Sex-Based Differences in Early Outcomes Following Mitral Valve Surgery for Degenerative Disease


  • Fadi I Al-Zubaidi Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, BS2 8ED Bristol, UK
  • Maria Pufulete Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, BS2 8ED Bristol, UK
  • Mohammad Yousuf Salmasi Department of Surgery and Cancer, Imperial College London, SW7 2BX London, UK
  • Gianni D Angelini Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, BS2 8ED Bristol, UK
  • Hunaid A Vohra Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, BS2 8ED Bristol, UK



degenerative, mitral, valve, disease, sex, differences


Objectives: To determine whether sex-based differences exist following surgery for degenerative mitral valve disease. Methods: Using a national database, we analysed data on mitral valve surgery for degenerative disease (n = 22,658) between January 2000 and March 2019 in the UK. We split the cohort into men (n = 14,681) and women (n = 7977) and compared background characteristics, intraoperative variables and early postoperative outcomes. Our primary outcome was hospital mortality; secondary outcomes included re-exploration for bleeding, prolonged admission (>10 days) and mitral replacement. We used binary logistic regression models for all outcomes, with multiplicative interaction terms to determine the nature of any differences. Results: Women presented older (70 ± 11 years vs. 67 ± 11 years, p < 0.001) with worse symptom profiles (New York Heart Association Class III–IV 57% vs. 44%, p < 0.001). They had higher rates of preoperative atrial fibrillation (39% vs. 35%, p < 0.001) and tricuspid disease requiring surgery (21% vs. 15%, p < 0.001). They had lower repair rates (66% vs. 76%, p < 0.001), higher mortality (3% vs. 2%, p < 0.001) and were more likely to have a prolonged admission (48% vs. 40%, p < 0.001). Female sex was an independent predictor of mortality (odds ratio (OR): 1.52, 95% CI: 1.21–1.90, p < 0.001). Age and Canadian Cardiovascular Society (CCS) score showed significant interactions with sex. The relationship between advancing age and mortality was found to be more pronounced in women. Conclusions: (1) Female sex is an independent predictor of hospital mortality, prolonged hospital admission and mitral valve replacement. (2) The relationship between female sex and mortality is exacerbated by worsening CCS score and advancing age. (3) Women have significantly lower repair rates.


Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet (London, England). 2009; 373: 1382–1394.

Chivasso P, Bruno VD, Farid S, Malvindi PG, Modi A, Benedetto U, et al. Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study. The Journal of Thoracic and Cardiovascular Surgery. 2018; 155: 1474–1482.e2.

Filsoufi F, Carpentier A. Principles of reconstructive surgery in degenerative mitral valve disease. Seminars in Thoracic and Cardiovascular Surgery. 2007; 19: 103–110.

Suri RM, Schaff HV, Dearani JA, Sundt TM, 3rd, Daly RC, Mullany CJ, et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. The Annals of Thoracic Surgery. 2006; 82: 819–826.

Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL. Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. Circulation. 1995; 91: 1022–1028.

Braunberger E, Deloche A, Berrebi A, Abdallah F, Celestin JA, Meimoun P, et al. Very long-term results (more than 20 years) of valve repair with carpentier's techniques in nonrheumatic mitral valve insufficiency. Circulation. 2001; 104: I8–I11.

Piazza N, Onuma Y, de Jaegere P, Serruys PW. Guidelines for reporting mortality and morbidity after cardiac valve interventions–need for a reappraisal? The Annals of Thoracic Surgery. 2009; 87: 357–358; discussion 359–360.

Anyanwu AC, Itagaki S, Chikwe J, El-Eshmawi A, Adams DH. A complexity scoring system for degenerative mitral valve repair. The Journal of Thoracic and Cardiovascular Surgery. 2016; 151: 1661–1670.

Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, et al. Durability of mitral valve repair for degenerative disease. The Journal of Thoracic and Cardiovascular Surgery. 1998; 116: 734–743.

Seeburger J, Eifert S, Pfannmüller B, Garbade J, Vollroth M, Misfeld M, et al. Gender differences in mitral valve surgery. The Thoracic and Cardiovascular Surgeon. 2013; 61: 42–46.

Kaczmarek I, Meiser B, Beiras-Fernandez A, Guethoff S, Überfuhr P, Angele M, et al. Gender does matter: gender-specific outcome analysis of 67,855 heart transplants. The Thoracic and Cardiovascular Surgeon. 2013; 61: 29–36.

Beller CJ, Farag M, Wannaku S, Seppelt P, Arif R, Ruhparwar A, et al. Gender-specific differences in outcome of ascending aortic aneurysm surgery. PLoS ONE. 2015; 10: e0124461.

El-Andari R, Bozso SJ, Fialka NM, Kang JJH, Nagendran J. Does sex impact outcomes after mitral valve surgery? A systematic review and meta-analysis. Scandinavian Journal of Surgery: SJS: Official Organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2022; 111: 99–109.

DesJardin JT, Chikwe J, Hahn RT, Hung JW, Delling FN. Sex Differences and Similarities in Valvular Heart Disease. Circulation Research. 2022; 130: 455–473.

Weidner G. Why do men get more heart disease than women? An international perspective. Journal of American College Health. 2000; 48: 291–294.

Vassileva CM, McNeely C, Mishkel G, Boley T, Markwell S, Hazelrigg S. Gender differences in long-term survival of Medicare beneficiaries undergoing mitral valve operations. The Annals of Thoracic Surgery. 2013; 96: 1367–1373.

Corrigendum to: 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2022; 43: 2022.

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, 3rd, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021; 143: e72–e227.

McNeely C, Vassileva C. Mitral Valve Surgery in Women: Another Target for Eradicating Sex Inequality. Circulation. Cardiovascular Quality and Outcomes. 2016; 9: S94–S96.

Avierinos JF, Inamo J, Grigioni F, Gersh B, Shub C, Enriquez-Sarano M. Sex differences in morphology and outcomes of mitral valve prolapse. Annals of Internal Medicine. 2008; 149: 787–795.

Kislitsina ON, Zareba KM, Bonow RO, Andrei AC, Kruse J, Puthumana J, et al. Is mitral valve disease treated differently in men and women? European Journal of Preventive Cardiology. 2019; 26: 1433–1443.

Al-Zubaidi F, Pufulete M, Sinha S, Kendall S, Moorjani N, Caputo M, et al. Mitral repair versus replacement: 20-year outcome trends in the UK (2000–2019). Interdisciplinary CardioVascular and Thoracic Surgery. 2023; 36: ivad086.

Wallis CJD, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, et al. Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes. JAMA Surgery. 2022; 157: 146–156.



How to Cite

Al-Zubaidi, F. I., Pufulete, M., Salmasi, M. Y., Angelini, G. D., & Vohra, H. A. (2023). Sex-Based Differences in Early Outcomes Following Mitral Valve Surgery for Degenerative Disease. The Heart Surgery Forum, 26(5), E566-E576.