Gender Differences in Long-Term Survival of Medicare Beneficiaries Undergoing Mitral Valve Operations

Vassileva, Christina M.; McNeely, Christian; Mishkel, Gregory; Boley, Theresa M.; Markwell, Stephen; Hazelrigg, Stephen R.

doi:10.1016/j.athoracsur.2013.04.055

Cited by 104 publications

(101 citation statements)

References 27 publications

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“…After adjustment for differences in baseline characteristics, operative mortality for mitral repair seemed similar between women and men, suggesting that this sex disparity might be largely because of worse preoperative profiles of women compared with men. 7 Longterm survival differences after mitral valve surgery based on sex have also been reported. A study by Seeburger et al 9 of 3761 patients undergoing minimally invasive mitral surgery reported 10-year survival of 58% for women compared with 72% for men.…”

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confidence: 99%

“…At the time of mitral valve surgery, women are also more likely to undergo concomitant surgery for atrial fibrillation and tricuspid intervention, presumably reflecting higher incidence of atrial fibrillation and tricuspid regurgitation-factors known to reflect more advanced disease. 6,7 The higher comorbid burden at presentation offers an explanation of the higher mortality in women undergoing mitral valve surgery compared with men. [6][7][8] Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) demonstrated that in patients aged between 40 and 59 years, women had 2.5 times higher riskadjusted mortality compared with men for isolated mitral valve operations.…”

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confidence: 99%

“…6,7 The higher comorbid burden at presentation offers an explanation of the higher mortality in women undergoing mitral valve surgery compared with men. [6][7][8] Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) demonstrated that in patients aged between 40 and 59 years, women had 2.5 times higher riskadjusted mortality compared with men for isolated mitral valve operations. The survival disadvantage seemed to diminish with age.…”

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confidence: 99%

“…When taking sex into account, mitral repair seemed to restore normal life expectancy for men but not for women, and this might help explain the higher observed long-term mortality. 7 Lower mitral repair rates for women have been documented across multiple data sources, including the Nationwide Inpatient Sample database, the Medicare database, and the STS ACSD. 6,7,10 Considering the established superiority of mitral repair over replacement, addressing the lower likelihood of women to receive mitral repair compared with men represents an important opportunity in quality of care initiatives aimed at eradicating healthcare disparities.…”

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Mitral Valve Surgery in Women

McNeely

Vassileva

2016

Circ: Cardiovascular Quality and Outcomes

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S94S ex differences in outcomes have been noted in many areas of cardiovascular medicine. In mitral valve surgery, this topic is particularly important because in appropriately selected patients, mitral valve repair restores normal life expectancy, which cannot be said for other cardiac surgical operations. Current literature is replete with evidence supporting continued sex inequality in the detection and treatment of mitral valve disease. Women, although just as likely to have significant MR, are less likely to receive surgery than men, and when they do, they have worse observed outcomes after their operation. When women are referred for surgery, they typically present with more comorbidities and later in the disease process and have a lower likelihood of receiving mitral repair, the superiority of which over replacement has been firmly established for degenerative disease. 1,2There is no established medical therapy for degenerative mitral regurgitation (MR), and surgery remains the gold standard for severe MR associated with symptoms and ventricular dysfunction.3 Longstanding MR leads to many untoward consequences, including ventricular dysfunction, left atrial enlargement, development of secondary atrial fibrillation, pulmonary hypertension, and tricuspid regurgitation, and if left untreated, it inevitably leads to decompensated heart failure. 4 Late referral to surgery does not always reverse these negative sequela. It is, therefore, important that this condition is detected early to prevent these untoward consequences and provide patients with the full benefit of their operation. 5Significant differences are noted in the baseline characteristics of women versus men presenting for mitral valve surgery. Women present at an older age, with excess comorbidity burden, including higher incidence of preoperative transient ischemic attack/stroke, atrial fibrillation, heart failure, respiratory failure, anemia, and others, and are more likely than men to have an urgent operation. At the time of mitral valve surgery, women are also more likely to undergo concomitant surgery for atrial fibrillation and tricuspid intervention, presumably reflecting higher incidence of atrial fibrillation and tricuspid regurgitation-factors known to reflect more advanced disease.6,7 The higher comorbid burden at presentation offers an explanation of the higher mortality in women undergoing mitral valve surgery compared with men.6-8 Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) demonstrated that in patients aged between 40 and 59 years, women had 2.5 times higher riskadjusted mortality compared with men for isolated mitral valve operations. The survival disadvantage seemed to diminish with age.8 In a study of 47 602 Medicare beneficiaries with isolated mitral valve surgery, we demonstrated higher operative mortality for women compared with men (7.7% versus 6.1%; P<0.0001), and this was true both for the subset undergoing repair (4.2% versus 3.5%; P=0.0112) and replacement (9.3% versus 8.2%; P=0.001...

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Mitral Valve Surgery in Women

McNeely

Vassileva

2016

Circ: Cardiovascular Quality and Outcomes

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“…Another possible influencing factor could be the gender distribution: The higher number of females in group II might influence the force values: several studies about contractility and calcium sensitivity illustrate greater tension and higher calcium sensitivity [27,28]. A gender dependent impact on the extent of mitral prolapse was demonstrated by Avierinos et al [9], who found that female patients more often have anterior prolapse and more leaflet thickening and therefore lower regurgitation grades and higher ejection fraction.…”

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confidence: 96%

Contractile Properties of the Right Atrial Myofilaments in Patients with Myxomatous Mitral Valve Degeneration

Sikand¹,

Bening²,

Conzelmann³

et al. 2015

Thorac cardiovasc Surg

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Background: Myxomatous degeneration of the mitral valve is a common pathological finding in mitral valve surgery and the most common reason for severe mitral valve regurgitation. Considering the importance of right ventricular remodeling and global function after mitral valve surgery we tried to elucidate a possible association of myxomatous mitral valve and impairment of right atrial and ventricular function, which might have an impact on global ventricular performance after mitral valve surgery. Methods: Right atrial tissue was harvested from 47 patients undergoing mitral valve surgery. We took the trabeculae from the right auricle, which was resected at the right auricle for implementation of extracorporal circulation. The tissue was skinned and prepared in a 24 h-lasting procedure to create small fibers for hinging them in the "muscle machine", an experimental set-up, created for pCa-force measurements. Results: Patients without myxomatous mitral valve developed significantly more force (4.0 mN ± 0.8 mN) at the highest step of calcium concentration compared to 2.7 mN ± 0.4 mN in group of patients with myxomatous valve degeneration (p 0.03). Calcium sensitivity in the myxomatous valve group was at pCa 6.0 and in the non-myxomatous group at pCa 5. Furthermore we observed a significant difference in ejection fraction (EF) among the groups: 49% in the non-myxomatous group versus 57% in the myxomatous group (p 0.03). In the non-myxomatous group 5 patients had diastolic dysfunction grade I-II (22,7%), in group I 10 patients (40%). This was also significant (p 0.04). Conclusions: Patients with myxomatous mitral valve degeneration seem to have reduced force capacities. Calcium sensitivity is higher compared to the non-myxomatous group, which might be a compensatory mechanism to cover the physiological demand. Furthermore we suggest a higher incidence of diastolic dysfunction in patients with myxomatous mitral valve degeneration, which might have an impact on ventricular remodeling after mitral valve surgery.

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Failure to Rescue Female Patients Undergoing High-Risk Surgery

Wagner,

Joynt Maddox,

Ailawadi

et al. 2024

JAMA Surg

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ImportanceFemale patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death—so-called failure to rescue.ObjectiveTo evaluate sex differences in failure to rescue across high-risk surgical procedures.Design, Setting, and ParticipantsThis retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024.ExposuresThe primary exposure was patient sex.Main Outcomes and MeasuresThe primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test.ResultsA total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P &lt; .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P &lt; .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P &lt; .001). A similar pattern was observed when stratified by each procedure.Conclusions and RelevanceIn this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients’ complications postoperatively may narrow the sex disparity after high-risk surgery.

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Gender Differences in Long-Term Survival of Medicare Beneficiaries Undergoing Mitral Valve Operations

Cited by 104 publications

References 27 publications

Mitral Valve Surgery in Women

Mitral Valve Surgery in Women

Contractile Properties of the Right Atrial Myofilaments in Patients with Myxomatous Mitral Valve Degeneration

Failure to Rescue Female Patients Undergoing High-Risk Surgery

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