Circulation. 2018;138:1749–1751. DOI: 10.1161/CIRCULATIONAHA.118.035789 October 16, 2018 1749 Key Words: coronary artery bypass ◼ heart valve diseases ◼ mitral valve ◼ sex characteristics S urgical mitral valve disease is an entity that has evolved over the past 30 years. 1 With increasing rates of early coronary revascularization and a de- creasing 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 par- alleled by an evolution in surgical technique. Mitral valve repair has allowed surgeons to reconstruct a degenerative valve without the use of a mechani- cal 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 regurgita- tion 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 necessitat- ing 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 surgi- cal 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 un- dergoing 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 prospec- tively adjudicated at the time of surgery based on standards using a combination of clinical information, surgical impression of the valve, echocardiographic pa- rameters, 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 Data- base Collection Form. The prevalence of valve etiology was first stratified by sex with differences in categorical data compared by using χ 2 testing. The subjects were then divided into 5-year intervals, and differences in etiology were further 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 Leslie Cho, MD © 2018 American Heart Association, Inc. RESEARCH LETTER Sex Differences in the Etiology of Surgical Mitral Valve Disease Circulation https://www.ahajournals.org/journal/circ Downloaded from http://ahajournals.org by on June 4, 2020