillance of asymptomatic MR, increased recruitment of women in large clinical trials, and mandatory reporting of sex-based subgroup analyses are recommended.

Contemporary socioeconomic-based disparities in cardiac surgery: Are we closing the disparities gap?

OBJECTIVE

Female sex and lower income residence location are associated with worse health care outcomes. In this study we analyzed the national, contemporary status of socioeconomic disparities in cardiac surgery.

METHODS

Adult patients within the Nationwide Readmissions Database who underwent coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve (MV) replacement, MV repair, or ascending aorta surgery from 2016 to 2018 were included. Sex and median household income quartile (MHIQ) were compared within each surgery group. Primary outcome was 30-day mortality. Multivariable analysis was adjusted for patient characteristics and hospital-level factors.

RESULTS

A weighted total of 358,762 patients were included. Fewer women underwent CABG (22.3%), SAVR (32.2%), MV repair (37.5%), and ascending aorta surgery (29.7%). In adjusted analysis, female sex was independently associated with higher 30-day mortality rates after CABG (adjusted odds ratio [aOR], 1.6), SAVR (aOR, 1.4), MV repair (aOR, 1.8), and ascending aorta surgery (aOR, 1.2; all P < .03). The lowest MHIQ was independently associated with higher 30-day mortality rates after CABG (aOR, 1.4), SAVR (aOR, 1.5), MV replacement (aOR, 1.3), and ascending aorta surgery (aOR, 1.8; all P < .004) compared with the highest quartile. Women were less likely to receive care at urban and academic hospitals for CABG compared with men. Patients of lower MHIQ received less care at urban and academic institutions for all surgeries.

CONCLUSIONS

Despite advances in the techniques and safety, women and patients of lower socioeconomic status continue to have worse outcomes after cardiac surgery. These persistent disparities warrant the need for root cause analysis.

Impact of Gender on Mortality After Transcatheter Edge-to-Edge Repair for Functional Mitral Regurgitation

Recent studies suggested short-term mortality after transcatheter edge-to-edge repair (TEER) was comparable between men and women. However, the gender-specific prognostic difference in the long-term follow-up after TEER is still unknown. To evaluate the impact of gender on long-term mortality after TEER for functional mitral regurgitation (FMR) using multicenter registry data. We retrospectively analyzed 1,233 patients (male 60.3%) who underwent TEER for FMR at 24 centers. The impact of gender on all-cause death and hospitalization for heart failure (HF) after TEER was evaluated using multivariate regression analysis and propensity score (PS) matching methods. During the 2-year follow-up, 207 all-cause death and 263 hospitalizations for HF were observed after TEER for FMR. Men had a significantly higher incidence of all-cause death than women (18.6% vs 14.1%, log-rank p = 0.03). After adjustment by multivariate Cox regression and PS matching, the male gender was significantly associated with a higher incidence of all-cause mortality after TEER than the female gender (hazard ratio 2.11, 95% confidence interval 1.42 to 3.14 in multivariate Cox regression; hazard ratio 1.89, 95% confidence interval 1.03 to 3.48 in PS matching). The gender-specific prognostic difference was even more pronounced after 1-year of TEER. On the contrary, there was no gender-related difference in hospitalization for HF after TEER. In conclusion, women with FMR had a better prognosis after TEER than men, whereas this was not observed in hospitalization for HF. This result might indicate that women with FMR are more likely to benefit from TEER.

Heart valve disease gender difference in the era of transcatether treatment

Available data have demonstrated important sex-related differences in patients with valvular heart  disease, regarding clinical presentation, treatment, and outcomes. Although the calcific aortic  stenosis (AS) is more frequent in men compared to women, the majority of AS patients over 80  years old are women, in whom fibrotic remodeling of aortic valve is typically found. Mitral valve  disease is more common in women. However females are under-referred or delayed referrals to  treatment, probably due to the absence of sex-based LV dimension values guiding surgical timing.  The development of transcatheter devices have revolutionized the treatment of valvular heart disease and increased the interest in this topic. In this context, the consideration of gender differences in presentation, diagnosis, treatment success, and prognosis is of great importance.    

Does sex impact outcomes after mitral valve surgery? A systematic review and meta-analysis

Background and objective:

The published literature investigating the impact of sex on outcomes after mitral valve (MV) surgery has demonstrated inferior outcomes for females over males. However, the true relationship between sex and outcomes after MV surgery continues to be poorly understood.

Materials:

PubMed, Medline, and Embase were systematically searched for articles published from 1 January 2005 to 1 August 2021. This systematic review included retrospective and prospective studies investigating the relationship between sex and outcomes after MV surgery. In all, 2068 articles were initially screened and 12 studies were included in this review.

Results:

Few studies were adequately powered or structured to investigate this topic. Few studies propensity matched patients or isolated for surgical approach. In individual studies, females experienced increased rates of short-term and long-term mortality and increased 1-year mortality in the pooled data. Males experienced increased rates of required pacemaker insertion. The remaining rates of morbidity and mortality did not differ significantly between males and females.

Conclusions:

This review identified increased rates of 1-year mortality in the pooled data for females, while males had increased rates of pacemaker insertion. Despite this, the absence of propensity matching and isolating for surgical approach has introduced confounding variables that impair the ability of the included studies to interpret the results found in the current literature. Studies isolating for surgical approach, propensity matching patients, and examining outcomes with long-term follow-up are required to elucidate the true nature of this relationship.

Sex Related Differences in Transcatheter Mitral Valve Repair: A Systematic Review and Meta-analysis

OBJECTIVE

Inequalities in postoperative outcomes between males and females are well described with females often experiencing inferior outcomes after heart valve surgery. Recent literature has demonstrated equivalent or improved outcomes for females after transcatheter aortic valve replacement. Transcatheter mitral valve repair (TMVr) and replacement (TMVR) is a relatively newer field with significantly less literature comparing sex differences. This systematic review and meta-analysis looks to provide a comprehensive summary of the published literature comparing outcomes between males and females undergoing transcatheter MV interventions.

METHODS

PubMed, Medline, and Scopus were systematically searched for all studies comparing outcomes between males and females undergoing TMVr and TMVR. 2,178 English manuscript titles and abstracts were reviewed. Articles were excluded if data was not provided regarding sex differences, transcatheter MV intervention, full-length text was not accessible, or if insufficient data was provided. 2,170 articles were excluded and 8 articles were included in this study.

RESULTS

Pooled estimates of outcomes demonstrated rates of acute kidney injury [OR 1.28 (95% CI, 1.14-1.44; p<0.0001)] favored females while rates of major bleeding favored males [OR 0.85 (95% CI 0.76-0.96; p=0.01)]. Rates of mortality, postoperative MI, and stroke did not differ significantly.

CONCLUSION

A trend has emerged in heart valve interventions with males tending to have improved outcomes after surgical intervention and females experiencing equivalent or improved outcomes after transcatheter interventions. This meta-analysis identified increased rates of acute kidney injury for males, increased rates of major bleeding for females, and otherwise comparable morbidity and mortality in males and females undergoing TMVr.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.

Sex Differences and Similarities in Valvular Heart Disease

As populations age worldwide, the burden of valvular heart disease has grown exponentially, and so has the proportion of affected women. Although rheumatic valve disease is declining in high-income countries, degenerative age-related causes are rising. Calcific aortic stenosis and degenerative mitral regurgitation affect a significant proportion of elderly women, particularly those with comorbidities. Women with valvular heart disease have been underrepresented in many of the landmark studies which form the basis for guideline recommendations. As a consequence, surgical referrals in women have often been delayed, with worse postoperative outcomes compared with men. As described in this review, a more recent effort to include women in research studies and clinical trials has increased our knowledge about sex-based differences in epidemiology, pathophysiology, diagnostic criteria, treatment options, outcomes, and prognosis.

Gender differences in primary mitral regurgitant volumes at specific regurgitant fractions as assessed by magnetic resonance imaging

Guidelines suggest using a regurgitant fraction of 50% and regurgitant volume of 60 ml for determination of severe mitral insufficiency. Recent MRI data has suggested that a regurgitant fraction of 40% defines severe primary mitral insufficiency. We sought to determine whether there were gender differences in primary mitral regurgitant volumes for regurgitant fractions of 40% and 50%. A database search identified 394 patients that had MRI with a mitral regurgitant volume ≥ 10 ml or a study indication of mitral insufficiency. Chart review identified 97 patients with primary mitral insufficiency. Of these patients, 53 (54%) were women. Men had significantly larger left ventricular volumes, myocardial mass, stroke volumes and mitral regurgitant volumes (37 ± 25 ml vs. 24 ± 12 ml). The difference in regurgitant fraction between genders was not significant (27 ± 14% vs. 24 ± 11%; p-value = 0.24). Regurgitant fraction and regurgitant volume had a strong linear correlation in both men (r = .95) and women (r = .92). Despite similar linear correlations, the slope-intercept equations differed significantly between men and women (p < .001). A regurgitant fraction of 40% correlated with a regurgitant volume of 59 ml in men and 39.5 ml in women, while a regurgitant fraction of 50% correlated with a regurgitant volume of 76.2 ml in men and 49.6 ml in women. Regurgitant fraction, determined by cardiac MRI, provides a gender independent assessment of primary mitral insufficiency, and suggests that regurgitant volume thresholds for severe primary mitral insufficiency may be lower in women.

Sex and Race Differences in the Pathophysiology, Diagnosis, Treatment, and Outcomes of Valvular Heart Diseases

Valvular heart diseases have long been considered to be similar in men and women and across races/ethnicities. Recently, studies have demonstrated major differences between sexes. Unfortunately, studies on valvular heart diseases, as on other cardiovascular diseases, are mostly performed in Caucasian men or in cohorts with a vast majority of Caucasian men. Therefore, our knowledge on valvular diseases in women and non-Caucasians remains limited. Nevertheless, aortic stenosis has been shown to be almost as prevalent in women as in men, and less prevalent in African Americans. Men appear to have a more calcified aortic valve lesion, and women tend to have a more fibrosed one. Primary mitral regurgitation is more frequent in women who have more rheumatic and Barlow etiologies, whereas men have more fibroelastic deficiency and posterior leaflet prolapse/flail. Left ventricular remodelling due to valvular heart diseases is sex related in terms of geometry and probably also in composition of the tissue. Outcomes seem to be worse in women after surgical interventions and better than or equivalent to men after transcatheter ones. Regarding other valvular heart diseases, very few studies are available: Aortic regurgitation is more frequent in men, isolated tricuspid regurgitation more frequent in women. Rheumatic valve diseases are more frequent in women and are mostly represented by mitral and aortic stenoses. Many other sex/gender- and race/ethnic-specific studies are still needed in epidemiology, pathophysiology, presentation, management, and outcomes. This review aims to report the available data on sex differences and race specificities in valvular heart diseases, with a primary focus on aortic stenosis and mitral regurgitation.

Impact of sex on long-term outcomes following mitral valve repair

Introduction

Previous studies have identified inferior outcomes for women undergoing mitral valve (MV) surgery compared to men, although the cause of this discrepancy has not been identified. We look to isolate surgical approach to identify any impact that sex has on outcomes in order to better inform clinical decision making.

Materials and methods

In this propensity matched, retrospective, single-center study, outcomes were compared between males and females undergoing a MV repair between 2004 and 2018. The primary outcome was defined as mortality at any point in the follow-up period. Secondary outcomes included stroke, myocardial infarction (MI), repeat revascularization, complications arising from the initial procedure, and postoperative cardiac remodeling.

Results

A total of 188 males and 188 females were included after propensity matching. At a median follow up time of 7.6 years, there were 25 deaths in the male group (26.8%) and 23 in the female group (28.2%) (p = 0.771). There were no significant differences in MI, stroke, post-operative pacemaker insertion, or rehospitalization following MV repair. Left ventricular (LV) size for males was reduced from an initial 55.6 ± 7.3 mm to 49.9 ± 7.4 mm (p < 0.001), and for females from an initial 51.5 ± 7 mm to 46.9 ± 7.1 mm (p < 0.001). LV ejection fraction (LVEF) was reduced with a preoperative LVEF for males of 57.7% ± 8.9% and 53.7% ± 9.6% postoperatively (p = 0.002), and LVEF for females of 57.8% ± 9.1% preoperatively and 54.8% ± 9.2% postoperatively (p < 0.001). Left atrial (LA) volume was reduced from an initial 51 ± 22 ml/m2 to 43.7 ± 25.2 ml/m2 (p < 0.001), and 50.9 ± 19.2 ml/m2 to 44.2 ± 19.8 ml/m2 (p < 0.001), for males and females respectively. LA diameter was reduced for males from an initial 49.7 ± 9.7 mm to 47.3 ± 9.4 mm (p = 0.043), and from 48 ± 8.7 mm to 44.3 ± 9.1 mm for females postoperatively (p = 0.017).

Conclusions

Current literature demonstrates inferior outcomes for females when compared to males undergoing MV surgery with patients undergoing a variety of surgical approaches. The results of this study suggest that surgical intervention for a subset of patients, those undergoing repair of the MV, is safe and offers similar outcomes for males and females.

Mortality Due to Mitral Regurgitation Among Adults in the United States: 1999-2018

OBJECTIVE

To evaluate the nationwide trends in mortality due to mitral regurgitation (MR) among American adults from 1999 to 2018.

PATIENTS AND METHODS

Trends in mortality due to MR were assessed using retrospective cross-sectional analyses of nationwide mortality data from death certificates of all American residents between January 1, 1999, and December 31, 2018, using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Piecewise linear regression was used to evaluate the trends in the overall population and in subgroups.

RESULTS

Among 45,982 deaths due to MR during the study period, higher mortality rates were seen in older White females from the western United States. In 1999, the crude and age-adjusted mortality rates were 27.4 (95% CI, 26.3 to 28.4) and 27.5 (95% CI, 26.4 to 28.5) per 1,000,000 persons, respectively. By 2018, these rates declined to 18.0 (95% CI, 17.3 to 18.7) and 17.7 (95% CI, 17.0 to 18.4) per 1,000,000 persons, respectively (P<.001 for trend for both). Crude mortality rates declined from 1999 to 2012 (annual percentage change [APC], -4.1 (95% CI, -4.6 to -3.6) but then increased after 2012 (APC, 2.6 [95% CI, 0.8 to 4.4; P<.001 for change in trend]). The age-adjusted mortality rates declined from 1999 to 2012 (APC, -3.9 [95% CI, -4.4 to -3.4]) but subsequently increased after 2012 (APC, 1.4 [95% CI, -0.4 to 3.2; P<.001 for change in trend]). The observed decrease was consistent across age, sex, race, geographic region, and urbanization subgroups (P<.05 for all).

CONCLUSION

Mortality due to MR in American adults declined at an annual rate of approximately 4% until 2012 and has since then increased by about 1.5% annually. These mortality trends warrant further investigation.

Sex Disparity in Cardiovascular Disease Outcomes: Do Our Current Echocardiographic Reference Ranges Measure Up?

Reducing inequity in access to health care and disparity in health outcomes remain key objectives in cardiovascular medicine. Echocardiography is often the primary diagnostic tool used to detect cardiovascular disease (CVD), and relies on comparison with published reference ranges to appropriately detect pathology. Our understanding of the contribution of age, sex and ethnicity to quantification of cardiac size is improving, but cardiovascular disease management guidelines have yet to evolve. While recently, sex, age and ethnicity-specific reference values have been produced, treatment thresholds in many clinical guidelines do not differentiate between sexes. As a result, in order to reach management thresholds, women are often required to have more severe pathology. In order to reduce potential disadvantage to women, future research efforts should be directed to develop more personalised treatment approaches by identification of sex-appropriate management thresholds.

Sex-Based Differences in Outcomes After Mitral Valve Surgery for Severe Ischemic Mitral Regurgitation: From the Cardiothoracic Surgical Trials Network

OBJECTIVES

This study investigated sex-based differences in outcomes after mitral valve (MV) surgery for severe ischemic mitral regurgitation (SIMR).

BACKGROUND

Whether differences in outcomes exist between men and women after surgery for SIMR remains unknown.

METHODS

Patients enrolled in a randomized trial comparing MV replacement versus MV repair for SIMR were included and followed for 2 years. Endpoints for this analysis included all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE) (defined as the composite of death, stroke, hospitalization for heart failure, worsening New York Heart Association functional class or MV re-operation), quality of life (QOL), functional status, and percentage of change in left ventricular end-systolic volume index (LVESVI) from baseline through 2 years.

RESULTS

Of 251 patients enrolled in the trial, 96 (38.2%) were women. Compared with men, women had smaller LV volumes and effective regurgitant orifice areas (EROA) but greater EROA/left ventricular (LV) end-diastolic volume ratios. At 2 years, women had higher rates of all-cause mortality (27.1% vs. 17.4%, respectively; adjusted hazard ratio [adjHR]: 1.85; 95% confidence interval [CI]: 1.05 to 3.26; p = 0.03) and of MACCE (49.0% vs. 38.1%, respectively; adjHR: 1.58; 95% CI: 1.06 to 2.37; p = 0.02). Women also reported worse QOL and functional status at 2 years. There were no significant differences in the percentage of change over 2 years in LVESVI between women and men (adjβ: -10.4; 95% CI: -23.4 to 2.6; p = 0.12).

CONCLUSIONS

Women with SIMR displayed different echocardiographic features and experienced higher mortality and worse QOL after MV surgery than men. There were no significant differences in the degree of reverse LV remodeling between sexes. (Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation [Severe Ischemic Mitral Regurgitation]; NCT00807040).

Gender Differences in Postoperative Outcomes After Cardiac Surgery

Women presenting for cardiac surgery tend to be older and have hypertension, diabetes, and overweight or underweight body mass index than men. Despite improvements in surgical techniques and medications, women have increased risk for morbidity and mortality after multiple types of cardiac surgery. Women presenting for transcatheter aortic valve replacement are older and frailer than men, and have increased risk of intraoperative complications, but lower mortality at mid- and long-term ranges compared with men. Adherence to recovery and rehabilitation from cardiac surgery is challenging for women. Solutions should focus on increased family support, and use of group exercise and activities.

Sex Differences in Long-Term Survival After Major Cardiac Surgery: A Population-Based Cohort Study

Background

Little attention has been paid to the importance of sex in the long‐term prognosis of patients undergoing cardiac surgery.

Methods and Results

We conducted a retrospective cohort study of Ontario residents, aged ≥40 years, who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral, or tricuspid valve surgery between October 1, 2008, and December 31, 2016. The primary outcome was all‐cause mortality. The mortality rate in each surgical group was calculated using the Kaplan‐Meier method. The risk of death was assessed using multivariable Cox proportional hazard models. Sex‐specific mortality risk factors were identified using multiplicative interaction terms. A total of 72 824 patients were included in the study (25% women). The median follow‐up period was 5 (interquartile range, 3–7) years. The long‐term age‐standardized mortality rate was lowest in patients who underwent isolated CABG and highest among those who underwent combined CABG/multiple valve surgery. Women had significantly higher age‐standardized mortality rate than men after CABG and combined CABG/mitral valve surgery. Men had lower rates of long‐term mortality than women after isolated mitral valve repair, whereas women had lower rates of long‐term mortality than men after isolated mitral valve replacement. We observed a statistically significant association between female sex and long‐term mortality after adjustment for key risk factors.

Conclusions

Female sex was associated with long‐term mortality after cardiac surgery. Perioperative optimization and long‐term follow‐up should be tailored to younger women with a history of myocardial infarction and percutaneous coronary intervention and older men with a history of chronic obstructive pulmonary disease and depression.

Prognostic Value of Late Gadolinium Enhancement in Postoperative Morbidity following Mitral Valve Surgery in Rheumatic Mitral Stenosis

Myocardial fibrosis in rheumatic mitral stenosis (MS) is caused by chronic inflammatory process. Its occurrence may lead to hemodynamic problems, especially after cardiac surgery. Myocardial fibrosis predicts worse morbidity after cardiac surgery, notably in coronary heart disease and aortic valve abnormalities. However, this issue has not been explored yet among patients with rheumatic MS. The aim of the study was to investigate prognostic impact of myocardial fibrosis to postoperative morbidity after mitral valve surgery in patients with rheumatic MS. This is a prospectively enrolled observational study of 47 consecutive rheumatic MS patients. All patients had preoperative evaluation with cardiac magnetic resonance imaging (CMR) including late gadolinium enhancement (LGE) protocol for left ventricular myocardial fibrosis assessment prior to mitral valve surgery. All patients were followed during hospitalization period. Postoperative morbidities were defined as stroke, renal failure, and prolonged mechanical ventilation. This study involved 33 women (70.2%) and 14 men (29.8%) with a mean age of 46 ± 10 years. Preoperative myocardial fibrosis was identified in 43 patients (91.5%). Estimated fibrosis volume ranged from 0% to 12.8% (median 2.8%). Postoperative morbidities occurred in 11 patients (23.4%). Significant mean difference of myocardial fibrosis volume was observed between patients with and without morbidity after mitral valve surgery (5.97 ± 4.16% and 3.12 ± 2.62%, p  = 0.04). This significant association was allegedly influenced by different postoperative hemodynamic changes between the two groups. More extensive myocardial fibrosis is associated with postoperative morbiditiy after mitral valve surgery in patients with rheumatic MS.

Disparities in Cardiac Care of Women: Current Data and Possible Solutions

PURPOSE OF REVIEW

Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women.

RECENT FINDINGS

Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.

Impact of sex on short term in-hospital outcomes with transcatheter edge-to-edge mitral valve repair

BACKGROUND AND AIM OF THE STUDY

Transcatheter edge-to-edge mitral valve repair with the mitraclip device for treatment of severe mitral regurgitation has been shown to be an effective treatment. However, the impact of sex on in-hospital outcomes has not been studied on a large scale with "real-world" patients. The aim of this study was to assess for disparities of sex in patients treated with mitraclip.

MATERIALS AND METHODS

Data from the National Inpatient Sample (NIS) (2012 through 2014) using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 35.97 for transcatheter mitral valve repair was analyzed for this study. SAS 9.4 (SAS institute, Cary, NC) was used for univariate and multivariate analysis. Multivariate analysis was used to adjust for various confounders.

RESULTS

A total of 521 patients were identified that were treated with MitraClip, with 57.97% males (n=302) and 42.03% females (n=219). There was no significant difference in the primary outcome, in-hospital mortality between two sex [2.6% vs. 3.6%, p=0.43, Odds Ratio 1.62 (95% Confidence Interval, 0.50-5.28)]. After performing multivariate analysis, no difference in any secondary outcomes existed. Additionally, length of stay and median hospitalization cost was similar regardless of sex.

CONCLUSIONS

Analysis of this large database of patients undergoing treatment with MitraClip suggests that MitraClip in females is not associated with increased in-hospital mortality, morbidity, length of stay or cost. A prospective registry with excluded patients from the clinical trials needed to be fully access if sex disparities in patients being treated with MitraClip exist.