Sex Differences in the Management, Treatment, and Outcomes of Patients with Severe Primary Mitral Regurgitation

C. Waldron¹, M. Krane², A. Geirsson³, M. Mori^4
1Yale School of Medicine, New Haven, Connecticut ²Yale School of Medicine, Greenwich, Connecticut ³Yale University, New Haven, Connecticut ⁴Yale, Hamden, Connecticut

Purpose: Sex-based outcome differences in mitral valve (MV) disease exist, but the driver remains unclear1,2,3,4. Identifying the treatment phases where the disparity occurs is essential in devising a strategy to mitigate this disparity. We evaluated the sex-based difference among severe primary MR patients across treatment phases from diagnosis to intervention outcomes.

Methods: We conducted a retrospective cohort study of patients with new diagnoses of severe primary MR in the echocardiogram database in a healthcare network consisting of 10 inpatient and 440 outpatient sites between 2016-2020. Among the 70,510 echocardiograms performed in the study period, 391 had severe primary MR. We compared the incidence of evaluation by cardiac surgery service and 2-year survival of patients with severe primary MR between male and female patients. We also analyzed a subgroup meeting Class 1 indications for intervention in primary MR: symptomatic severe MR or severe asymptomatic MR with EF < 60% and LVESD > 40 mm5. Logistic regression models identified predictors associated with the likelihood of being evaluated by a multidisciplinary team.

Results: Among 391 patients with severe primary MR (median age 77 years [IQR 65, 85]; 46% female) with median follow-up of 730 days, women were older (79 vs. 76 years, p=0.004) and experienced higher 2-year mortality (39%, n=71 vs. 26%, n=55, p=0.005) than men. Prevalence of Class 1 indication was similar between men and women (79%, n=165 vs. 71%, n=127, p=0.07). Among 292 patients meeting Class 1 indications (median age 77 [66,85], 43% female), women were older (79 vs 76 years, p=0.008) and had higher STS risk scores for MV repair than men (2.9% [1.3%,8.6%] vs. 2.2% [0.9%,5.0%], p=0.01). Women were referred to surgical teams at a lower rate (62%, n=79 vs. 87%, n=144, p< 0.001) and were less likely to undergo intervention
(51%, n=54 Surgery, n=10 TEER vs. 75%, n=96 Surgery, n=24 TEER, p< 0.001). Median days-to-intervention since the index echocardiogram for women and men were 72 and 46, respectively. Women had higher 2-year mortality than men (33%, n=42 vs. 21%, n=35, p=0.02). On multivariable model, female sex and older age were associated with lower odds of undergoing multidisciplinary evaluation among patients meeting Class 1 indication (OR: 0.3, 95% CI 0.14,0.63, p=0.002; OR: 0.94, 95% CI 0.9,0.97, p< 0.001, respectively).

Conclusion: Compared with men, women with severe primary MR with Class 1 indication for intervention were less likely to receive HT evaluation, less likely to undergo MV intervention, had longer interval to intervention among those treated, and had worse overall survival. Sex-based disparities in MV disease exist across broad treatment phases.

Identify the source of the funding for this research project: NA