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Robotic Mitral Valve Surgery Mitigates Sex-based Disparities In Minimally Invasive Access
Xander Jacquemyn, Andrea Amabile, Kei Kobayashi, Irsa Hasan, Takuya Ogami, Danny Chu, Derek Serna-Gallegos, David Kaczorowski, Ibrahim Sultan, Johannes Bonatti.
University of Pittsburgh, Pittsburgh, PA, USA.
BACKGROUND: Sex disparities in access to and outcomes of mitral valve (MV) surgery have been reported. We examined whether female patients are less likely to undergo thoracotomy or robotic MV surgery, and assessed differences in surgical outcomes.
METHODS: We analyzed 2,269 patients undergoing isolated MV surgery (sternotomy: 1,688; mini-thoracotomy: 581; female 49.5%). Univariable and multivariable logistic regression evaluated predictors of mini-thoracotomy. Within the thoracotomy cohort, 581 patients underwent robotic (n=363) or non-robotic (n=218) procedures; utilization by sex and predictors of robotic adoption were assessed. Early outcomes and 10-year survival were compared.
RESULTS:Univariable analysis showed that female patients were significantly less likely to receive a mini-thoracotomy than a sternotomy (39.1% vs 53.1%, OR 0.57, 95% CI 0.47-0.69, P < 0.001). However, after adjusting for clinical factors, female sex was no longer independently associated with not receiving a thoracotomy (adjusted OR 0.81, 95% CI 0.51-1.29, P=0.375), indicating that the apparent disparity was largely explained by for instance the need for replacement (OR 0.45, 95% CI 0.29-0.67, P<0.001), presence of rheumatic heart disease or endocarditis (OR 0.22, 95% CI 0.10-0.43, P<0.001) If a patient received minimally invasive MV surgery, robotic adoption was similar for females and males (OR 0.97, 95% CI 0.69-1.38, P=0.885). However, females in the robotic group were more likely to undergo MV replacement than males (9.9% vs 3.1%; OR 3.85, 95% CI 1.54-10.46, P=0.005; adjusted OR 60.8, 95% CI 7.51-921.6, P=0.001). Female patients presented with more advanced heart failure (NYHA III-IV: 29% vs 14%, P=0.004). Early outcomes between female and male patients including 30-day mortality, transfusion, and stroke were comparable. Unadjusted 10-year survival was lower for females (HR 2.51, 95% CI 1.28-4.93, P=0.007), but differences were attenuated after adjustment (HR 2.29, 95% CI 0.94-5.60, P=0.069). Surgical reintervention rates were low and similar.
CONCLUSIONS: Although unadjusted disparities exist in mini-thoracotomy utilization, female sex is not an independent predictor after adjustment. Within the robotic cohort, utilization is equitable, but females are more likely to undergo replacement. Early outcomes and long-term survival are comparable after adjustment. Robotic approaches appear to mitigate sex-based disparities in minimally invasive MV surgery and support equitable adoption.
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