Sex Disparities in Concomitant Tricuspid Valve Repair at the Time of Mitral Valve Surgery

C. Wagner¹, W. Fu², J. Woodford², C. Green², J. Proebstle², G. Pawar³, T. Ravi², D. Ahmetovic², D. Likosky⁴, R. Hawkins², M. Romano⁴, G. Ailawadi⁵, S. Bolling^6
1University of Michigan, Ypsilanti, Michigan ²University of Michigan, Ann Arbor, Michigan ³University of Michigan, Haslett, Michigan ⁴University of Michigan Medical Center, Ann Arbor, Michigan ⁵The University of Michigan Cardiovascular Center, Ann Arbor, Michigan ⁶University of Michigan Hospital, Ann Arbor, Michigan

Purpose: Guidelines recommend tricuspid valve repair at the time of mitral valve surgery for moderate or worse tricuspid regurgitation (TR). Given sex disparities in cardiac surgical care, the purpose of this analysis was to evaluate potential sex disparities in concomitant tricuspid valve procedures.

Methods: All adult patients undergoing mitral valve surgery for degenerative mitral valve disease, excluding concomitant aortic procedures, VAD, and myectomy, at a single, high-volume center from 2014-2023 were identified. Patients with previous tricuspid intervention or mild or less preoperative TR were excluded. Multivariable logistic regression, controlling for age, comorbidities (BMI, hypertension, diabetes, creatinine, prior stroke, lung disease, liver disease, tobacco use, urgent procedure, redo surgery), ejection fraction, and severity of preoperative TR was performed to risk adjust and identify predictors of concomitant tricuspid procedure. Risk-adjusted rate of concomitant tricuspid procedure was compared by sex. Next, among patients with TR who did not undergo tricuspid intervention at the time of mitral valve surgery, a composite outcome including development of severe TR or reoperation for tricuspid valve disease was evaluated. Time to event analysis compared development of the composite outcome by sex.

Results: Of 1,665 patients undergoing surgery for degenerative MR, 388 patients (female: 55%, n=214) had moderate or severe TR. The median age for the cohort was 73 (IQR 65, 79). The median predicted PROM for the entire cohort was 1.6% (IQR 0.7%, 3.3%), and was 1.4% (IQR 0.7%, 3.6%) for females and 1.8% (IQR 0.8%, 3.1%) (p=0.605) for males. Severity of preoperative TR was similar by sex, including 73% (283) of patients with moderate TR and 27% (105) with severe TR. Unadjusted rate of concomitant tricuspid procedure was 57% (122/214) for females and 73% (127/174) for males (p < 0.001). New permanent pacemaker occurred in 5% (9/196) of females and 6% (9/150) of males (p=0.649). After risk adjustment, females had 48% lower odds of concomitant tricuspid repair compared to males (ORadj 0.52 95% CI 0.21-0.86, p=0.011) (Table). Among patients who did not undergo concomitant tricuspid intervention at the time of mitral valve surgery, at four years 0% of males and 15% (95% CI 6%-35%) of females had severe TR or required reoperation for tricuspid valve disease (p=0.049) (Figure).

Conclusion: Despite similar severity of TR, males were more likely to receive concomitant tricuspid valve repair at the time of mitral valve surgery, a disparity that persisted after risk adjustment. Moreover, females were more likely to progress to severe TR or need reoperation for tricuspid valve disease when not treated at the index operation. Tricuspid valve disease may be under-treated in females at the time of mitral valve surgery.

Identify the source of the funding for this research project: Institute for Healthcare Policy and Innovation, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor MI