Sex-specific differences and outcomes of transcatheter mitral valve replacement in women
I Von Der Heide, A Coisne, A Duncan, J Hausleiter, A Mangieri, V Ninios, W Rottbauer, J G Webb, J Rodes-Cabau, A Latib, S Blankenberg, J F Granada, T Modine, L Conradi, S LudwigAbstract
Background
Transcatheter mitral valve replacement (TMVR) has emerged as a treatment option for patients with mitral regurgitation (MR), ineligible for surgery or transcatheter edge-to-edge repair. Anatomical conditions and clinical risk profiles differ substantially between women and men. Evidence on sex-specific differences and outcomes after TMVR remains limited.
Purpose
To evaluate sex-specific differences in clinical and anatomical phenotypes, procedural, and mid-term clinical outcomes following TMVR using data from an international multicentre registry.
Methods
The CHOICE-MI registry included patients with symptomatic MR treated with dedicated TMVR devices at 41 international centres. Clinical, echocardiographic, and CT parameters were compared between sexes. Kaplan-Meier analyses assessed all-cause and cardiovascular (CV) mortality and heart failure (HF) hospitalization up to 36 months. Multivariable Cox regression identified independent predictors of outcomes stratified by sex.
Results
A total of 545 patients (median age 77 years [IQR 71–81], EuroSCORE II 5.6% [3.6–10.6]) undergoing TMVR were included and stratified by sex. TMVR was performed in 236 women (43%), using transapical devices in 73.7% (n=174) and transfemoral in 26.3% (n=62). Women more frequently had arterial hypertension, but less coronary artery disease and fewer prior PCI, CABG, and SAVR. The prevalence of primary MR (female vs. male: 36.3% vs. 36.0%, p=0.99) and secondary MR (47.0% vs. 45.5%, p=0.80) was similar between sexes. Atrial secondary MR was more common in women (27.0% vs. 13.2%, p=0.002), whereas ischemic MR was more frequent in men (24.7% vs. 41.6%, p=0.001). Women had smaller LV volumes (LVEDV 125 vs. 166 mL; LVESV 63 vs. 95 mL; both p<0.001) and annular dimensions (annulus area 10.5 vs. 11.5 cm², p=0.001). Technical success (94.5% vs. 92.6%, p=0.47) and MR reduction to ≤1+ (96.4% vs. 95.5%, p=0.96) were comparable. NYHA class improved significantly from baseline to 1 year and remained stable at 2 years (both p<0.001), without sex differences. At 3 years, no significant differences were observed between women and men regarding all-cause mortality (47.1% vs. 52.6%, p=0.55), CV mortality (31.4% vs. 25.5%, p=0.37), or HF hospitalization (35.2% vs. 44.3%, p=0.19). In multivariable analysis restricted to women, renal function assessed by eGFR predicted 3-year survival (HR 0.99 [95% CI 0.97–1.00], p=0.012).
Conclusions
Despite marked sex-related differences in baseline characteristics and cardiac geometry, TMVR showed comparable procedural efficacy, sustained symptomatic improvement, and similar mid-term outcomes in women and men. Women more often had atrial functional MR, indicating a distinct phenotype warranting further study. These findings indicate that sex-specific anatomical and remodeling differences do not translate into differential clinical benefit, supporting TMVR as an effective therapeutic strategy across sexes.Graphical Abstract TMVR in WomenFor image description, please refer to the figure legend and surrounding text.Outcomes of TMVR in WomenFor image description, please refer to the figure legend and surrounding text.