Sex differences in the long-term outcomes of moderate rheumatic mitral stenosis

Abstract Background There are limited data on the sex differences in the long-term outcomes of moderate mitral stenosis (MS). Purpose This study aimed to investigate sex differences in long-term outcomes of moderate AS. Methods From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included patients with moderate MS (1.5 < mitral valve area ≤ 2.0 cm2) between January 2000 and December 2021 who had not undergone previous percutaneous of surgical treatment of MS. Primary outcomes were a composite of all-cause death, heart failure (HF) hospitalization, ischemic stroke, and mitral valve intervention. We analyzed clinical and echocardiographic variables based on sex. Results A total of 788 patients (mean 62.2 ± 12.9 years, women 74.5%) were followed over a mean duration of 7.0 ± 6.0 years. During follow-up, 287 patients (36.4%) experienced primary outcomes. Women (n=587) had more atrial fibrillation (AF) (p=0.022), higher left ventricular (LV) ejection fraction (EF) (p<0.001), and smaller LV chamber (LV mass index; p<0.001) compared to men. Primary outcomes did not differ for both sexes (p=0.285). However, on the analysis of both sexes according to right ventricular systolic pressure (RVSP), men with elevated RVSP had poorer outcomes (p<0.001) but women did not differ (p=0.238) (Figure 1). On the multivariate Cox regression analysis, elevated RVSP was the only factor that was independently associated with poorer outcomes (hazard ratio [HR], 1.30 [95% CI, 1.10-1.05], p=0.005) in men. However, in women, several factors including older age (HR 1.02, 95% CI 1.00-1.03, p=0.012), presence of AF (HR 2.40, 95% CI 1.66-3.48, p<0.001), decreased LV EF (HR 0.98, 95% CI 0.97-1.00, p=0.007), and higher mean diastolic pressure gradient (HR 1.09, 95% CI 1.01-1.17, p=0.027) showed the independent association with poorer outcome, but not in RVSP (Figure 2). Conclusions In moderate MS, RVSP showed a significant prognostic role in men, but in women, various comorbidities other than that were associated with prognosis. Therefore, different follow-up strategy using specific parameters for each gender would be needed.