Gender differences in mortality after mitral valve operation: evidence for higher mortality in perimenopausal women

Outcomes of mitral valve reoperation and first-time surgery for mitral regurgitation: A nationwide study

BACKGROUND

While mitral reoperation has been assumed to carry higher surgical risk than first-time mitral surgery, outcomes of this procedure remain uncertain.

AIMS

To examine characteristics and outcomes associated with mitral valve reoperation and first-time surgery for mitral regurgitation.

METHODS

Patients undergoing surgery for mitral regurgitation were identified using Danish nationwide registries. The population was categorized into 1) patients undergoing first-time mitral surgery, 2) patients undergoing mitral reoperation. Mortality rates were examined during 180-day follow-up using Reverse Kaplan-Meier and Multivariable Cox-analysis.

RESULTS

In total, 7734 patients underwent surgery for mitral regurgitation. Of these, 428 patients also underwent mitral reoperation. Compared to first-time surgery, reoperated patients were younger (median 64.9 and 66.7 years) and had more cardiovascular comorbidities including atrial fibrillation (61.6 % and 38.8 %) and heart failure (48.7 % and 29.9 %). Median time to reoperation was 2.3 years. Prosthetic replacement was performed in 34.0 % of first-time surgeries and 78.7 % of reoperations. Mortality was 7.1 % following first-time surgery and 10.1 % following reoperation. Following first-time surgery, factors associated with increased mortality rate was prior myocardial infarction (HR = 1.98, 95 %CI 1.62-2.41), heart failure (HR = 1.59, 95 %CI 1.33-1.90), concomitant aortic valve surgery (HR = 1.61-1.27, 95 % CI 1.27-2.02) and bypass grafting (HR = 1.58, 95 %CI 1.31-1.91). Following reoperation, heart failure was associated with increased mortality rate (HR = 2.23, 95 %CI 1.17-4.60).

CONCLUSIONS

Patients undergoing mitral reoperation are young but have developed high burden of comorbidities at the time of reoperation. In spite of this, outcomes of mitral reoperation were acceptable, reflecting that this procedure can be performed safely in selected patients.

Sex dimorphism in kidney health and disease: mechanistic insights and clinical implication

Sex is a key variable in the regulation of human physiology and pathology. Many diseases disproportionately affect one sex: autoimmune diseases, such as systemic lupus erythematosus, are more common in women but more severe in men, whereas the incidence of other disorders such as gouty arthritis and malignant cancers is higher in men. Besides the pathophysiology, sex may also influence the efficacy of therapeutics; participants in clinical trials are still predominately men, and the side effects of drugs are more common in women than in men. Sex dimorphism is a prominent feature of kidney physiology and function, and consequently affects the predisposition to many adult kidney diseases. These differences subsequently influence the response to immune stimuli, hormones, and therapies. It is highly likely that these responses differ between the sexes. Therefore, it becomes imperative to consider sex differences in translational science from basic science to preclinical research to clinical research and trials. Under-representation of one sex in preclinical animal studies or clinical trials remains an issue and key reported outcomes of such studies ought to be presented separately. Without this, it remains difficult to tailor the management of kidney disease appropriately and effectively. In this review, we provide mechanistic insights into sex differences in rodents and humans, both in kidney health and disease, highlight the importance of considering sex differences in the design of any preclinical animal or clinical study, and propose guidance on how to optimal design and conduct preclinical animal studies in future research.

Gender-Tailored Heart Team Decision Making Equalizes Outcomes for Female Patients after Aortic Valve Replacement through Right Anterior Small Thoracotomy (RAST)

BACKGROUND

Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort.

METHODS

This study is a retrospective analysis of 338 patients (2013-2022). Subgroup analysis included a gender-dependent comparison of age groups ≤60 and >60 years.

RESULTS

Women were older (69.27 ± 7.98 vs. 64.15 ± 11.47, p < 0.001) with higher Euroscore II (1.25 ± 0.73 vs. 0.94 ± 0.45, p < 0.001). Bypass and cross-clamp time were shorter (109.36 ± 30.8 vs. 117.65 ± 33.1 minutes, p = 0.01; 68.26 ± 21.5 vs. 74.36 ± 23.3 minutes, p = 0.01), while ICU, hospital stay and atrial fibrillation were higher (2.48 ± 8.2 vs. 1.35 ± 1.4 days, p = 0.005; 11 ± 7.8 vs. 9.48 ± 2.3 days, p = 0.002; 6.7% vs. 4.4%, p = 0.024). Mortality was 0.9%, while stroke was 0.6%. Age subgroup analysis showed that women were older (p = 0.025) with longer ICU and hospital stays (p < 0.001, p = 0.007). On mid-term follow-up (4.52 ± 2.67 years) of 315 patients (94.3%), there was no significant difference in survival, MACCE and re-intervention comparing gender and age groups.

CONCLUSIONS

Despite older age, higher Euroscore II, longer ICU and hospital stay in women, mortality, MACCE and reoperation were low and comparable in gender and age groups. We believe that our patient-tailored heart team decision making combined with RAST translates into gender-tailored medicine, which equalizes the widely reported negative outcomes of female patients after cardiac surgery.

Aortic and Mitral Valve Endocarditis-Simply Left-Sided Endocarditis or Different Entities Requiring Individual Consideration?-Insights from the CAMPAIGN Database

Background: Aortic valve infective endocarditis (AV-IE) and mitral valve infective endocarditis (MV-IE) are often grouped together as one entity: left-sided endocarditis. However, there are significant differences between the valves in terms of anatomy, physiology, pressure, and calcification tendency. This study aimed to compare AV-IE and MV-IE in terms of patient characteristics, pathogen profiles, postoperative outcomes, and predictors of mortality. Methods: We retrospectively analyzed data from 3899 patients operated on for isolated AV-IE or MV-IE in six German cardiac surgery centers between 1994 and 2018. Univariable and multivariable analyses were performed to analyze the risk factors for 30 day and 1 year mortality. A Log-rank test was used to test for differences in long-term mortality. Results: Patients with MV-IE were more likely to be female (41.1% vs. 20.3%.; p < 0.001). Vegetation was detected more frequently in the MV-IE group (66.6% vs. 57.1%; p < 0.001). Accordingly, the rates of cerebral embolic events (25.4% vs. 17.7%; p < 0.001) and stroke (28.2% vs. 19.3%; p < 0.001) were higher in the MV-IE group. Staphylococci had a higher prevalence in the MV-IE group (50.2% vs. 36.4%; p < 0.001). Patients with MV-IE had comparable 30 day mortality (16.7% vs. 14.6%; p = 0.095) but significantly higher 1 year mortality (35.3% vs. 29.0%; p < 0.001) than those with AV-IE. Kaplan-Meier survival analysis showed significantly lower long-term survival in patients with MV-IE (log-rank p < 0.001). Conclusions: Due to the relevant differences between MV-IE and AV-IE, it might be useful to provide individualized, valve-specific guideline recommendations rather than general recommendations for left-sided IE.

Gender Differences in 381 Patients Undergoing Isolated Mitral Regurgitation Repair

OBJECTIVE

 This study aimed to compare the gender differences in isolated mitral regurgitation (MR) repair.

METHODS

 Of 381 adults aged 54.8 ± 12.3 years undergoing mitral valve repair (MVP) for isolated MR from January 2019 to December 2022, the baseline and operative data, and outcomes were compared between 161 women (42.3%) and 220 men (57.7%).

RESULTS

 Women tended to be nonsmokers (98.1 vs. 45%, p < 0.001), and have more cerebrovascular accidents (38.5% vs. 24.1%, p = 0.004) and isolated annular dilatation (19.3 vs. 9.1%, p = 0.010), lower creatinine (70.0 ± 19.5 vs. 86.3 ± 19.9 μmol/dL, p < 0.001), and smaller left ventricular end-diastolic diameter (LVEDD; 54.4 ± 6.7 vs. 57.8 ± 6.6 mm, p < 0.001). One female died of stroke at 2 days (0.3%). Another female (0.3%) underwent mitral valve replacement for failed repair. Stroke occurred in 4 (1.0%). Two underwent reexploration for bleeding (0.5%). Women were more likely to have less 24-hour drainage (290 ± 143 vs. 385 ± 196 mL, p < 0.001). Over a mean follow-up of 2.1 ± 1.1 years (100% complete), 1 woman died and 1 man underwent a reoperation; 28 had moderate MR, and 9 had severe MR. Neither did early and late mortality and reoperation, nor freedom from late moderate or severe MR (71.6 vs. 71.4% at 5 years; p = 0.992) differ significantly between the two genders. Predictors for late moderate or severe MR were anterior leaflet prolapse (hazard ratio [HR] 4.45; 95% confidence interval [CI] 1.18-16.72; p = 0.027) and isolated annular dilation (HR 5.47, 95% CI 1.29-23.25; p = 0.021).

CONCLUSION

 In this series of patients undergoing isolated MR repair, despite significant differences in smoking, cerebrovascular accidents, creatinine, LVEDD, and isolated annular dilatation at baseline, and 24-hour drainage postoperatively, women and men did not show significant differences in early and late survival, reoperation, and freedom from late moderate or severe MR.

Systematic review and meta-analysis of the impact of sex on outcomes after aortic valve replacement

AIMS

In recent years, extensive literature has been produced demonstrating inferior outcomes for women when compared with men undergoing heart valve interventions. Herein, we seek to analyze the literature comparing outcomes between men and women undergoing surgical aortic valve replacement (SAVR).

METHODS

A systematic literature search of PubMed, MEDLINE, and Embase was conducted for articles comparing differences in outcomes between adult men and women undergoing SAVR. One thousand nine hundred and ninety titles were screened, of which 75 full texts were reviewed, and a total of 19 manuscripts met the inclusion criteria and were included in this review.

RESULTS

Pooled estimates of mortality demonstrated that women tended to have lower rates of survival within the first 30 days post-SAVR, although mid-term and long-term mortality did not differ significantly up to 10 years postoperatively. Pooled estimates of postoperative data indicated no difference in the rates of stroke and postoperative bleeding. Rates of aortic valve reoperation and acute kidney injury favored women.

CONCLUSION

Despite the inferior outcomes for women post-SAVR that have been reported in recent years, the results of this meta-analysis demonstrate comparable results between the sexes with comparable mid- to long-term mortality in data pooled from the literature. Although mortality favored men in the short term, rates of aortic valve reoperation and acute kidney injury favored women. Future investigation into this field should focus on identifying discrepancies in diagnosis and initial surgical management in order to address any potential factors contributing to discrepant short-term outcomes.

GRAPHICAL ABSTRACT

http://links.lww.com/JCM/A651.

Sex-Based Differences in Concomitant Tricuspid Repair During Degenerative Mitral Surgery

BACKGROUND

Women with mitral valve disease have higher rates of tricuspid regurgitation (TR) than men. Although tricuspid valve repair (TVr) decreases the progression of TR, we hypothesize that there may be sex-based differences in concomitant TVr at the time of mitral valve operations.

METHODS

Adults undergoing mitral valve operation for degenerative disease with moderate or worse preoperative TR at a high-volume center from 2014 to 2023 were identified. Patients with a previous tricuspid intervention were excluded. A multivariable logistic regression identified predictors of concomitant TVr. To evaluate the clinical impact of not performing TVr, a competing risk model compared development of severe TR or valve-related reoperation by sex among patients without TVr.

RESULTS

Most included patients were women (55% [n = 214 of 388]), and the median age was 73 years (quartile 1-quartile 3, 65-79 years). There was no difference in the rate of severe TR by sex (female, 28%; male, 26%; P = .63). The unadjusted rate of concomitant TVr was 57% for women and 73% for men (P < .001). Overall, women had 52% lower adjusted odds of TVr (adjusted odds ratio, 0.48; 95% CI, 0.29-0.81; P = .006), including a lower adjusted rate for moderate TR (47% [95% CI, 45%-49%] vs 66% [95% CI, 64%-69%]) and for severe TR (83% [95% CI, 81%-86] vs 92% [95% CI, 90%-93%]) Among those without TVr, 12% of women and 0% of men had severe TR or required a valve-related reoperation at 4 years (P < .001).

CONCLUSIONS

Women with moderate or severe TR undergoing mitral valve operation for degenerative disease were less likely to receive concomitant TVr, severe TR was more likely to develop, or they would more likely need a valve-related reoperation. Evaluation of sex-based treatment differences is imperative to improve outcomes for women.

Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery

BACKGROUND AND AIMS

Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR).

METHODS AND RESULTS

In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups.

CONCLUSIONS

For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

Sex-Related Differences Between Patients Undergoing Surgery for Acute Type A Aortic Dissection

Introduction This study aimed to evaluate the sex-specific characteristics and surgical outcomes in patients with acute type A aortic dissection (ATAAD). Materials and methods We reviewed the surgical records of patients who underwent ATAAD repair at our institution between 2004 and 2020 (n=213). Results Of the 213 patients, 100 (46.9%) were male, and 113 (53.1%) were female. Males were younger than females (62.5 vs. 72.9 years, p<0.0001). Females had more nonspecific symptoms (p=0.04), more frequently developed ATAAD before noon (45.0% vs. 53.1%, p=0.01), and had a significantly longer time from onset to surgery (425.1 vs. 595.8 min, p=0.03). The ascending aorta was replaced more frequently in females than in males (54.5% vs. 72.8%, p<0.01). No significant difference was observed in the in-hospital mortality rate between males and females (9.0% vs. 10.6%, p=0.69). The multivariable logistic analysis demonstrated that being male was not an independent predictor of operative mortality (OR, 0.96; 95% CI, 0.18-5.21; p=0.96). At 10 years, males had significantly better long-term survival rates in the unadjusted cohort than females (79.4% vs. 55.9%, p=0.02). Conclusions Male sex was not an independent predictor of early death in patients with ATAAD after surgery, although significant differences were noted in terms of age, onset time, chief complaint, imaging findings, and surgical procedures. A sex-based management strategy involving specific differences should be considered to improve outcomes.

Considerations & challenges of mitral valve repair in females: diagnosis, pathology, and intervention

PURPOSE OF REVIEW

Disparities in mitral valve (MV) repair outcomes exist between men and women. This review highlights sex-specific differences in MV disease aetiology, diagnosis, as well as timing and type of intervention.

RECENT FINDINGS

Females present with more complicated disease: anterior or bileaflet prolapse, leaflet dysplasia/thickening, mitral annular calcification, and mixed mitral lesions. The absence of indexed echocardiographic mitral regurgitation (MR) severity parameters contributes to delayed intervention in women, resulting in more severe symptom burden at time of surgery. The sequelae of chronic MR also necessitate concomitant procedures (e.g. tricuspid repair, arrhythmia surgery) at the time of mitral surgery. Complex MV pathology, greater patient acuity, and more complicated procedures collectively pose challenges to successful MV repair and postoperative recovery. As a consequence, women receive disproportionately more MV replacement than men. In-hospital mortality after MV repair is also greater in women than men. Long-term outcomes of MV repair are comparable after risk-adjustment for preoperative status; however, women experience a greater incidence of postoperative heart failure.

SUMMARY

To address the inequity in MV repair outcomes between sexes, indexed diagnostic measurements, diligent surveillance of asymptomatic MR, increased recruitment of women in large clinical trials, and mandatory reporting of sex-based subgroup analyses are recommended.

Sex differences in blood pressure regulation and hypertension: renal, hemodynamic, and hormonal mechanisms

The teleology of sex differences has been argued since at least as early as Aristotle's controversial Generation of Animals more than 300 years BC, which reflects the sex bias of the time to contemporary readers. Although the question "why are the sexes different" remains a topic of debate in the present day in metaphysics, the recent emphasis on sex comparison in research studies has led to the question "how are the sexes different" being addressed in health science through numerous observational studies in both health and disease susceptibility, including blood pressure regulation and hypertension. These efforts have resulted in better understanding of differences in males and females at the molecular level that partially explain their differences in vascular function and renal sodium handling and hence blood pressure and the consequential cardiovascular and kidney disease risks in hypertension. This review focuses on clinical studies comparing differences between men and women in blood pressure over the life span and response to dietary sodium and highlights experimental models investigating sexual dimorphism in the renin-angiotensin-aldosterone, vascular, sympathetic nervous, and immune systems, endothelin, the major renal sodium transporters/exchangers/channels, and the impact of sex hormones on these systems in blood pressure homeostasis. Understanding the mechanisms governing sex differences in blood pressure regulation could guide novel therapeutic approaches in a sex-specific manner to lower cardiovascular risks in hypertension and advance personalized medicine.

Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients

OBJECTIVE

The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives.

METHODS

The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery.

RESULTS

There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival.

CONCLUSIONS

Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.

Comparative Outcomes of Groin Hernia Repair by Sex Among Medicare Beneficiaries

OBJECTIVE

To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair.

BACKGROUND DATA

Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females.

METHODS

Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery.

RESULTS

Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P <0.01), more often white (89.5% vs. 86.7%, P <0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60-0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67-0.68) vs. 0.88% (0.88-0.89)], 3 years [1.91% (1.89-1.92) vs. 2.49% (2.47-2.5)], and 5 years [2.85% (2.82-2.88) vs. 3.7% (3.68-3.75)]. We found no significant difference in the 30-day risk of complications.

CONCLUSIONS

We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition.

Comparison of safety and healthcare utilization following sleeve gastrectomy or gastric bypass among medicare beneficiaries using sex as a biologic variable

BACKGROUND

Bariatric surgery is a common operation, but differences in outcomes between males and females are unknown.

OBJECTIVES

To compare the risk of mortality, complications, reintervention, and healthcare utilization after sleeve gastrectomy or gastric bypass using sex as a biologic variable.

SETTING

United States.

METHODS

Retrospective cohort study of adults undergoing sleeve gastrectomy or gastric bypass from January 1, 2012 to December 31, 2018 using Medicare claims data. We performed a heterogeneity of treatment effect analysis to determine the impact of sleeve gastrectomy versus gastric bypass comparing males to females. The primary outcome was safety (mortality, complications, and reinterventions) up to 5 years after surgery. The secondary outcome was healthcare utilization (hospitalization and emergency department use).

RESULTS

Among 95,405 patients the majority (n = 71,348; 74.8%) were female and most (n = 57,008; 59.8%) underwent sleeve gastrectomy. For all patients, compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of complications and reintervention but a higher risk of revision. Compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of mortality for females (adjusted hazard ratio .86, 95% CI .75-.96) but not males. We found no difference in procedure treatment effect by sex for mortality, hospitalization, emergency department use, or overall reintervention when comparing sleeve to gastric bypass.

CONCLUSIONS

Females and males have similar outcomes following bariatric surgery. Females have a lower risk of complications but a higher risk of reintervention. Decisions surrounding treatment for this common procedure should be tailored to include a discussion of sex-specific differences in treatment outcome.

Mitral Regurgitation in Female Patients: Sex Differences and Disparities

Mitral regurgitation is the most common valvular disease, particularly in older adults. Recent literature has consistently supported that there are significant differences in mitral regurgitation outcomes between male and female patients and that this is likely multifactorial. Numerous sex differences in anatomy and pathophysiology may play a role in delayed diagnoses, referrals, and treatments for female patients. Despite the recognition of these discrepancies in the literature, many guidelines that steer clinical care do not incorporate these factors into society recommendations. Identifying and validating sex-specific diagnostic parameters and increasing the representation of female patients in trials of new mitral regurgitation treatment modalities are key factors in improving outcomes for female patients.

Propensity Matched Outcomes of Minimally Invasive Mitral Surgery: Does a Heart-Team Approach Eliminate Female Gender as an Independent Risk Factor?

BACKGROUND

There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort.

METHODS

In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups.

RESULTS

Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008-8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3).

CONCLUSIONS

Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

Differences among sexes in presentation and outcomes in acute type A aortic dissection repair

OBJECTIVE

Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair.

METHODS

From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database.

RESULTS

Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes.

CONCLUSIONS

Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.

Postacute Care Utilization and Episode of Care Payments Following Common Elective Operations

OBJECTIVE

To describe PAC utilization and associated payments for patients undergoing common elective procedures.

SUMMARY OF BACKGROUND DATA

Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures.

METHODS

Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization.

RESULTS

Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039).

CONCLUSIONS

We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors.

Does sex impact outcomes after mitral valve surgery? A systematic review and meta-analysis

Background and objective:

The published literature investigating the impact of sex on outcomes after mitral valve (MV) surgery has demonstrated inferior outcomes for females over males. However, the true relationship between sex and outcomes after MV surgery continues to be poorly understood.

Materials:

PubMed, Medline, and Embase were systematically searched for articles published from 1 January 2005 to 1 August 2021. This systematic review included retrospective and prospective studies investigating the relationship between sex and outcomes after MV surgery. In all, 2068 articles were initially screened and 12 studies were included in this review.

Results:

Few studies were adequately powered or structured to investigate this topic. Few studies propensity matched patients or isolated for surgical approach. In individual studies, females experienced increased rates of short-term and long-term mortality and increased 1-year mortality in the pooled data. Males experienced increased rates of required pacemaker insertion. The remaining rates of morbidity and mortality did not differ significantly between males and females.

Conclusions:

This review identified increased rates of 1-year mortality in the pooled data for females, while males had increased rates of pacemaker insertion. Despite this, the absence of propensity matching and isolating for surgical approach has introduced confounding variables that impair the ability of the included studies to interpret the results found in the current literature. Studies isolating for surgical approach, propensity matching patients, and examining outcomes with long-term follow-up are required to elucidate the true nature of this relationship.

Dimorphic Response of Sex and Hospital-acquired Acute Kidney Injury

The risk of hospital-acquired acute kidney injury (HA-AKI) depends on a person's intrinsic susceptibility, the presence of risk factors, and on the type and extent of exposure to kidney insults. Older cohort studies have focused on male-only or mostly male populations, assuming a lower incidence of HA-AKI in women. Insufficient statistical power suggested that female sex was a shared susceptibility factor for HA-AKI. It was included as a risk factor in risk prediction models of HA-AKI. With the inclusion of women in clinical research studies, this presumption was challenged. Recent meta-analyses of sex-stratified studies showed that the risk for HA-AKI was significantly higher in men. These results suggested a protective role of female sex hormones. However, these studies were complicated by the inclusion of women across an age spectrum that includes the menopausal shift. Preliminary clinical and basic research data suggest that postmenopausal women lose their protection from HA-AKI. The number, size, and quality of reported clinical studies are low. There is an unmet need to characterize the susceptibility factor sex, to assess its clinical relevance and to evaluate renoprotection by sex hormone administration.

Sex Related Differences in Transcatheter Mitral Valve Repair: A Systematic Review and Meta-analysis

OBJECTIVE

Inequalities in postoperative outcomes between males and females are well described with females often experiencing inferior outcomes after heart valve surgery. Recent literature has demonstrated equivalent or improved outcomes for females after transcatheter aortic valve replacement. Transcatheter mitral valve repair (TMVr) and replacement (TMVR) is a relatively newer field with significantly less literature comparing sex differences. This systematic review and meta-analysis looks to provide a comprehensive summary of the published literature comparing outcomes between males and females undergoing transcatheter MV interventions.

METHODS

PubMed, Medline, and Scopus were systematically searched for all studies comparing outcomes between males and females undergoing TMVr and TMVR. 2,178 English manuscript titles and abstracts were reviewed. Articles were excluded if data was not provided regarding sex differences, transcatheter MV intervention, full-length text was not accessible, or if insufficient data was provided. 2,170 articles were excluded and 8 articles were included in this study.

RESULTS

Pooled estimates of outcomes demonstrated rates of acute kidney injury [OR 1.28 (95% CI, 1.14-1.44; p<0.0001)] favored females while rates of major bleeding favored males [OR 0.85 (95% CI 0.76-0.96; p=0.01)]. Rates of mortality, postoperative MI, and stroke did not differ significantly.

CONCLUSION

A trend has emerged in heart valve interventions with males tending to have improved outcomes after surgical intervention and females experiencing equivalent or improved outcomes after transcatheter interventions. This meta-analysis identified increased rates of acute kidney injury for males, increased rates of major bleeding for females, and otherwise comparable morbidity and mortality in males and females undergoing TMVr.

Sex-Specific Difference in Outcomes after Transcatheter Mitral Valve Repair with MitraClip Implantation: A Systematic Review and Meta-Analysis

Background

Implantation of the MitraClip is a safe and effective therapy for mitral valve repair in patients ineligible for surgery or at high risk of adverse surgical outcomes. However, only limited information is available concerning sex differences in transcatheter mitral valve repair. We therefore sought to conduct a comprehensive meta-analysis of studies that investigated differences between men and women in outcomes following MitraClip implantation.

Methods

The PubMed and Embase databases were searched until November 2019 for studies reporting outcomes after MitraClip implantation in women versus men. Outcomes included all-cause mortality and major complications at 30 days and one year of follow-up.

Results

Six studies (n = 1,109 women; n = 1,743 men) were analyzed. At 30 days, women had a similar risk of postoperative complications, such as stroke, major bleeding, and pericardium effusion, without differences in all-cause mortality, procedure success, or MitraClip usage. At one year, the all-cause mortality, the reduction of mitral regurgitation, and the risk of rehospitalization for heart failure were also comparable between male and female patients.

Conclusion

Gender disparity was not found in complications or prognosis of patients undergoing MitraClip implantation. This study suggests that gender should not be considered as a critical factor in the selection of patients as candidates for MitraClip implantation of concern during follow-up.

Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors

Introduction

Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality.

Materials and methods

The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods.

Results

There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality.

Conclusion

Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Sex differences in health resource utilization, costs and mortality during hospitalization for infective endocarditis in the United States

Background

Few studies have assessed the association between sex and outcomes among patients with infective endocarditis. The aim of the study was to better understand the association between biologic sex, clinical outcomes and surgical treatment patterns among a contemporary cohort of patients admitted to hospital with infective endocarditis.

Methods

We used the National Inpatient Sample dataset from the Health Care Utilization Project to identify adult patients admitted for infective endocarditis between January and December 2016. We compared outcomes between men and women including inpatient hospital mortality, direct hospital costs, length of stay, and inpatient surgical treatment patterns. Multivariable analyses were performed with adjustment for age, socioeconomic status, and comorbidity burden.

Results

Among 18,702 patients with infective endocarditis, there were 8730 (46.7%) women and 1753 (8.4%) in-hospital deaths. In multivariable analysis, female sex was associated with a trend toward lower in-hospital mortality (adjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.80 to 1.01, p = 0.06). Additionally, female sex was associated with significantly shorter hospital length of stay (-0.5 days; 95% CI -0.88 to -0.12, p = 0.009) and lower hospital costs (-$3035; 95% CI -$4277 to -$1792; p < 0.001). Notably, women were less likely to undergo surgical intervention (adjusted OR 0.59; 95% CI 0.52 to 0.67, p < 0.001).

Conclusions

In a contemporary, nationally representative cohort of patients admitted for IE in the United States, there were sex-specific differences in management and in-hospital outcomes. Possible sex-based bias in treatment patterns and access to inpatient surgical intervention for infective endocarditis warrants further study.

Impact of sex on cardiac remodeling and long-term outcomes, following mitral valve replacement

BACKGROUND

Differences in cardiac remodeling after mitral valve (MV) surgery between the sexes is poorly understood. Inferior outcomes for females undergoing MV surgery compared with males have been suggested in the literature, although causative factors behind this discrepancy have not been identified. MATERIALS AND METHODS: In this propensity-matched, retrospective, single-center study, we sought to identify the impact that sex may have on cardiac remodeling and long-term outcomes to better inform clinical decision-making in MV surgical intervention. Outcomes were compared between males and females undergoing MV replacement (MVR) between 2004 and 2018. The primary outcome was cardiac remodeling 1 year postoperatively. Secondary outcomes included mortality, stroke, myocardial infarction (MI), reoperation of the MV, and rehospitalization.

RESULTS

A total of 311 males and 311 females were included after propensity matching. Both groups demonstrated significant improvement in left atrial remodeling, although only males demonstrated a significant degree of improved left ventricular remodeling while their female counterparts did not. Mortality rates were relatively equivalent between the two groups, although males were more likely to develop sepsis and require rehospitalization due to MI.

CONCLUSIONS

There has been little research exploring the differences in cardiac remodeling between the sexes after MVR. The results of this study have suggested that MVR is equally safe for both sexes and has demonstrated a difference in the heart's ability to remodel after MVR. The significance of this difference has the potential to result in largely different clinical outcomes for males and females. Further study is necessary to fully elucidate this relationship.

The Influence of Sex on Clinical Outcomes after Surgical Mitral Valve Replacement in Spain (2001-2015)

(1) Background: Mitral regurgitation (MR) is the second most prevalent valvular heart disease in developed countries. Mitral valve (MV) disease is a common cause of heart failure and a leading cause of morbidity and mortality in the U.S.A. and Europe. (2) Methods: We performed a retrospective study using the Spanish National Hospital Discharge Database, 2001–2015. We included patients that had surgical mitral valve replacement (SMVR) listed as a procedure in their discharge report. We sought to (i) examine trends in incidence of SMVR among women and men in Spain, (ii) compare in-hospital outcomes for mechanical and bioprosthetic SMVR by sex, and (iii) identify factors associated with in-hospital mortality (IHM) after SMVR. (3) Results: We identified 44,340 hospitalizations for SMVR (84% mechanical, 16% bioprosthetic). The incidence of SMVR was higher in women (IRR 1.51; 95% CI 1.48–1.54). The use of mechanical SMVR decreased over time in both sexes and the use of bioprosthetic valves increased over time in both sexes. Men who underwent mechanical and bioprosthetic SMVR had higher comorbidity than women. IHM was significantly lower in women who underwent SMVR than in men (10% vs. 12% p < 0.001 for mechanical and 14% vs. 16% p = 0.025 for bioprosthetic valve, respectively). Major adverse cardiovascular and cerebrovascular events (MACCE) were also significantly lower in women who underwent mechanical and bioprosthetic SMVR. A significant reduction in both in-hospital MACCEs and IHM was observed over the study period regardless of sex. After multivariable logistic regression, male sex was associated with increased IHM only in bioprosthetic SMVR (OR 1.28; 95% CI 1.1–1.5). (4) Conclusions: This nationwide analysis over 15 years of sex-specific outcomes after SMVR showed that incidences are significantly higher in women than men for mechanical and bioprosthetic SMVR. IHM and MACCE have improved over time for SMVR in both sexes. Male sex was independently associated with higher mortality after bioprosthetic SMVR.

Mortality Due to Mitral Regurgitation Among Adults in the United States: 1999-2018

OBJECTIVE

To evaluate the nationwide trends in mortality due to mitral regurgitation (MR) among American adults from 1999 to 2018.

PATIENTS AND METHODS

Trends in mortality due to MR were assessed using retrospective cross-sectional analyses of nationwide mortality data from death certificates of all American residents between January 1, 1999, and December 31, 2018, using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Piecewise linear regression was used to evaluate the trends in the overall population and in subgroups.

RESULTS

Among 45,982 deaths due to MR during the study period, higher mortality rates were seen in older White females from the western United States. In 1999, the crude and age-adjusted mortality rates were 27.4 (95% CI, 26.3 to 28.4) and 27.5 (95% CI, 26.4 to 28.5) per 1,000,000 persons, respectively. By 2018, these rates declined to 18.0 (95% CI, 17.3 to 18.7) and 17.7 (95% CI, 17.0 to 18.4) per 1,000,000 persons, respectively (P<.001 for trend for both). Crude mortality rates declined from 1999 to 2012 (annual percentage change [APC], -4.1 (95% CI, -4.6 to -3.6) but then increased after 2012 (APC, 2.6 [95% CI, 0.8 to 4.4; P<.001 for change in trend]). The age-adjusted mortality rates declined from 1999 to 2012 (APC, -3.9 [95% CI, -4.4 to -3.4]) but subsequently increased after 2012 (APC, 1.4 [95% CI, -0.4 to 3.2; P<.001 for change in trend]). The observed decrease was consistent across age, sex, race, geographic region, and urbanization subgroups (P<.05 for all).

CONCLUSION

Mortality due to MR in American adults declined at an annual rate of approximately 4% until 2012 and has since then increased by about 1.5% annually. These mortality trends warrant further investigation.

Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth?

BACKGROUND

Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability.

METHODS

All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years.

RESULTS

Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21).

CONCLUSIONS

Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.

Sex Differences in Long-Term Survival After Major Cardiac Surgery: A Population-Based Cohort Study

Background

Little attention has been paid to the importance of sex in the long‐term prognosis of patients undergoing cardiac surgery.

Methods and Results

We conducted a retrospective cohort study of Ontario residents, aged ≥40 years, who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral, or tricuspid valve surgery between October 1, 2008, and December 31, 2016. The primary outcome was all‐cause mortality. The mortality rate in each surgical group was calculated using the Kaplan‐Meier method. The risk of death was assessed using multivariable Cox proportional hazard models. Sex‐specific mortality risk factors were identified using multiplicative interaction terms. A total of 72 824 patients were included in the study (25% women). The median follow‐up period was 5 (interquartile range, 3–7) years. The long‐term age‐standardized mortality rate was lowest in patients who underwent isolated CABG and highest among those who underwent combined CABG/multiple valve surgery. Women had significantly higher age‐standardized mortality rate than men after CABG and combined CABG/mitral valve surgery. Men had lower rates of long‐term mortality than women after isolated mitral valve repair, whereas women had lower rates of long‐term mortality than men after isolated mitral valve replacement. We observed a statistically significant association between female sex and long‐term mortality after adjustment for key risk factors.

Conclusions

Female sex was associated with long‐term mortality after cardiac surgery. Perioperative optimization and long‐term follow‐up should be tailored to younger women with a history of myocardial infarction and percutaneous coronary intervention and older men with a history of chronic obstructive pulmonary disease and depression.

Is mitral valve disease treated differently in men and women?

PURPOSE

This study was performed to determine if there is a sex-based bias in referral practices, complexity of disease, surgical treatment, or outcomes in patients undergoing mitral valve surgery at our institution.

METHODS

Data were collected from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and they were defined according to the Society of Thoracic Surgeons National Database ( www.sts.org ). All patients who had mitral valve replacement, mitral valve repair with annuloplasty ring placement, and mitral valve annuloplasty alone were evaluated, including patients who underwent concomitant tricuspid valve surgery, atrial fibrillation ablation, patent foramen ovale closure, and coronary artery bypass grafting. An unmatched comparison was made between the 836 men and 600 women in the entire cohort (N = 1436) and propensity score-matching was performed in 423 pairs of men and women. Additional propensity score-matching for 219 pairs of men and women with Type II mitral valve functional class and no coronary artery disease and for 68 pairs of men and women with Type 1 or Type IIIb mitral valve functional class. Propensity score matching was used to compare sex differences involving a greedy algorithm with a caliper of size 0.1 logit propensity score standard deviation units.

RESULTS

Between 1 April 2004 and 30 June 2017, 1436 patients (41.8% women, mean age 61.1 ± 12.6 years (men), 62.9 ± 13.3 years (women)) underwent mitral valve surgery. The unmatched comparison for the entire cohort showed that, on average, at the time of surgery, women had higher Society of Thoracic Surgery risk scores, were older and had more heart failure, coronary artery disease, and mitral stenosis than men. Women received proportionately fewer mitral repairs and more atrial fibrillation ablation, and tricuspid valve surgery. Women had longer intensive care unit and hospital stays, required more dialysis, and suffered more transient ischemic attacks and cardiac arrests postoperatively, and 30-day mortality rate was higher for women. However, propensity score-matching of 846 of the patients (423 men; 423 women) indicated that both the surgical approaches and surgical outcomes were comparable for men and women who had similar levels of disease and co-morbidities. Additional propensity score-matching of only those patients with degenerative mitral regurgitation (DMR) (219 men; 219 women) and those with Type 1 or Type III mitral valve disease showed no differences in the surgical procedures performed or in 30-day mortality rates.

CONCLUSIONS

Women appear to be referred for mitral valve surgery later in the course of their disease, which could possibly be on the basis of sex bias, but they may also have a more aggressive form of mitral valve disease than men. Regardless of the reasons for the later referral of women for mitral valve surgery, the clinical outcomes are dependent upon the severity of the mitral disease and associated co-morbidities at the time of surgery, not on the basis of sex bias.

Effect of gender on perioperative outcomes after robotic-assisted pulmonary lobectomy

BACKGROUND

Female gender has been associated with worse outcomes after cardiovascular surgery and critical illness. We investigated the effect of gender on perioperative outcomes following robotic-assisted pulmonary lobectomy.

METHODS

We retrospectively analyzed 282 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 53 months. Perioperative outcomes and clinically significant intraoperative and postoperative complications, including respiratory and cardiovascular events, were noted. Chi-Square (χ²), Fisher's exact test, Analysis of Variance (ANOVA), Student's t-test, and Kruskal-Wallis or Mood's median test were used to compare variables, with significance at P≤0.05.

RESULTS

There were 128 men (mean age, 68.8 yr) and 154 women (mean age, 65.9 yr; P=0.02). Women had higher preoperative forced expiratory volume in 1 second as percent of predicted (FEV1%; P=0.001). There were more former smokers in the male cohort (P=0.03) and more nonsmokers in the female cohort (P<0.001). Women had smaller tumors (3.0±0.1 vs. 3.5±0.2 cm, P=0.04), lower estimated blood loss (EBL) (150±34 vs. 250±44 mL, P<0.001), and shorter operative time (168±6 vs. 196±7 min, P=0.01). Rates of intraoperative complications (7.1% vs. 8.6%, P=0.65) and of conversion to open lobectomy (7.8% vs. 8.6%; P=0.81) were similar between genders. Postoperative complications were fewer in women (27.9% vs. 44.5%; P=0.004), the most common of which, in both women and men, were prolonged air leak for ≥7 days (13.0% vs. 22.7%, P=0.03), atrial fibrillation (7.1% vs. 14.8%, P=0.04), and pneumonia (7.8% vs. 10.2%, P=0.49). Hospital length of stay (LOS) (4±0.3 vs. 5±0.5 days) was also shorter for women (P=0.02). Despite the higher postoperative complication rate in men, in-hospital mortality did not differ between genders (P=0.23). Multivariable analyses did not identify female gender as an independent predictor of post-operative complications.

CONCLUSIONS

Female gender was associated with rates of intraoperative complications and of conversion to open lobectomy as low as those for men, but with better perioperative outcomes, lower risk of intraoperative bleeding, and fewer postoperative complications. Thus, robotic-assisted pulmonary lobectomy is feasible and safe for women.

Determinants of late outcomes in women undergoing mitral repair of myxomatous degeneration

OBJECTIVES

Studies have consistently shown that women have worse perioperative outcomes following mitral surgery compared with men. Few data are available that explain these divergent outcomes. This study was conducted to determine whether women with degenerative mitral valve disease present to surgery with more advanced disease than men, and to determine whether these differences influence long-term clinical outcomes.

METHODS

Seven hundred and forty-three patients underwent repair of mitral regurgitation due to myxomatous degeneration between 2001 and 2014. Of these, 208 (28%) were females and concomitant coronary bypass grafting was performed in 103 (14%). The mean clinical follow-up was for 3.1 years, and extended to 11.9 years.

RESULTS

Perioperative mortality was 0.1%. Preoperatively, women had a larger indexed left atrial diameter (27.9 ± 5.7 vs 25.3 ± 4.7 mm/m², P = 0.0001), larger indexed left ventricle end-systolic dimension (20.6 ± 5.5 vs 18.7 ± 5.1 mm/m², P = 0.028) and higher right ventricular systolic pressure (44.4 ± 14.4 vs 41.7 ± 13.3 mmHg, P = 0.026) compared with men. Five-year survival and freedom from recurrent MR ≥2+ were 88.7 ± 1.8 and 90.7 ± 1.6%, respectively. Although gender was not associated with survival (hazard ratio: 1.04 ± 0.4, P = 0.91), women were more likely to develop recurrent MR ≥2+ at follow-up compared with men (hazard ratio: 1.9 ± 0.5, P = 0.007).

CONCLUSIONS

In this large series, women with degenerative mitral valve disease presented with echocardiographic markers suggestive of more advanced disease at the time of surgery. Although there was no difference in early or late survival between groups, women were more likely to develop recurrent MR ≥2+ over the course of follow-up. Earlier surgical referral of women may, therefore, be advised.

Male-female differences and survival in patients undergoing isolated mitral valve surgery: a nationwide cohort study in the Netherlands

OBJECTIVES

The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery.

METHODS

All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients.

RESULTS

Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74).

CONCLUSIONS

There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease.

Excess short-term mortality in women after isolated coronary artery bypass graft surgery

Objective

Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the ‘excess’ deaths occurring in women.

Methods

Short-term mortality was investigated in 13 327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach.

Results

Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 ‘excess’ deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 ‘excess’ deaths among the ∼40 000 women undergoing isolated CABG in the USA each year.

Conclusions

The higher risk associated with female sex lead to 35 ‘excess’ deaths in women in this study cohort (over 10% of the total deaths) and to 392 ‘excess’ deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce women's mortality following CABG. Based on our results, if such work brought women's short-term mortality into line with men's, total short-term mortality could be reduced by up to 10%.

Estrogen administered after cardiac arrest and cardiopulmonary resuscitation ameliorates acute kidney injury in a sex- and age-specific manner

Introduction

There is a sex difference in the risk of ischemic acute kidney injury (AKI), and estrogen mediates the protective effect of female sex. We previously demonstrated that preprocedural chronic restoration of physiologic estrogen to ovariectomized female mice ameliorated AKI after cardiac arrest and cardiopulmonary resuscitation (CA/CPR). In the present study, we hypothesized that male mice and aged female mice would benefit from estrogen administration after CA/CPR. We tested the effect of estrogen in a clinically relevant manner by administrating it after CA/CPR.

Methods

CA/CPR was performed in young (10–15 weeks), middle-aged (43–48 weeks), and aged (78–87 weeks) C57BL/6 male and female mice. Mice received intravenous 17β-estradiol or vehicle 15 min after resuscitation. Serum chemistries and unbiased stereological assessment of renal injury were completed 24 h after CA. Regional renal cortical blood flow was measured by a laser Doppler, and renal levels of estrogen receptor alpha (ERα) and G protein-coupled estrogen receptor (GPER) were evaluated with immunoblotting.

Results

Post-arrest estrogen administration reduced injury in young males without significant changes in renal blood flow (percentage reduction compared with vehicle: serum urea nitrogen, 30 %; serum creatinine (sCr), 41 %; volume of necrotic tubules (VNT), 31 %; P < 0.05). In contrast, estrogen did not affect any outcomes in young females. In aged mice, estrogen significantly reduced sCr (80 %) and VNT (73 %) in males and VNT (51 %) in females. Serum estrogen levels in aged female mice after CA/CPR were the same as levels in male mice. With age, renal ERα was upregulated in females.

Conclusions

Estrogen administration after resuscitation from CA ameliorates renal injury in young males and aged mice in both sexes. Because injury was small, young females were not affected. The protective effect of exogenous estrogen may be detectable with loss of endogenous estrogen in aged females and could be mediated by differences in renal ERs. Post-arrest estrogen administration is renoprotective in a sex- and age-dependent manner.

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.

Gender differences in outcomes following cardiac surgery: implications for managing patients with mitral valve disease

PURPOSE OF REVIEW

This review summarizes the differences in clinical outcomes following cardiac surgery according to gender.

RECENT FINDINGS

Women comprise a large proportion of patients presenting with coronary artery or valvular heart disease. Although it is well known that women have poorer survival following bypass surgery compared with men, more recent data confirm that women also have poorer outcomes after heart valve surgery. Women are also more likely to receive mitral valve replacement instead of repair, when compared with men. These divergent outcomes are because of many factors, including valve disease and clinical presentation, which may result in delayed surgical referral in women.

SUMMARY

Factors that result in poorer outcomes following heart valve surgery, including mitral valve surgery, between men and women remain incompletely understood. These may relate to differences in clinical presentation, valve morphology, and physiology. Further research is needed to clarify differences in heart valve outcomes according to gender.

Estrogen-mediated renoprotection following cardiac arrest and cardiopulmonary resuscitation is robust to GPR30 gene deletion

Introduction

Acute kidney injury is a serious,sexually dimorphic perioperative complication, primarily attributed to hypoperfusion. We previously found that estradiol is renoprotective after cardiac arrest and cardiopulmonary resuscitation in ovariectomized female mice. Additionally, we found that neither estrogen receptor alpha nor beta mediated this effect. We hypothesized that the G protein estrogen receptor (GPR30) mediates the renoprotective effect of estrogen.

Methods

Ovariectomized female and gonadally intact male wild-type and GPR30 gene-deleted mice were treated with either vehicle or 17β-estradiol for 7 days, then subjected to cardiac arrest and cardiopulmonary resuscitation. Twenty four hours later, serum creatinine and urea nitrogen were measured, and histologic renal injury was evaluated by unbiased stereology.

Results

In both males and females, GPR30 gene deletion was associated with reduced serum creatinine regardless of treatment. Estrogen treatment of GPR30 gene-deleted males and females was associated with increased preprocedural weight. In ovariectomized female mice, estrogen treatment did not alter resuscitation, but was renoprotective regardless of GPR30 gene deletion. In males, estrogen reduced the time-to-resuscitate and epinephrine required. In wild-type male mice, serum creatinine was reduced, but neither serum urea nitrogen nor histologic outcomes were affected by estrogen treatment. In GPR30 gene-deleted males, estrogen did not alter renal outcomes. Similarly, renal injury was not affected by G1 therapy of ovariectomized female wild-type mice.

Conclusion

Treatment with 17β-estradiol is renoprotective after whole-body ischemia-reperfusion in ovariectomized female mice irrespective of GPR30 gene deletion. Treatment with the GPR30 agonist G1 did not alter renal outcome in females. We conclude GPR30 does not mediate the renoprotective effect of estrogen in ovariectomized female mice. In males, estrogen therapy was not renoprotective. Estrogen treatment of GPR30 gene-deleted mice was associated with increased preprocedural weight in both sexes. Of significance to further investigation, GPR30 gene deletion was associated with reduced serum creatinine, regardless of treatment.