Impact of Female Sex on Survival and Outcomes After Mitral Valve Surgery

BACKGROUND: Mitral valve disease is a common indication for cardiac surgery, yet long-term, sex-specific outcomes remain incompletely understood. OBJECTIVES: The objective of the study was to evaluate the impact of female sex on survival, reoperation, and recurrent mitral regurgitation (MR) after mitral valve surgery. METHODS: We performed a systematic review and meta-analysis of studies comparing men and women undergoing surgical mitral valve surgery. Time-to-event data were reconstructed and pooled with random-effects models; meta-regression evaluated effect modifiers. RESULTS: Sixteen studies comprising 42,587 patients were included. Women were under-represented, accounting for 39% of the cohort (95% CI: 36%-42%), and were significantly older than men (mean difference: 2.8 years; 95% CI: 1.5-4.0). Women were more than twice as likely to undergo primary mitral valve replacement compared with men (21.9% vs 11.0%; OR: 2.15; 95% CI: 1.62-2.84) and had higher in-hospital mortality than men (OR: 1.38; 95% CI: 1.27-1.50). In unadjusted analyses, female sex was associated with higher all-cause mortality (HR: 1.35; 95% CI: 1.25-1.47) and recurrent MR (HR: 1.57; 95% CI: 1.14-2.15), whereas reoperation rates were similar (HR: 1.35; 95% CI: 0.96-1.89). After adjustment, mortality (HR: 0.96; 95% CI: 0.91-1.01) and reoperation (HR: 1.33; 95% CI: 0.81-2.18) were not significantly different, but recurrent MR remained higher in women (HR: 1.68; 95% CI: 1.13-2.51). Meta-regression revealed higher mitral valve replacement proportion was associated with increased mortality in women. CONCLUSIONS: Women are more likely to undergo mitral valve replacement and have higher recurrent regurgitation, whereas adjusted mortality is similar, suggesting potential benefit of repair-focused strategies when feasible.