# The Silent Cost of Gender in Mitral Valve Surgery: A Propensity-Score Matched Analysis

## TL;DR

Women undergoing mitral valve surgery face higher mortality and lower repair rates, mainly due to more complex disease at diagnosis rather than their sex itself.

## Contribution

This study identifies that sex-related disparities in mitral valve surgery outcomes are largely due to disease morphology and later presentation in women.

## Key findings

- Women had higher 30-day and 5-year mortality compared to men.
- Women were less likely to undergo minimally invasive surgery and valve repair.
- After adjusting for morphology, sex was no longer an independent predictor of outcomes.

## Abstract

Mitral valve (MV) disease shows sex-specific differences in morphology and outcomes. Women often present later, undergo replacement more frequently, and experience worse survival. This study investigated sex-related disparities in surgical approach, repair rates, and outcomes of MV surgery.

A total of 1531 consecutive patients undergoing MV surgery with or without concomitant tricuspid valve procedure were analysed retrospectively. Baseline characteristics, operative strategies, and outcomes were compared between sexes. Propensity score matching was used to adjust for baseline differences. Primary outcomes were 30-day and 5-year mortality. Baseline and procedural characteristics, including morphology, repair rates, use of minimally invasive MV surgery (MIMVS), and concomitant tricuspid disease, were compared between groups.

Female patients (44%) were older (68 vs 62 years, P < .001), more symptomatic (New York Heart Association [NYHA] III: 60% vs 46%, P < .001), and more likely to have annular calcification (15% vs 5%, P < .001) or concomitant tricuspid disease (25% vs 36%, P < .001). Carpentier type IIIa was more prevalent in women (21% vs 4%), while type II predominated in men (75% vs 49%). MIMVS and repair were less frequent in women (49% vs 65% and 67% vs 85%, both P < .001). Female sex was associated with increased 30-day (HR 4.07, 95% CI 1.51-11.0; P = .006) and 5-year mortality (HR 1.58, 1.02-2.46; P = .043). After adjusting for morphology and calcification, sex was no longer an independent predictor of repair rates or long-term mortality.

Women present at a later stage of the disease and with more complex MV pathology, resulting in lower repair and MIMVS rates and higher perioperative mortality. These disparities are largely attributable to disease morphology rather than sex per se. Earlier referral of women is essential to improve outcomes.

Significant sex-based disparities persist in the diagnosis, treatment, and outcomes of cardiovascular diseases, including mitral valve (MV) disorders.