Impact of gender on in‐hospital mortality and 90‐day readmissions in patients undergoing transcatheter edge‐to‐edge mitral valve repair: Analysis from the National Readmission Database

Abstract

Background: Patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) carry a high risk of rehospitalization due to disease, procedure, patient, hospital, and system related factors.Aims: We aimed to explore the impact of gender on in-hospital mortality and 90-day readmissions in patients undergoing TEER.Methods: We utilized the National Readmission Database from 2012 to 2018 to identify individuals who underwent TEER for mitral regurgitation. Gender-based differences in in-hospital mortality and 90-day readmissions were explored using multivariable logistic regression models.Results: Between 2012 and 2018, an estimated 21,415 TEER procedural hospitalizations were identified, of which 9893 (46.2%) were in women and 11,522 (53.8%) were in men. Compared with men, women were older, from a lower socioeconomic status but had a lower co-morbidity burden. In-hospital mortality rate during the index hospitalization was similar in women and men (2.1% vs. 2.1%, p = 0.908). Ninety-day allcause and heart failure readmission rates were significantly higher in women compared to men (30.2% vs. 25.4%; p < 0.001 and 28.1% vs. 23.9%; p = 0.020 respectively). In a multivariable analysis, women had 36% greater odds of 90-day readmission compared to men (adjusted odds ratio [aOR] 1.36, 95% CI: 1.22-1.52; p < 0.001). Trend analysis revealed no significant improvement in rates of 90-day readmission during the observation period for men or women (p = 0.245, p = 0.429, respectively).Conclusions: Following TEER, there has been no significant improvement in 90-day readmission rates between 2012 and 2018. Female gender is associated with higher 90-day all-cause and heart failure readmission rates.

Impact of sex on in‐hospital mortality and 90‐day readmissions in patients undergoing transcatheter mitral valve replacement (TMVR): Analysis from the nationwide readmission database

“…In contrast, in another study that evaluated sex differences in post-TEER readmissions, 90-day readmissions were significantly higher in women compared to men (30.2% vs. 25.4%, p < 0.001). 12 This observation was supported by Goel et al, 32 who found an association between female sex and higher readmission rates following both surgical mitral valve repair and replacement. Potential explanations for higher readmissions in females following TEER and mitral valve surgery include: (a) women tend to be frailer and older at the time of TEER compared to men; 33 (b) women tend to have more comorbidities with delayed referral for intervention; 34 (c) women tend to have less improvement in New York Heart Association (NYHA) functional status and more frequent residual ≥grade III MR at follow-up compared to men; 33 (d) women have a higher rate of concomitant tricuspid valve disease leading to residual tricuspid regurgitation after mitral TEER and worse clinical outcomes; 35 (e) anatomical abnormalities including bileaflet mitral prolapse are reported more often in women; 36 (f) the degree of calcification in mitral stenosis are noted to be higher in women.…”

“…Congruently, in a study that evaluated sex differences following TEER, in-hospital mortality rates were identical in males and females (2.1% vs. 2.1%; p = 0.908). 12 However, in a previous study that evaluated sex differences in TAVR outcomes, women had higher in-hospital mortality compared to men (2.7% vs. 2.3%; p = 0.002). 11 The higher rate of in-hospital mortality in women following TAVR was attributed to several factors: (a) women had higher Society of Thoracic Surgery Predicted Risk of Mortality (STS-PROM) scores; (b) higher rates of vascular and bleeding complications in women compared to men; (c) greater use of non-femoral access due to inadequate femoral vessel caliber in women compared to men, which has been shown in numerous studies to have worse outcomes compared to femoral access; 25 (d) higher rates of conversion from TAVR to open surgery in women for complications such as annular rupture.…”

“…In our study, the overall 90-day readmission rate following TMVR was 28.99% which was similar to TEER (27.6%) but slightly higher compared to TAVR (24.6%), as reported in previous studies. 11,12 Potential explanations for such higher readmissions following TMVR include: (a) the complex anatomy of the mitral valve, including position which makes it a challenge to approach percutaneously, and saddle shape of the annulus with the lack of stable wall calcifications for anchoring; 15 (b) dynamic changes that occur in the mitral annulus area and the annular circumference during the cardiac cycle; 28 (c) higher rates of structural bioprosthesis degeneration in MV compared to aortic valves, as bioprosthetic valves are more likely to experience structural degeneration in younger patients due to higher mechanical and hemodynamic stress on the valve, 29 and patients undergoing MV replacement are a decade younger on average than those undergoing aortic valve replacement; 30 (d) the need for a sufficiently rigid device to withstand the flow traction but at the same time not too rigid to prevent injury or perforation of the surrounding structures; 14 (e) more expertise with TAVR, which is attributed to the larger number of TAVR procedures performed leading to a significant improvement in the procedure's techniques and operators' experience. 2,31 All these factors help explain the complexity and risks associated with TMVR leading to higher rates of readmission compared to TAVR.…”

“…These causes are similar to the causes of TMVR readmission reported by Elbadawi et al 38 and the causes following other valvular procedures including TAVR and TEER. 11,12 Pajjuru et al 11 reported the most common causes of readmission following TAVR to be heart failure followed by sepsis. Guddeti et al 12 reported the most common causes of readmission following TEER to be heart failure followed by atrial fibrillation, which is common in patients with MVD due to left atrial enlargement.…”

“…9 Optimization of goal-directed medical therapy (GDMT) is associated with improved morbidity and mortality in patients with heart failure. 10 While sex differences in mortality and readmission following TAVR 11 and mitral transcatheter edge-to-edge repair (TEER; MitraClip) 12 have been studied in the past, rates post-TMVR have not been reported. Therefore, we analyzed the Nationwide Readmissions Database (NRD) to investigate the in-hospital mortality and 90-day readmission rates post-TMVR in men and women and to assess the trends, causes, and predictors of 90-day readmission.…”