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Sex-Specific Outcomes of Mitral Repair for Degenerative MR
Quick Takes
- In a large single-center, retrospective, cohort study of consecutive patients who underwent isolated mitral valve repair (MVr) for degenerative MR, the LV end-systolic diameter indexed to body surface area threshold associated with increased all-cause mortality risk is lower in women compared to men.
- Similarly, the mortality risk associated with decreasing LVEF is higher in women compared to men.
- These data support re-examination of guideline thresholds for intervention for degenerative MR with the potential implementation of sex-specific thresholds for LV size and systolic function.
Study Questions:
Does sex influence long-term mortality following mitral valve repair (MVr) for degenerative mitral regurgitation (MR) based on preoperative left ventricular (LV) systolic dimensions and ejection fraction (EF)?
Methods:
In a large single-center, retrospective, cohort study, consecutive patients who underwent isolated MVr for degenerative MR between 1994 and 2016 were screened. Echocardiographic parameters were obtained from the most recent study performed prior to surgery. Adjusted hazard ratios for the primary outcome measure of all-cause mortality were compared according to baseline LV end-systolic diameter (LVESD), LVESD indexed to body surface area (LVESDi), and LVEF for men and for women.
Results:
Among 4,589 patients, 1,825 (40%) were women and 2,764 (60%) were men. After a median follow-up of 7.4 years (interquartile range [IQR], 4.1-11.3) for women and 7.2 years (IQR, 3.9-11.1) for men, 344 (7.5%) patients died. Women and men had similar preoperative LVEF (59% vs. 59%, p = 0.167) and LVESD (3.3 cm vs. 3.4 cm, p = 0.124); however, women were more likely than men to have New York Heart Association (NYHA) class III-IV symptoms (37.6% vs. 23.2%, p < 0.001) and women had a larger LVESDi compared to men (1.9 cm/m2 vs. 1.7 cm/m2, p < 0.001). After adjusting for age, LVEF, NYHA class, year of surgery, and history of atrial fibrillation, diabetes mellitus, hypertension, and myocardial infarction, the all-cause mortality risk for women increased from the baseline hazard at an LVESD of 3.6 cm, whereas an inflection point for increased risk with LVESD was not evident for men. The risk of mortality for women increased at LVESDi 1.8 cm/m2 compared to 2.1 cm/m2 in men. Women and men had a similar mortality risk inflection point of LVEF 58%; however, mortality was higher among women as LVEF decreased.
Conclusions:
After MVr for degenerative MR, women have a higher risk of all-cause mortality at lower LVESD, LVESDi, and higher LVEF. The authors conclude that these results support consideration of sex-specific thresholds for LVESDi in surgical decision making for patients with severe MR.
Perspective:
Chamber size (including chamber size indexed to body surface area) is smaller and LVEF is higher in women compared to men, and cardiac remodeling is different in women and in men. However, current guidelines for intervention for severe MR use thresholds for LV size and systolic function (LVESV ≥40 mm, LVEF <60%) that are not sex specific; and women are less likely than men to meet class I surgical thresholds. This single-center, retrospective, cohort study found that the LVESDi threshold associated with increased mortality hazard after MVr is lower in women compared to men, and the mortality risk associated with decreasing LVEF is higher in women compared to men. As the authors suggest, these data support re-examination of guideline thresholds for intervention for degenerative MR with the potential implementation of sex-specific thresholds for LV size and systolic function.
Clinical Topics: Valvular Heart Disease, Mitral Regurgitation, Cardiac Surgery and VHD
Keywords: Heart Valve Diseases, Mitral Valve Insufficiency
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