Page 40 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation

Chapter two. Sex differences in prognosis of significant secondary mitral regurgitation
Sex differences in secondary mitral regurgitation
Important differences in prevalence, pathophysiology and prognosis of various cardiovascular diseases have been described between men and women 17. In mitral valve pathology two different mechanisms of MR can be distinguished; primary MR (i.e. the result of pathology of the MV apparatus itself) and secondary MR (i.e. the result of changes in the LV geometry due to ischemic or non-ischemic heart failure) 18. A large echocardiography-based registry by Monteagudo Ruiz et al. 3 described the sex differences among 3309 patients with moderate and severe MR and showed that secondary MR was more prevalent among men vs. women (39.2% vs. 21.8%, respectively). However, the study did not elaborate further on the differences between men and women with significant secondary MR. The randomized clinical trial from the Cardiothoracic Surgical Trials Network (CTSN) comparing mitral valve repair vs. replacement in 251 patients with ischemic secondary MR showed that 38% were women while the remaining 62% were men 9. In the present study ischemic etiology of secondary MR was observed in 61% of men vs. 37% of women. When analyzing the clinical and echocardiographic characteristics of the patients enrolled in the CTNS trial 9, men were comparable to women in terms of age, body mass index, frequency of atrial fibrillation, history of myocardial infarction and renal dysfunction; however, men more frequently had a history of ventricular arrhythmias while women presented more frequently with diabetes mellitus and hypertension. Furthermore, men had larger LV dimensions and effective regurgitant orifice areas when compared to women. However, when the effective orifice regurgitant orifice area was corrected for the LV end-diastolic volume, women had a larger ratio than men suggesting more severe MR in women than in men. These results are similar to the data reported in this study. However, it should be noted that the present study population is larger and includes both etiologies of secondary MR (ischemic and non-ischemic). Although other studies have compared sex-differences in MR19, 20, this is the first and largest study focusing specifically on secondary MR.
Sex differences in outcomes in patients with secondary MR
Although men with significant secondary MR seem to receive interventional treatment more often than women,1, 21-23 men seem to have a worse prognosis. A study by Estevez- Loureiro et al. 8 investigated the effect of gender on results after transcatheter edge- to-edge MV repair with the Mitraclip in 173 patients (64 women vs. 109 men) and showed no differences between the sexes in MR reduction, heart failure hospitalization and all-cause mortality. Similarly, data from the German TRAnscatheter Mitral Valve Interventions (TRAMI) registry, including 501 men and 327 women showed no differences in prognosis after successful transcatheter MV repair with the MitraClip 20.
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