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• W2896048718 abstract "HomeCirculationVol. 138, No. 16Sex Differences in the Etiology of Surgical Mitral Valve Disease Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBSex Differences in the Etiology of Surgical Mitral Valve Disease Sneha Vakamudi, MD, Christine Jellis, MD, PhD, Stephanie Mick, MD, Yuping Wu, PhD, A. Marc Gillinov, MD, Tomislav Mihaljevic, MD, Delos M. Cosgrove, MD, Lars Svensson, MD, PhD and Leslie Cho, MD Sneha VakamudiSneha Vakamudi Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Christine JellisChristine Jellis Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Stephanie MickStephanie Mick Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Yuping WuYuping Wu Department of Mathematics, Cleveland State University, OH (Y.W.). Search for more papers by this author , A. Marc GillinovA. Marc Gillinov Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Tomislav MihaljevicTomislav Mihaljevic Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Delos M. CosgroveDelos M. Cosgrove Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author , Lars SvenssonLars Svensson Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author and Leslie ChoLeslie Cho Leslie Cho, MD, FACC, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Desk JB-1, Cleveland, OH 44195. Email E-mail Address: [email protected] Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH. Search for more papers by this author Originally published15 Oct 2018https://doi.org/10.1161/CIRCULATIONAHA.118.035789Circulation. 2018;138:1749–1751Surgical mitral valve disease is an entity that has evolved over the past 30 years.1 With increasing rates of early coronary revascularization and a decreasing prevalence of rheumatic fever, the etiology of surgical disease in developed countries has shifted from rheumatic and ischemic in origin to one predominated by degenerative disease. This shift in etiology has been paralleled by an evolution in surgical technique. Mitral valve repair has allowed surgeons to reconstruct a degenerative valve without the use of a mechanical or biological prosthesis. In comparison with male patients, female patients undergo higher rates of mitral valve replacement than repair.2,3 This difference has been theorized to be a factor to account for worse outcomes following mitral valve surgery in women. Attempts to explain this disparity in procedure choice have been linked to sex differences in the type of valve lesions.4 Mitral valve repair has the greatest success in cases of degenerative mitral regurgitation with posterior leaflet prolapse, and women have been shown to have less posterior prolapse than men.4,5 In addition, women have a higher incidence of mitral stenosis as an indication for operation, thereby typically necessitating replacement.5 Prior studies have not accounted for sex differences in the etiology of surgical mitral valve disease and whether they have changed in the modern era.The aim of this research was to assess sex differences in the etiology of surgical mitral valve disease and whether those differences have persisted over time. A retrospective analysis was performed of consecutive patients undergoing primary mitral valve surgery, either replacement or repair, at our institution from 1993 to 2016. Patients were identified from the Cardiovascular Information Registry, which represents a subset of the national Society of Thoracic Surgeons database. The Cardiovascular Information Registry collects information on all patients undergoing cardiothoracic surgery at our institution. Permission for use of data from this registry was granted by our institution’s Institutional Review Board, and informed consent was not required. We included patients who had undergone concomitant coronary artery bypass grafting or another valve procedure at the time of their mitral intervention. Patients who had previously undergone cardiac surgery were excluded. Coding of mitral valve disease etiology had been prospectively adjudicated at the time of surgery based on standards using a combination of clinical information, surgical impression of the valve, echocardiographic parameters, and surgical pathology. The information regarding etiology is available through our Cardiovascular Information Registry database. Terms applied for the etiology of valve disease were based on the Society of Thoracic Surgeons Database Collection Form. The prevalence of valve etiology was first stratified by sex with differences in categorical data compared by using χ2 testing. The subjects were then divided into 5-year intervals, and differences in etiology were further stratified by time with temporal trends analyzed using the Cochran-Armitage test.Our study cohort included 23 806 unique patients, 40.8% women (n=9713). For our overall cohort, the majority of patients presented with degenerative disease (58%). The next most prevalent etiologies of disease were ischemic (11.7%) and rheumatic (11.9%). The remaining 8 etiologies made up 18% of the population, each representing ≤6% of the cohort.In analyzing sex-specific differences among the 3 most prevalent disease types, women had a markedly higher rates of rheumatic valve disease than men. Men presented with more degenerative and ischemic valve disease. All these differences were highly statistically significant (P<0.001). When our analysis was stratified by year, there were significant differences in the rates of these 3 causes of valve disease—degenerative, ischemic, and rheumatic—over time. We observed 2 distinct trends in this group. There was a significant increase in the percentage of degenerative valve disease (46.8%–63.4%, P<0.001) and a reduction in the prevalence of ischemic (14.1%–5.7%, P<0.001) and rheumatic disease (19.9%–8.3%, P<0.001). In evaluating disease prevalence over time by sex, despite the rates of rheumatic and ischemic valve disease declining overall, women maintained a significantly higher prevalence of rheumatic involvement than men (P<0.001) and a significantly lower prevalence of ischemic diseases (P<0.01) throughout the years studied. Although degenerative valve disease increased overall, women consistently had lower rates than men (P<0.001) (Figure). Our study highlights the differences in the etiology of surgical mitral valve disease between female and male patients. The most striking finding is a disproportionate amount of rheumatic mitral valve disease in women. The time analysis clarifies that, although there is a temporal shift in the etiology of surgical mitral valve disease for all patients, differences between the sexes persist even in the modern era of cardiac surgery. This variance in etiology is an important signal to be noted for surgical mitral valve disease. In identifying sex differences in the etiology of mitral valve disease, we have identified another avenue that potentially links patient to sex differences in procedure selection and outcomes.Download figureDownload PowerPointFigure. Etiology of mitral valve disease by sex and time. A, Prevalence of different etiologies of surgical mitral valve disease for the entire cohort and each sex. P<0.001 for difference in etiologies between sexes. B, Sex-based differences for the most prevalent causes of surgical mitral valve disease from 1993 to 2016. P<0.001 for degenerative and rheumatic disease. P<0.01 for ischemic disease.Sources of FundingThis work was supported by Women’s Cardiovascular Research at the Cleveland Clinic.DisclosuresNone.FootnotesData sharing: The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.https://www.ahajournals.org/journal/circLeslie Cho, MD, FACC, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Desk JB-1, Cleveland, OH 44195. Email [email protected]orgReferences1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD; ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 129:2440–2492. doi: 10.1161/CIR.0000000000000029LinkGoogle Scholar2. Gammie JS, Sheng S, Griffith BP, Peterson ED, Rankin JS, O’Brien SM, Brown JM. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.Ann Thorac Surg. 2009; 87:1431–1437; discussion 1437–1439.CrossrefMedlineGoogle Scholar3. Vassileva CM, Stelle LM, Markwell S, Boley T, Hazelrigg S. Sex differences in procedure selection and outcomes of patients undergoing mitral valve surgery.Heart Surg Forum. 2011; 14:E276–E282. doi: 10.1532/HSF98.20111030CrossrefMedlineGoogle Scholar4. Avierinos JF, Inamo J, Grigioni F, Gersh B, Shub C, Enriquez-Sarano M. Sex differences in morphology and outcomes of mitral valve prolapse.Ann Intern Med. 2008; 149:787–795.CrossrefMedlineGoogle Scholar5. Seeburger J, Eifert S, Pfannmüller B, Garbade J, Vollroth M, Misfeld M, Borger M, Mohr FW. Gender differences in mitral valve surgery.Thorac Cardiovasc Surg. 2013; 61:42–46.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Gual-Capllonch F, Sáenz de Ibarra J, Bayés-Genís A and Delgado V (2022) Atrial Mitral and Tricuspid Regurgitation: Sex Matters. A Call for Action to Unravel the Differences Between Women and Men, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.877592, 9 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Rafael Sádaba J, Tribouilloy C and Wojakowski W (2022) Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías, Revista Española de Cardiología, 10.1016/j.recesp.2021.11.023, 75:6, (524.e1-524.e69), Online publication date: 1-Jun-2022. 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Hartjes T and Lester D (2019) Minimally Invasive Surgical Options with Valvular Heart Disease, Critical Care Nursing Clinics of North America, 10.1016/j.cnc.2019.04.002, 31:3, (257-265), Online publication date: 1-Sep-2019. Delgado V, Ajmone Marsan N and Bax J (2019) Characterizing mitral regurgitation in a contemporary population: prognostic implications, European Heart Journal, 10.1093/eurheartj/ehz432, 40:27, (2203-2205), Online publication date: 14-Jul-2019. October 16, 2018Vol 138, Issue 16 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.035789PMID: 30354470 Originally publishedOctober 15, 2018 Keywordscoronary artery bypasssex characteristicsheart valve diseasesmitral valvePDF download Advertisement SubjectsCardiovascular DiseaseEtiology" @default.
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