Sex differences in preoperative cardiac damage in patients with primary mitral regurgitation: impact on surgical outcomes

INTRODUCTION AND OBJECTIVES Prior evidence suggests that women have worse outcomes after surgery for mitral regurgitation (MR). We aimed to examine sex-related differences in preoperative cardiac damage among patients with severe primary MR and to assess the impact of these differences on surgical outcomes. METHODS We performed a retrospective analysis of a prospective cohort of patients undergoing surgery for primary MR at a tertiary hospital (2014-2022). Baseline clinical and echocardiographic data and 1-year outcomes (all-cause mortality and heart failure [HF] hospitalizations) were compared by sex. RESULTS A total of 349 patients were included; 154 (44%) were female. Women were older, had a higher comorbidity burden and were more frequently symptomatic at the time of surgery. Compared with men, women had significantly more advanced (right-sided) cardiac damage before surgery (54.5% vs 36.5%; P = .017), greater impairment of left ventricular global longitudinal strain and left atrial reservoir strain, and worse right ventricular-pulmonary arterial coupling. Mitral valve repair was more common in men, whereas women more often required concomitant tricuspid valve repair. At 1 year, the incidence of HF hospitalizations was higher in women (7% vs 1%; HR, 2.41; 95%CI, 1.14-6.30), and there was a nonsignificant trend toward higher all-cause mortality (11% vs 6.2%; HR, 1.72; 95%CI, 0.79-3.76). CONCLUSIONS Women with primary MR were more often symptomatic at the time of surgery, presented with more advanced biventricular and left atrial dysfunction preoperatively, and had higher HF hospitalization rates after surgery. New strategies are needed to ensure equitable management and outcomes between sexes.