A team of cardiologists from the Sant Pau Research Institute (IR Sant Pau) and Hospital Sant Pau, in collaboration with the Autonomous University of Barcelona and the Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), has analyzed the anatomical differences between men and women with mitral regurgitation treated with transcatheter edge-to-edge repair (TEER), a minimally invasive technique that corrects improper valve closure without the need for open-heart surgery.
The study, published in the Revista Española de Cardiología, shows that although women have a smaller and more calcified mitral valve, their clinical outcomes are just as favorable as those of men. According to Dr. Chi-Hion Pedro Li, the study’s first author, “Our goal was to determine whether there were anatomical differences between sexes and whether those could have a real impact on repair outcomes. What we found is that, even though women’s valves are smaller (even after adjusting for body surface area), these anatomical differences do not affect outcomes. Women benefit from the treatment to the same extent as men.”
Mitral regurgitation is one of the most common valvular heart diseases and a major cause of heart failure, especially among older adults. It occurs when the mitral valve—which separates the left atrium from the left ventricle—does not close properly, allowing blood to flow backward into the atrium. This forces the heart to work harder to maintain adequate blood flow, which over time can lead to cardiac dilation, fatigue, and shortness of breath.
Until recently, open-heart surgery was the only option for repairing or replacing the valve. However, many elderly patients or those with comorbidities are not candidates for surgery. For them, transcatheter edge-to-edge repair (TEER) offers a safe and effective alternative.
According to Dr. Dabit Arzamendi, senior author of the study, “Transcatheter edge-to-edge repair has radically changed how we manage mitral regurgitation. It allows us to safely treat patients who previously had no viable therapeutic option and, in most cases, achieves a significant reduction in symptoms and immediate functional improvement.”
However, despite the high prevalence of this condition, women have traditionally been underrepresented in clinical trials on mitral regurgitation, which has limited our understanding of their specific anatomical characteristics and their response to treatment. This study aimed to fill that gap and provide a more precise picture based on real-world clinical practice.
The study included 252 patients treated for severe symptomatic mitral regurgitation between May 2012 and December 2023. Of these, 78 were women (31%) and 174 were men (69%). On average, women were seven years older (82 vs. 75 years) and had a smaller body surface area (1.66 vs. 1.86 m²).
Regarding disease type, primary mitral regurgitation—caused by valve degeneration—was more frequent in women (40% vs. 27%), whereas the secondary form, associated with left ventricular dilation or dysfunction, was predominant in men (57% vs. 40%). Cardiac imaging revealed that women had a smaller and more calcified mitral valve, resulting in a smaller opening area (5.0 vs. 5.8 cm²) and shorter leaflets.
Mitral annular calcification, a form of tissue hardening around the valve, was three times more common in women (32% vs. 10%). Despite these differences, the procedure was equally successful in both sexes: in 96% of cases, mitral regurgitation was reduced to mild or moderate levels, with no additional complications in women. The only technical difference was a slightly higher mean mitral gradient in women (3.0 vs. 2.0 mmHg), attributable to the valve’s smaller size and greater stiffness, but without any impact on efficacy or clinical outcomes.
The researchers emphasize that the anatomical differences between sexes did not translate into worse clinical outcomes. The transcatheter repair procedure proved effective and safe in all cases, confirming that the technique is suitable for various anatomical profiles. According to Dr. Chi-Hion Pedro Li, “The main contribution of this work is showing that, although the procedure is equally successful in men and women, the female mitral anatomy—smaller and with greater annular calcification—results in a slightly higher transmitral gradient after repair. This finding encourages us to take that into account when planning each case, particularly when selecting the type and number of devices.”
Dr. Dabit Arzamendi adds, “Our results confirm that transcatheter edge-to-edge repair is a safe and effective technique in both sexes. However, knowing that female sex and smaller body surface area are factors associated with a higher gradient can help us optimize device selection and procedural approach.”
The specialist notes that this information could be valuable not only for current clinical practice but also for the development of new generations of mitral repair devices tailored to the anatomical differences between men and women. “Understanding these anatomical characteristics,” adds Arzamendi, “allows us to move toward more personalized and precision medicine, where each patient receives the treatment best suited to their individual anatomy.”
The study’s findings provide a more detailed view of how sex-specific anatomical characteristics can influence treatment planning. Incorporating this perspective from the initial evaluation will help tailor procedural strategies to each patient’s anatomy, improve device selection, and minimize the risk of residual gradients.
In addition, these findings could help refine imaging criteria used in echocardiography and patient selection, ensuring that structural differences between men and women are considered before the intervention. In the medium and long term, this line of research could foster the development of more versatile and adaptable devices capable of accommodating smaller or more calcified valves.
For the Sant Pau researchers, advancing in this direction means strengthening a more personalized approach to structural cardiology, in which therapeutic decisions are based on each patient’s anatomical and physiological features. This study also reinforces the role of clinical research as a tool to improve health equity and ensure balanced representation of men and women in cardiovascular studies.
According to Dr. Chi-Hion Pedro Li, “For decades, cardiovascular research has been based primarily on male populations, so understanding how sex and anatomy influence the outcomes of structural therapies is key to offering truly personalized treatments.”
The specialist also stresses that such long-term clinical studies allow researchers to translate scientific knowledge directly into patient care. In his view, this integrative approach not only enhances the quality and safety of interventions but also helps reduce long-standing inequities in cardiovascular health.
Li C-HP, Asmarats L, Massó van Roessel A, Capellades H, Fernández-Peregrina E, Arzamendi D. Sex Differences in Mitral Regurgitation Anatomy and Outcomes of Transcatheter Edge-to-Edge Repair. Rev Esp Cardiol 2025;78:1010–2. https://doi.org/10.1016/j.recesp.2025.01.024
