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

Abstract

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).

Keywords: ischemic mitral regurgitation; mitral valve repair; mitral valve replacement; women.

Figure 1

Kaplan-Meier curves for all-cause death (Panel A) and major adverse cardiac and cerebrovascular events (Panel B) in women and men.

Figure 2

Proportion of treatment failures between women and men over 2 years after mitral valve surgery for severe ischemic mitral regurgitation. Treatment failure is defined as the composite of death, mitral valve reoperation, or recurrence of moderate or severe mitral regurgitation

Figure 3

Rates of death and New York Heart Association class from baseline through 2 years in women and men after mitral valve surgery for severe ischemic mitral regurgitation.

Central Illustration. Outcomes of women and men with severe ischemic mitral regurgitation undergoing mitral valve surgery.

Women with severe ischemic mitral regurgitation displayed features of more disproportionate mitral regurgitation despite smaller LV volumes and EROA. After mitral valve surgery, women were at significantly higher risk of mortality, adverse events and worse quality of life / functional status over 2 years. Such differences did not seem to be explained by a differential LV reverse remodeling between sexes. EROA: Effective Regurgitant Orifice Area; LV: Left Ventricle; LVEDV: Left Ventricular End-Diastolic Volume; QOL: Quality of Life..