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Surgical Presentation, Cardiac Remodeling and Long-term Outcome of Organic Mitral Regurgitation according to Gender
francesca mantovani, Marie-Annik Clavel, Rakesh M. Suri, Maurice Enriquez-Sarano.
mayo clinic, rochester, MN, USA.

Objective: Guidelines for management of mitral regurgitation (MR) do not provide sex-specific MR severity grading, cardiac remodeling assessment or surgical indications. Guidelines do not suggest gender differences in presentation and outcome of MR surgery but recent data suggest lower repair rate and long-term survival in women. Methods: In 201 women and 454 men with 1) mitral surgery for organic MR (1990-2000), 2) comprehensive pre-operative MR quantification, and 3) pre and post-operative echocardiographic assessment of cardiac remodeling, long-term follow-up was analyzed. Results: Pre-operatively women vs. men had similar age and ejection fraction but smaller left ventricular (LV) diastolic diameter (56±6 vs. 60±7, p<0.0001) more often labeled normal size (21 vs. 13%, p=0.0007) and smaller LV systolic and left atrium size (all p<0.0001). Women had smaller quantified regurgitant volume (82±32 vs. 98±46 mL/beat, p<0.0001) but higher pulmonary pressure (p<0.0001) more heart failure symptoms (37 vs. 19%, p=0.01), which more often triggered surgery (p=0.02). Normalizing for body size, LV diastolic diameter (33±5 vs. 30±4 mm/m2, p0.19) demonstrating similar reduction of large volume overload by surgery. Valve repair (91%) was lower in women but similar in repairable valves (degenerative or endocarditic MR, both p>0.56). During follow-up (9.8±4.1 years) women vs. men had similar survival (15-year 59±5 vs. 59±3%, p=0.6) but more frequent heart failure (15-year 36±7 vs. 19±3%, p=0.02; adjusted hazard-ratio 1.63[1.06-2.48], p=0.03) linked to the more frequent pre-operative heart failure symptoms (p<0.001). Conclusions: Women underwent surgery for organic MR with more advanced clinical presentation but with smaller absolute LV dimensions and lower regurgitant volume, suggestive of underestimation of MR severity in women, demonstrated by profound post-operative reverse remodeling. Excess postoperative heart failure linked to worse preoperative presentation also points to late surgical referral. Valve repair similarly achieved in repairable lesions and similar long-term survival in women and men suggest that women should not be denied early surgery for organic MR.

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