Presentation and outcomes of women and men undergoing surgery for degenerative mitral regurgitation

OBJECTIVES

Degenerative mitral regurgitation is associated with heart failure, arrhythmia and mortality. The impact of sex on timing of surgical referral and outcomes has not been reported comprehensively. We examined preoperative status and surgical outcomes of male versus female degenerative mitral valve regurgitation patients undergoing surgery.

METHODS

We reviewed our institutional database for all patients undergoing surgery for degenerative mitral regurgitation between 2013 and 2021. Preoperative clinical and echocardiographic variables, surgical characteristics and outcomes were compared, and left atrial strain in available images.

RESULTS

Of 963 patients, 314 (32.6%) were female. Women were older (67 vs 64 years, P = 0.031) and more often had bileaflet prolapse (19.4% vs 13.8%, P = 0.028), mitral annular calcification (12.1% vs 5.4%, P < 0.001) and tricuspid regurgitation (TR; 31.8% vs 22.5%, P = 0.001). Indexed left ventricular end-diastolic and end-systolic diameters were higher in women, with 29.4 vs 26.7 mm/m2 (P < 0.001) and 18.2 vs 17 mm/m2 (P < 0.001), respectively, and left atrial conduit strain lower (17.6% vs, 21.2%, P = 0.001). Predicted risk of mortality was 0.73% vs 0.54% in men (P = 0.023). Women required mechanical circulatory support more frequently (1.3% vs 0%, P = 0.011), had longer intensive care unit stay (29 vs 26 h, P < 0.001), mechanical ventilation (5.4 vs 5 h, P = 0.036), and overall hospitalization (7 vs 6 days, P < 0.001). There was no difference in long-term reoperation-free survival (P = 0.35).

CONCLUSIONS

Women undergoing mitral valve repair are older and show indicators of more advanced disease with long-standing left ventricular impairment. Guidelines may need to be adjusted and address this disparity, to improve postoperative recovery times and outcomes.

Perioperative Management of Valvular Heart Disease in Patients Undergoing Non-Cardiac Surgery

Postoperative cardiovascular complications (either in a hospital or within 30 days after the operation) are among the most common problems with non-cardiac surgeries (NCSs). Pre-existing cardiac comorbidities add significant risk to the development of such complications. Valvular heart disease (VHD), a rather frequent cardiac comorbidity (especially in the elderly population), can pose serious life-threatening peri-/postoperative complications. Being familiar with the recommended perioperative management of patients with VHD or an implanted prosthetic heart valve who are scheduled for NCS is of great importance in daily clinical practice. Although recently published guidelines by the European Society of Cardiology (ESC) and the American College of Cardiology and American Heart Association (ACC/AHA) for the management of VHD and perioperative management of patients undergoing NCS addresses the mentioned problem, a comprehensive review of the guidelines that provides an easy-to-use summary of the recommendations and their similarities and differences is missing in the published literature. In this review article, we summarize all of the relevant important information based on the latest data published in both guidelines needed for practical decision-making in the perioperative management of patients with VHD or after valvular repair (with prosthetic heart valve) who are scheduled for NCS.

Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care?

Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.