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Sex Differences in Transcatheter Repair for Secondary Mitral Regurgitation
Quick Takes
- In this European cohort of 1,233 patients (36% women) undergoing transcatheter edge-to-edge repair for secondary mitral regurgitation from 2008-2018, procedural success was >90%, and 2-year survival was approximately 75% for both women and men.
- At the time of mitral valve repair, women were older and had less unfavorable LV remodeling than men.
- Although both women and men exhibited significant improvements in functional class, quality of life, and 6-minute walk distances following valve repair, women had lower 6-minute walk distances than men both at baseline and at follow-up.
Study Questions:
Among patients undergoing transcatheter edge-to-edge mitral valve repair (TMVR) for secondary mitral regurgitation (MR), how do clinical characteristics and outcomes differ between women and men?
Methods:
This was a cohort study based on the multicenter, retrospective EuroSMR Registry (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation), which includes patients who underwent TMVR from 2008-2018. All patients were symptomatic and deemed to be at high or prohibitive surgical risk. Endpoints of interest included 1- and 2-year survival, procedural success (defined as MR grade ≤2+ at discharge), and durability of MR reduction.
Results:
A total of 1,233 patients (445 women [36%]) were included. Women tended to be older than men (mean age 76 vs. 72 years, p < 0.01), but were less likely to have diabetes, coronary artery disease, and atrial fibrillation or flutter. Women had higher mean left ventricular (LV) ejection fraction (40% vs. 33%, p < 0.01) and smaller indexed LV volumes (LV end-diastolic volume [LVEDV] index 79 vs. 103 ml/m2, p < 0.01). The degree of MR relative to LV size tended to be greater in women (effective regurgitant orifice area/LVEDV 0.24 cm2/100 ml in women vs. 0.17 cm2/100 ml in men, p < 0.01).
Procedural success was achieved in 93.2% of women and 94.6% of men (p = 0.35). Durability of MR reduction was evaluable in 35% of patients who had serial echocardiograms. At a median 13 months post-procedure, women and men were similarly likely to have worsening of MR (MR grade ≥3+, 1.9% at discharge vs. 9.6% in women; 2.1% at discharge vs. 10.0% at follow-up). Women and men had similar mortality at 1 month (2.7% vs. 3.3%), 1 year (18.9% vs. 19.9%), and 2 years (26.5% vs. 25.4%) (p = nonsignificant for all). Based on a subset of patients with available data, both women and men exhibited significant improvements in symptomatology at follow-up, as evidenced by changes in New York Heart Association functional class, 6-minute walk distance, and Minnesota Living With Heart Failure Questionnaire score. However, women had significantly shorter 6-minute walk distances than men both at baseline (mean 202 m vs. 256 m, p < 0.01) and at follow-up (227 m vs. 281 m, p < 0.01).
Conclusions:
In this European cohort, women undergoing TMVR for secondary MR were older and had less unfavorable LV remodeling than men, although women had objectively worse exercise capacity than men. Procedural success and mortality at 1 month, 1 year, and 2 years were comparable between women and men.
Perspective:
This real-world cohort study suggests that women and men with secondary MR who are selected for TMVR experience similar benefits in terms of symptomatic improvement and mortality reduction. However, the fact that men comprised nearly two thirds of the cohort is deserving of further study; referral bias and underappreciation of MR severity in women might have played a role. Notably, a subgroup analysis of the COAPT trial suggested that women might be less likely to benefit from TMVR, based on heart failure hospitalization data. As the authors of the current manuscript point out, more women with end-stage heart failure might have been included in COAPT, as that study used a single end-systolic diameter cutoff (60 mm) for both sexes, without indexing to body size. Prospective longitudinal registries including all patients with significant secondary MR, not only those who undergo intervention, would be helpful to clarify how natural history and clinical outcomes differ between women and men.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Exercise, Mitral Regurgitation
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Artery Disease, Diabetes Mellitus, Exercise, Exercise Tolerance, Geriatrics, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Patient Discharge, Quality of Life, Sex Differentiation, Stroke Volume, Ventricular Function, Left
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