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Degenerative MR Due to Flail Leaflet According to Sex
Quick Takes
- Females are a minority of patients with degenerative mitral regurgitation (DMR) due to flail leaflet in tertiary centers and are referred at an older age, with more symptoms, and more often with HF and elevated pulmonary pressure.
- These differences in presentation and management culminate into major differences regarding total prognosis after referral including medical and postoperative outcome, as males enjoy normal life expectancy restoration, whereas females display persistent excess mortality and higher HF rates despite surgery.
- There is a need to apply the current guideline-based trend towards early surgery for DMR in both sexes, especially in females, to provide all DMR patients with optimized outcomes.
Study Questions:
What are the sex-specific baseline clinical and echocardiographic characteristics at referral for degenerative mitral regurgitation (DMR) due to flail leaflets and subsequent management and outcomes?
Methods:
The investigators compared females with males regarding presentation at referral, management, and outcome (survival/heart failure [HF]), under medical treatment, postoperatively, and encompassing all follow-up in the Mitral Regurgitation International Database (MIDA) international registry. Primary endpoints were mortality and HF under conservative treatment, after surgical correction of DMR and throughout follow-up including conservative and surgical management. The secondary endpoint was performance of mitral surgery during follow-up. Comparison between males and females used χ2 test (or Fisher exact test) and Student’s t-test (or Mann–Whitney test). Event incidence rates were estimated using Kaplan–Meier method. Univariable and multivariable Cox models allowed estimation of crude and adjusted hazard ratios (HRs) with 95% confidence interval (CI).
Results:
At referral, females (n = 650) versus males (n = 1,660) were older with more severe symptoms and had a higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality versus expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27–1.65), p < 0.001] but was higher in females [SMR 2.00 (1.67–2.38), p < 0.001]. Female sex was independently associated with mortality [adjusted HR 1.29 (1.04–1.61), p = 0.02], cardiovascular mortality [adjusted HR 1.58 (1.14–2.18), p = 0.007], and HF [adjusted HR 1.36 (1.02–1.81), p = 0.04] under medical management. Females versus males were less offered surgical correction (72% vs. 80%, p < 0.001); however, surgical outcome, adjusted for more severe presentation in females, was similar (p ≥ 0.09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality versus expected [SMR 1.31 (1.16–1.47), p < 0.001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85–0.99), p = 0.036].
Conclusions:
The authors report that 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.
Perspective:
This study conducted in US and European tertiary care centers shows considerable sex-specific differences in DMR presentation, management, and outcome. Females are a minority of patients with DMR due to flail leaflet in tertiary centers and are referred at an older age, with more symptoms and more often with HF and elevated pulmonary pressure. These differences in presentation and management culminate into major differences regarding total prognosis after referral including medical and postoperative outcome, as males enjoy normal life expectancy restoration, whereas females display persistent excess mortality and higher HF rates despite surgery. These data suggest a need to apply the current guideline-based trend towards early surgery for DMR in both sexes, especially in females, to provide all DMR patients with optimized outcomes.
Clinical Topics: Valvular Heart Disease, Mitral Regurgitation, Cardiac Surgery and VHD
Keywords: Mitral Valve Insufficiency, Sex Differentiation
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