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Final Program


Program-At-A-Glance

Rapid Fire Session

Session: Rapid Fire Session 1: Valvular Heart Disease (Monitor 8)

Leveraging Cardiac MRI to Reveal Sex-Specific Disparities in Aortic Regurgitation Outcomes and Surgical Referral Patterns

Thursday, February 5, 2026
10:50 AM - 10:57 AM  
Location: Galapagos / Aruba / Ilhabela (2nd Lower Level)
Background: Current guidelines for timing of aortic valve surgery in patient with chronic aortic regurgitation (AR) recommend valve intervention depending on patient’s symptoms, left ventricular (LV) ejection fraction, and LV size (specifically LV diameters measured by echocardiography). These guidelines are a one-size-fits-all strategy, meaning the same thresholds are applied to guide surgical decision making regardless of sex. This strategy is despite of the fact that evidence has emerged characterizing differences in LV remodeling and clinical outcomes between male and female patients. We aimed to compare sex-specific differences in cumulative incidence of surgery and adverse outcomes in patients with chronic AR, while accounting for other predictors of these events.

Methods: An observational multicenter study was performed of consecutive and unique patients with significant chronic AR across five U.S. institutions within the SCMR registry. Significant AR was defined by AR Fraction (ARFrac) ≥ 20% identified by CMR or ≥moderate AR by echocardiography were also included. The primary outcome was the composite of heart failure hospitalization and all- cause death. Fine-Gray modeling was performed in competing risk analysis adjusted for NYHA class, age, ARFrac, and study site, where aortic valve surgery and the composite outcome were competing risks.

Results: We evaluated 979 patients, 757 male (78%) and 222 female (23%). In cumulative distribution histograms, females had significantly higher prevalence of lower indexed left ventricular end systolic volume (LVESVi) and ARFrac compared to males (Figure 1). Male sex was independently associated with decreased risk of the composite outcome compared to female sex after accounting for the competing risk of surgery and other covariates (sHR: 0.64, 95% CI: 0.43, 0.96). Male sex was associated with a 39% higher probability of undergoing surgery compared to females (sHR: 1.39, 95% CI: 1.02, 1.90). Increasing LVESVi was associated with greater cumulative incidence of adverse outcomes in this model (sHR: 1.01, 95% CI: 1.002, 1.01). ARFrac was associated with a greater cumulative incidence of surgical intervention (sHR: 1.04, 95% CI: 1.03, 1.05) (Table 1, Figure 2).

Conclusion: Despite presenting with lower ARFrac and smaller LVESVi, females had increased risk of the composite outcome and lower probability of being referred for surgery. Furthermore, predictors of adverse outcomes and predictors of surgical referral diverged: LVESVi and female sex were associated with higher risk of death or heart failure hospitalization, while ARFrac and male sex were associated with greater likelihood of surgery. This discrepancy suggests that current surgical guidelines may fail to fully capture predictors of adverse outcomes, particularly in females. Incorporating volumetric

thresholds such as LVESVi by CMR and adopting sex-specific criteria may improve alignment of treatment selection with underlying biological risk.

Table 1. Fine-Gray analysis: subdistribution hazard ratios (SHR) for the competing risks of composite outcome and surgical intervention* 

Term 

SHR 

95% Confidence Interval 

P-value 

  

Risk of Composite Outcome 

  

LVESVi 

1.006 

1.002, 1.012  

0.003 

Sex 

Female (base) 

Male 

  

  

0.641 

  

  

0.429, 0.958 

  

  

0.030 

ARFrac

0.995 

0.980, 1.011 

0.562 

Age 

1.031 

1.017, 1.044 

< 0.0001 

NYHA 

I (base) 

II 

  

  

2.371 

  

  

1.544, 3.639 

  

0 

< 0.0001 

III 

3.205 

1.998, 5.142 

< 0.0001 

IV 

6.109 

2.368, 15.758 

< 0.0001 

  

Probability of Surgery 

LVESVi 

1.0004 

0.997, 1.004 

0.769 

Sex 

Female (base) 

Male 

  

  

1.389 

  

  

1.019, 1.896 

  

  

0.038 

ARFrac

1.042 

1.034, 1.051 

< 0.0001 

Age 

0.994 

0.987, 1.0003 

0.065 

NYHA functional class 

I (base) 

II 

III 

IV 

  

  

1.685 

1.575 

0.633 

  

  

1.276, 2.223 

0.982, 2.526 

0.1405, 2.849 

  

  

< 0.0001 

0.059 

0.551 

*Adjusted for study site 

Left ventricular end-systolic volume indexed (LVESVi), Aortic regurgitant fraction (ARFrac), New York Heart Association (NYHA) 

Cumulative histogram for left ventricular end systolic volume indexed to body surface area (LVESVi) aortic regurgitant fraction (ARFrac) by sex.
Forest Plot - Subdistribution hazard ratios (SHR) showing the association of sex and LVESVi with (A) risk of the composite outcome and (B) probability of surgery in patients with chronic aortic regurgitation.