Sex-specific differences and outcomes of transcatheter mitral valve replacement in women

Background Transcatheter mitral valve replacement (TMVR) has emerged as a treatment option for patients with mitral regurgitation (MR), ineligible for surgery or transcatheter edge-to-edge repair. Anatomical conditions and clinical risk profiles differ substantially between women and men. Evidence on sex-specific differences and outcomes after TMVR remains limited. Purpose To evaluate sex-specific differences in clinical and anatomical phenotypes, procedural, and mid-term clinical outcomes following TMVR using data from an international multicentre registry. Methods The CHOICE-MI registry included patients with symptomatic MR treated with dedicated TMVR devices at 41 international centres. Clinical, echocardiographic, and CT parameters were compared between sexes. Kaplan-Meier analyses assessed all-cause and cardiovascular (CV) mortality and heart failure (HF) hospitalization up to 36 months. Multivariable Cox regression identified independent predictors of outcomes stratified by sex. Results A total of 545 patients (median age 77 years [IQR 71–81], EuroSCORE II 5.6% [3.6–10.6]) undergoing TMVR were included and stratified by sex. TMVR was performed in 236 women (43%), using transapical devices in 73.7% (n=174) and transfemoral in 26.3% (n=62). Women more frequently had arterial hypertension, but less coronary artery disease and fewer prior PCI, CABG, and SAVR. The prevalence of primary MR (female vs. male: 36.3% vs. 36.0%, p=0.99) and secondary MR (47.0% vs. 45.5%, p=0.80) was similar between sexes. Atrial secondary MR was more common in women (27.0% vs. 13.2%, p=0.002), whereas ischemic MR was more frequent in men (24.7% vs. 41.6%, p=0.001). Women had smaller LV volumes (LVEDV 125 vs. 166 mL; LVESV 63 vs. 95 mL; both p<0.001) and annular dimensions (annulus area 10.5 vs. 11.5 cm², p=0.001). Technical success (94.5% vs. 92.6%, p=0.47) and MR reduction to ≤1+ (96.4% vs. 95.5%, p=0.96) were comparable. NYHA class improved significantly from baseline to 1 year and remained stable at 2 years (both p<0.001), without sex differences. At 3 years, no significant differences were observed between women and men regarding all-cause mortality (47.1% vs. 52.6%, p=0.55), CV mortality (31.4% vs. 25.5%, p=0.37), or HF hospitalization (35.2% vs. 44.3%, p=0.19). In multivariable analysis restricted to women, renal function assessed by eGFR predicted 3-year survival (HR 0.99 [95% CI 0.97–1.00], p=0.012). Conclusions Despite marked sex-related differences in baseline characteristics and cardiac geometry, TMVR showed comparable procedural efficacy, sustained symptomatic improvement, and similar mid-term outcomes in women and men. Women more often had atrial functional MR, indicating a distinct phenotype warranting further study. These findings indicate that sex-specific anatomical and remodeling differences do not translate into differential clinical benefit, supporting TMVR as an effective therapeutic strategy across sexes.