Evolving Perspectives in Surgery for Mitral Regurgitation: Why Sex Matters

There is a growing body of evidence investigating sex differences in the presentation, assessment, and outcomes of patients with mitral regurgitation (MR) undergoing mitral valve surgery. It has been shown that women present at older ages, with more comorbidities and more severe symptoms. Compared with male patients, female patients have longer intervals to surgery, lower rates of surgery, and receive fewer mitral valve repairs (as opposed to replacements). On imaging, left ventricular cavity sizes and many quantitative measures of MR severity differ significantly by sex, and current guidelines do not account for this. While sex differences in surgical outcomes have been documented, these are largely limited to primary MR and are based on older studies, underscoring the need for further research. Data on sex differences in transcatheter interventions for MR are inconclusive and heterogeneous, complicating comparisons to surgery. To address these disparities, sex-specific thresholds for intervention in primary MR, standardization of the quantification of MR severity by sex, and further prospective studies are required. As we move into an era of precision medicine, it is critical to recognize sex as a key determinant of cardiovascular care. In patients undergoing surgery for MR, further research should evaluate whether current intervention thresholds and management pathways are appropriately tailored to female patients.