Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Original Article

Volume 17, Number 4, August 2026, pages 277-287

Racial Disparities in Transcatheter Edge-to-Edge Repair Versus Open Mitral Valve Surgery: A Nationwide Analysis

↓ Figure 1. Study flow diagram. NIS: National Inpatient Sample; TEER: transcatheter edge-to-edge repair.

↓ Figure 2. Forest plot showing adjusted odds ratios (ORs) with 95% confidence intervals for in-hospital mortality by race/ethnicity, with White patients as the reference group.

↓ Figure 3. Forest plot of adjusted odds ratios (ORs) with 95% confidence intervals for late or emergent presentation by race/ethnicity, with White patients as the reference group.

↓ Figure 4. In-hospital mortality by race and procedure type. Bar plots comparing in-hospital mortality rates stratified by race/ethnicity for patients undergoing transcatheter edge-to-edge repair (TEER) and open mitral valve surgery. P values reflect adjusted comparisons between each racial group and White patients within each procedural stratum. PI: Pacific Islander.

↓ **Table 1.** Baseline Characteristics by Race/Ethnicity
Characteristic	Overall (n = 26,456)	White (n = 22,050)	Black (n = 2,178)	Hispanic (n = 1,382)	Asian/PI (n = 846)	P
^aSevere heart failure was defined as a heart-failure diagnosis with APR-DRG severity ≥ 3 and was used as a proxy for likely secondary (functional) mitral regurgitation. PI: Pacific Islander; ICD-10: ICD-10-CM: International Classification of Diseases, 10th Revision; SD: standard deviation; TEER: transcatheter edge-to-edge repair; COPD: chronic obstructive pulmonary disease; ED: emergency department.
Age, mean (years)	68.7	69.6	62.2	66.4	64.3	< 0.001
Age < 50, %	8.8	7.4	17.8	13.2	16.6	< 0.001
Age 50–64, %	26.1	24.8	36.0	28.6	30.3
Age 65–74, %	27.0	27.4	25.3	24.2	25.7
Age 75–84, %	26.8	28.2	16.8	23.4	20.0
Age ≥ 85, %	11.3	12.2	4.1	10.6	7.6
Male, %	57.8	59.1	47.2	54.6	56.2	< 0.001
Insurance						< 0.001
Medicare, %	61.7	63.6	52.9	55.9	44.7
Medicaid, %	4.8	3.2	14.3	12.2	10.6
Private, %	30.4	30.4	27.9	26.8	40.2
Other/Self-pay, %	3.2	2.8	4.9	5.1	4.5
Income quartile						< 0.001
Q1 (lowest), %	19.9	17.2	44.6	29.9	8.7
Q4 (highest), %	29.5	30.9	13.3	19.5	52.5
Large hospital, %	72.2	71.7	73.3	74.5	77.5	0.005
Teaching hospital, %	91.1	90.9	92.8	90.9	91.8	0.117
Region						< 0.001
Northeast, %	19.6	20.2	16.6	18.7	15.5
Midwest, %	24.1	26.0	19.5	8.8	11.4
South, %	33.9	32.3	53.2	40.4	16.1
West, %	22.4	21.6	10.7	32.1	57.1
Comorbidities (ICD-10 ascertained)
Hypertension, %	73.8	72.1	87.7	79.6	72.9	< 0.001
Diabetes, %	18.1	15.8	29.4	31.5	25.2	< 0.001
Obesity, %	14.3	13.4	22.8	18.7	8.4	< 0.001
Chronic kidney disease, %	23.8	21.8	40.5	29.7	22.5	< 0.001
COPD, %	11.9	11.9	15.3	10.2	5.7	< 0.001
Atrial fibrillation, %	58.7	60.5	44.2	53.0	58.0	< 0.001
Heart failure, %	60.6	58.6	75.8	69.3	57.7	< 0.001
Coronary artery disease, %	42.3	42.1	42.2	47.3	38.3	< 0.001
Cardiomyopathy, %	17.3	15.0	36.7	23.3	17.9	< 0.001
Pulmonary hypertension, %	22.9	21.6	32.5	26.3	26.0	< 0.001
Severe heart failure^a, %	31.4	29.1	47.1	41.2	32.9	< 0.001
Late presentation
Late referral composite, %	15.1	13.4	23.8	27.4	16.1	< 0.001
Nonelective admission, %	14.8	13.1	23.6	27.3	16.1	< 0.001
ED arrival, %	4.8	4.2	9.4	8.2	3.7	< 0.001
TEER (vs open repair), %	89.3	89.4	90.3	88.5	86.9	0.051

↓ Table 1. Baseline Characteristics by Race/Ethnicity

Characteristic

Overall (n = 26,456)

White (n = 22,050)

Black (n = 2,178)

Hispanic (n = 1,382)

Asian/PI (n = 846)

^aSevere heart failure was defined as a heart-failure diagnosis with APR-DRG severity ≥ 3 and was used as a proxy for likely secondary (functional) mitral regurgitation. PI: Pacific Islander; ICD-10: ICD-10-CM: International Classification of Diseases, 10th Revision; SD: standard deviation; TEER: transcatheter edge-to-edge repair; COPD: chronic obstructive pulmonary disease; ED: emergency department.

Age, mean (years)

68.7

69.6

62.2

66.4

64.3

< 0.001

Age < 50, %

8.8

7.4

17.8

13.2

16.6

< 0.001

Age 50–64, %

26.1

24.8

36.0

28.6

30.3

Age 65–74, %

27.0

27.4

25.3

24.2

25.7

Age 75–84, %

26.8

28.2

16.8

23.4

20.0

Age ≥ 85, %

11.3

12.2

4.1

10.6

7.6

Male, %

57.8

59.1

47.2

54.6

56.2

< 0.001

Insurance

< 0.001

Medicare, %

61.7

63.6

52.9

55.9

44.7

Medicaid, %

4.8

3.2

14.3

12.2

10.6

Private, %

30.4

27.9

26.8

40.2

Other/Self-pay, %

3.2

2.8

4.9

5.1

4.5

Income quartile

< 0.001

Q1 (lowest), %

19.9

17.2

44.6

29.9

8.7

Q4 (highest), %

29.5

30.9

13.3

19.5

52.5

Large hospital, %

72.2

71.7

73.3

74.5

77.5

0.005

Teaching hospital, %

91.1

90.9

92.8

90.9

91.8

0.117

Region

< 0.001

Northeast, %

19.6

20.2

16.6

18.7

15.5

Midwest, %

24.1

26.0

19.5

8.8

11.4

South, %

33.9

32.3

53.2

40.4

16.1

West, %

22.4

21.6

10.7

32.1

57.1

Comorbidities (ICD-10 ascertained)

Hypertension, %

73.8

72.1

87.7

79.6

72.9

< 0.001

Diabetes, %

18.1

15.8

29.4

31.5

25.2

< 0.001

Obesity, %

14.3

13.4

22.8

18.7

8.4

< 0.001

Chronic kidney disease, %

23.8

21.8

40.5

29.7

22.5

< 0.001

COPD, %

11.9

15.3

10.2

5.7

< 0.001

Atrial fibrillation, %

58.7

60.5

44.2

53.0

58.0

< 0.001

Heart failure, %

60.6

58.6

75.8

69.3

57.7

< 0.001

Coronary artery disease, %

42.3

42.1

42.2

47.3

38.3

< 0.001

Cardiomyopathy, %

17.3

15.0

36.7

23.3

17.9

< 0.001

Pulmonary hypertension, %

22.9

21.6

32.5

26.3

26.0

< 0.001

Severe heart failure^a, %

31.4

29.1

47.1

41.2

32.9

< 0.001

Late presentation

Late referral composite, %

15.1

13.4

23.8

27.4

16.1

< 0.001

Nonelective admission, %

14.8

13.1

23.6

27.3

16.1

< 0.001

ED arrival, %

4.8

4.2

9.4

8.2

3.7

< 0.001

TEER (vs open repair), %

89.3

89.4

90.3

88.5

86.9

0.051

↓ **Table 2.** Odds of Receiving TEER vs Open Surgery by Race/Ethnicity
Race (vs White)	Model 1 unadjusted	Model 2 + demographics	Model 3 + hospital	Model 4 fully adjusted*
PI: Pacific Islander; TEER: transcatheter edge-to-edge repair.
Black	1.10 (0.95–1.28) P = 0.200	1.53 (1.30–1.79) P < 0.001	1.53 (1.30–1.80) P < 0.001	1.36 (1.15–1.61) P < 0.001
Hispanic	0.92 (0.77–1.09) P = 0.323	1.07 (0.89–1.28) P = 0.476	1.12 (0.93–1.34) P = 0.241	1.04 (0.86–1.25) P = 0.699
Asian/PI	0.79 (0.63–0.98) P = 0.031	0.99 (0.79–1.24) P = 0.934	1.03 (0.82–1.30) P = 0.773	1.01 (0.81–1.27) P = 0.914

↓ Table 2. Odds of Receiving TEER vs Open Surgery by Race/Ethnicity

Race (vs White)

Model 1 unadjusted

Model 2 + demographics

Model 3 + hospital

Model 4 fully adjusted*

PI: Pacific Islander; TEER: transcatheter edge-to-edge repair.

Black

1.10 (0.95–1.28) P = 0.200

1.53 (1.30–1.79) P < 0.001

1.53 (1.30–1.80) P < 0.001

1.36 (1.15–1.61) P < 0.001

Hispanic

0.92 (0.77–1.09) P = 0.323

1.07 (0.89–1.28) P = 0.476

1.12 (0.93–1.34) P = 0.241

1.04 (0.86–1.25) P = 0.699

Asian/PI

0.79 (0.63–0.98) P = 0.031

0.99 (0.79–1.24) P = 0.934

1.03 (0.82–1.30) P = 0.773

1.01 (0.81–1.27) P = 0.914

↓ **Table 3.** Odds of In-Hospital Mortality by Race/Ethnicity (Sequential Adjustment)
Race (vs White)	Model 1 unadjusted	Model 2 + demographics	Model 3 + hospital	Model 4 + comorbidities	Model 5 fully adjusted†
Black	1.85 (1.33–2.57) P < 0.001	1.89 (1.34–2.65) P < 0.001	1.80 (1.27–2.53) P = 0.001	1.42 (0.98–2.06) P = 0.060	1.49 (1.01–2.19) P = 0.045
Hispanic	1.48 (0.94–2.33) P = 0.088	1.50 (0.95–2.36) P = 0.083	1.43 (0.90–2.27) P = 0.127	1.36 (0.85–2.16) P = 0.199	0.99 (0.62–1.61) P = 0.984
Asian/PI	1.99 (1.20–3.29) P = 0.007	2.48 (1.48–4.16) P < 0.001	2.57 (1.51–4.37) P < 0.001	2.52 (1.47–4.33) P = 0.001	2.20 (1.30–3.72) P = 0.003

↓ Table 3. Odds of In-Hospital Mortality by Race/Ethnicity (Sequential Adjustment)

Race (vs White)

Model 1 unadjusted

Model 2 + demographics

Model 3 + hospital

Model 4 + comorbidities

Model 5 fully adjusted†

Black

1.85 (1.33–2.57) P < 0.001

1.89 (1.34–2.65) P < 0.001

1.80 (1.27–2.53) P = 0.001

1.42 (0.98–2.06) P = 0.060

1.49 (1.01–2.19) P = 0.045

Hispanic

1.48 (0.94–2.33) P = 0.088

1.50 (0.95–2.36) P = 0.083

1.43 (0.90–2.27) P = 0.127

1.36 (0.85–2.16) P = 0.199

0.99 (0.62–1.61) P = 0.984

Asian/PI

1.99 (1.20–3.29) P = 0.007

2.48 (1.48–4.16) P < 0.001

2.57 (1.51–4.37) P < 0.001

2.52 (1.47–4.33) P = 0.001

2.20 (1.30–3.72) P = 0.003

↓ **Table 4.** Length of Stay and Hospital Charges by Race/Ethnicity
Race	Mean LOS (days)	Adjusted IRR (95% CI)	Mean charges ($)	Adjusted ratio (95% CI)	P value
PI: Pacific Islander; IRR: incidence rate ratio; LOS: length of stay; CI: confidence interval.
White	5.6	Reference	212,715	Reference	—
Black	7.9	1.06 (1.01–1.12)	255,844	1.07 (1.02–1.11)	0.011/0.002
Hispanic	7.2	1.07 (1.01–1.14)	292,812	1.19 (1.14–1.25)	0.016/< 0.001
Asian/PI	6.4	1.03 (0.98–1.09)	283,508	1.08 (1.03–1.14)	0.274/0.002

↓ Table 4. Length of Stay and Hospital Charges by Race/Ethnicity

Race

Mean LOS (days)

Adjusted IRR (95% CI)

Mean charges ($)

Adjusted ratio (95% CI)

P value

PI: Pacific Islander; IRR: incidence rate ratio; LOS: length of stay; CI: confidence interval.

White

5.6

Reference

212,715

Reference

—

Black

7.9

1.06 (1.01–1.12)

255,844

1.07 (1.02–1.11)

0.011/0.002

Hispanic

7.2

1.07 (1.01–1.14)

292,812

1.19 (1.14–1.25)

0.016/< 0.001

Asian/PI

6.4

1.03 (0.98–1.09)

283,508

1.08 (1.03–1.14)

0.274/0.002

↓ **Table 5.** Late or Emergent Presentation by Race/Ethnicity
Race	Late presentation (unadjusted %)	Composite OR (95% CI)	Nonelective OR (95% CI)	ED arrival OR (95% CI)
PI: Pacific Islander; CI: confidence interval; OR: odds ratio.
White	13%	Reference	Reference	Reference
Black	24%	1.23 (1.08–1.41) P = 0.002	1.25 (1.10–1.43) P = 0.001	1.26 (1.02–1.54) P = 0.031
Hispanic	27%	1.74 (1.47–2.06) P < 0.001	1.76 (1.48–2.08) P < 0.001	1.36 (1.06–1.75) P = 0.016
Asian/PI	16%	1.04 (0.85–1.27) P = 0.716	1.06 (0.86–1.29) P = 0.600	0.76 (0.50–1.15) P = 0.188

↓ Table 5. Late or Emergent Presentation by Race/Ethnicity

Race

Late presentation (unadjusted %)

Composite OR (95% CI)

Nonelective OR (95% CI)

ED arrival OR (95% CI)

PI: Pacific Islander; CI: confidence interval; OR: odds ratio.

White

13%

Reference

Black

24%

1.23 (1.08–1.41) P = 0.002

1.25 (1.10–1.43) P = 0.001

1.26 (1.02–1.54) P = 0.031

Hispanic

27%

1.74 (1.47–2.06) P < 0.001

1.76 (1.48–2.08) P < 0.001

1.36 (1.06–1.75) P = 0.016

Asian/PI

16%

1.04 (0.85–1.27) P = 0.716

1.06 (0.86–1.29) P = 0.600

0.76 (0.50–1.15) P = 0.188

↓ **Table 6.** Sensitivity Analyses for In-Hospital Mortality
Analysis	Black OR (95% CI)	Asian/PI OR (95% CI)	N
PI: Pacific Islander; CI: confidence interval; OR: odds ratio.
Primary analysis (fully adjusted)	1.49 (1.01–2.19), P = 0.045	2.20 (1.30–3.72), P = 0.003	26,076
Large hospitals (bedsize 3) only	1.72 (1.11–2.68), P = 0.016	2.42 (1.36–4.30), P = 0.003	19,092
Teaching hospitals only	1.47 (0.98–2.21), P = 0.065	1.82 (1.04–3.21), P = 0.037	24,089
Severe heart failure subgroup	1.84 (1.21–2.78), P = 0.004	1.94 (1.05–3.60), P = 0.036	8,292
Non-severe heart failure subgroup	1.26 (0.48–3.27), P = 0.640	2.41 (0.92–6.31), P = 0.072	18,161
Race-as-treatment IPTW (Black vs White)	1.29 (0.63–2.61), P = 0.483	Not applicable	23,892

↓ Table 6. Sensitivity Analyses for In-Hospital Mortality

Analysis

Black OR (95% CI)

Asian/PI OR (95% CI)

PI: Pacific Islander; CI: confidence interval; OR: odds ratio.

Primary analysis (fully adjusted)

1.49 (1.01–2.19), P = 0.045

2.20 (1.30–3.72), P = 0.003

26,076

Large hospitals (bedsize 3) only

1.72 (1.11–2.68), P = 0.016

2.42 (1.36–4.30), P = 0.003

19,092

Teaching hospitals only

1.47 (0.98–2.21), P = 0.065

1.82 (1.04–3.21), P = 0.037

24,089

Severe heart failure subgroup

1.84 (1.21–2.78), P = 0.004

1.94 (1.05–3.60), P = 0.036

8,292

Non-severe heart failure subgroup

1.26 (0.48–3.27), P = 0.640

2.41 (0.92–6.31), P = 0.072

18,161

Race-as-treatment IPTW (Black vs White)

1.29 (0.63–2.61), P = 0.483

Not applicable

23,892

↓ **Table 7.** Stratified Analyses by Procedure Type
Procedure	Race	Mortality, %	Adjusted OR (95% CI)	P value
TEER: transcatheter edge-to-edge repair; PI: Pacific Islander; CI: confidence interval; OR: odds ratio.
TEER	White	1.0	Reference	—
	Black	1.9	1.56 (1.02–2.36)	0.038
	Hispanic	1.5	1.06 (0.64–1.76)	0.824
	Asian/PI	2.0	1.96 (1.09–3.52)	0.024
Open surgery	White	1.8	Reference	—
	Black	2.4	2.41 (0.98–5.95)	0.056
	Hispanic	2.1	1.56 (0.45–5.48)	0.485
	Asian/PI	2.6	2.29 (0.62–8.51)	0.216

↓ Table 7. Stratified Analyses by Procedure Type

Procedure

Race

Mortality, %

Adjusted OR (95% CI)

P value

TEER: transcatheter edge-to-edge repair; PI: Pacific Islander; CI: confidence interval; OR: odds ratio.

TEER

White

1.0

Reference

—

Black

1.9

1.56 (1.02–2.36)

0.038

Hispanic

1.5

1.06 (0.64–1.76)

0.824

Asian/PI

2.0

1.96 (1.09–3.52)

0.024

Open surgery

White

1.8

Reference

—

Black

2.4

2.41 (0.98–5.95)

0.056

Hispanic

2.1

1.56 (0.45–5.48)

0.485

Asian/PI

2.6

2.29 (0.62–8.51)

0.216