Mitral Valve Surgery in Women

Abstract

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...

Does sex impact outcomes after mitral valve surgery? A systematic review and meta-analysis

“…The etiology of this discrepancy in outcomes is still unclear with the following variables proposed—females are underrepresented in cardiovascular trials, present with VHD at an older age with more advanced disease, are with a worse preoperative risk profile, are referred for surgical intervention less often and/or later in the disease process, and are more likely to receive replacement than their male counterparts. 8 – 11,13,14,20,21,29,30,31 Therefore, determining whether the major risk factor for inferior outcomes following MV surgery is sex itself or the treatment that patients receive remains challenging. Large retrospective and prospective studies isolating for surgical approach, matching patients based on preoperative characteristics and comorbidities, and examining outcomes with long-term follow-up are required to elucidate this relationship.…”

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

“…5 Prior studies have hypothesized that differences in mitral valve morphology, complexity of lesions, timing of interventions, and comorbid conditions place female patients at a disadvantage at the time of surgery. 3 Although women are as likely to have significant mitral valve disease, they are less likely to receive surgery than male patients 6 and, when they do, operative mortality is higher among women undergoing mitral valve repair or replacement compared to men. 3 The purpose of this article was to identify preoperative, intraoperative, and postoperative risk factors for morbidity and mortality in a Brazilian female group of patients who underwent isolated mitral valve replacement, to obtain pertinent information regarding the current scenario in Brazil and contribute to a more gender-specific and individualized treatment of women.…”

“…12,15,17 On the other hand, participants of studies carried out in high-income countries are older, due to the predominance of degenerative and ischemic etiology of valve disease. 10,19 Studies have shown that mortality of cardiac surgery among women is higher than of their male counterparts, 3,5,6,11,[20][21][22] since women receive surgery late and usually have more severe preoperative conditions. 3,6,11,21,23 One of the possibilities for this fact is the use of cutoff points for echocardiographic variables without considering their body mass, which is generally lower than men's.…”

The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease

“…112 Similarly, in the presence of severe mitral regurgitation, delays in surgical intervention, and associated poorer outcomes can occur due to failure to index left ventricular enlargement to smaller body size of women. 113 Sudden cardiac death associated with mitral valve prolapse is more frequent in women with bileaflet prolapse, mitral annular disjunction, and frequent and repetitive premature ventricular contractions. 114,115 Mitral annulus calcification develops more often and more extensively in women and could lead rarely to degenerative mitral stenosis or regurgitation.…”