Female gender does not increase perioperative risk in coronary bypass surgery

Sex-specific disparities in patients undergoing isolated CABG

Study objective

Examine sex-specific characteristics in patients undergoing coronary artery bypass grafting (CABG) at our institution.

Design

Retrospective chart review was performed utilizing our institutional Society of Thoracic Surgeons (STS) database.

Setting

An academic, quaternary care center from 2010 to 2021.

Participants

3163 females and 9573 males underwent isolated CABG.

Interventions

The institutional STS database was queried for preoperative, intraoperative, and postoperative variables.

Main outcome measures

Univariate comparisons between female and male groups were performed using chi-squared tests or fisher exact tests. Multivariate logistic regression was used to assess risk factors for 30-day mortality.

Results

Females had more preoperative comorbidities than males, including hypertension, diabetes, peripheral arterial disease, cerebrovascular disease, renal failure, and prior myocardial infarction. Females more frequently underwent urgent (61 % vs. 58 %) or emergent CABG (5.8 % vs. 4.3 %) compared to males (p < 0.0001). Females experienced longer total intensive care unit (ICU) hours (48.3 h vs. 43.5 h) (p < 0.0001), were more frequently discharged to an extended care facility (13 % vs. 6.4 %) (p < 0.0001) and prescribed less aspirin and beta blocker therapy at discharge than males. In-hospital mortality was higher in females (1.9 % vs. 1.2 %, p = 0.002), as was 30-day mortality (2.7 % vs. 1.6 %, p = 0.0001). Female sex was an independent risk factor for 30-day mortality (odds ratio = 1.46, 95 % CI: 1.06, 2.03, p = 0.02).

Conclusion

Over the past decade, females undergoing CABG had more preoperative comorbidities, urgent and emergent operations, longer postoperative ICU stay and a higher risk of mortality than their male counterparts. Further studies must investigate these disparities to improve outcomes for females undergoing CABG.

Gender-Related Discrepancies in Short-Term Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

The sex differences in patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery are still unclear. Our aim was to investigate the impact of gender on short-term outcomes in males and females after off-pump bypass procedures. Our research was designed as a double-center retrospective analysis. Generally, 343 patients (men (n = 255) and women (n = 88)) who underwent an OPCAB procedure were included in our study. To provide a statistical analysis of unequal cohorts, we created a propensity score-based matching (PSM) analysis (men, n = 61; women, n = 61). The primary endpoint was all-cause in-hospital mortality. Dialysis, transient ischemic attack (TIA), low cardiac output syndrome (LCOS), reoperation due to postoperative bleeding, wound infection and duration of hospital stay were secondary outcomes in our analysis. No significant differences were detected within the male and female groups regarding age (p = 0.116), BMI (p = 0.221), diabetes (p = 0.853), cardiogenic shock (0.256), STEMI (p = 0.283), NSTEMI (p = 0.555) and dialysis (p = 0.496). Males underwent significantly more frequently (p = 0.005) total-arterial revascularization with T-graft technique (p = 0.005) than females. In contrast, temporary pacer use was significantly higher (p = 0.022) in females compared to males. The in-hospital mortality rate was not significantly higher (p = 0.496) in the female group compared to the male group. Likewise, secondary outcomes did not differ significantly between the non-adjusted and the adjusted groups. Based on our findings, gender has no impact on short-term outcomes after OPCAB surgery.

Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis

OBJECTIVES

Previous reports have found females are a higher risk of morbidity and mortality following isolated coronary artery bypass grafting (CABG). Here, we describe the differences in outcomes following isolated CABG between males and females.

METHODS

Following a systematic literature search, studies reporting sex-related outcomes following isolated CABG were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was operative mortality. Secondary outcomes included rates of stroke, repeat revascularization, myocardial infarction, major adverse cardiac events, and late mortality. Subgroup analyses were performed for studies published before and after the year 2000 and for the type of risk adjustment.

RESULTS

Eighty-four studies were included with a total of 903 346 patients. Females were at higher risk for operative mortality (odds ratio: 1.77, 95% confidence interval [CI]: 1.64-1.92, P < 0.001). At subgroup analysis, there was no difference in operative or late mortality between studies published prior and after 2000 or between studies using risk adjustment. Females were at a higher risk of late mortality (incidence rate ratio [IRR]: 1.16, 95% CI: 1.06-1.26, P < 0.001), major adverse cardiac events (IRR: 1.40, 95% CI: 1.19-1.66, P < 0.001), myocardial infarction (IRR: 1.28, 95% CI: 1.13-1.45, P < 0.001) and stroke (IRR: 1.31, 95% CI: 1.15-1.51, P > 0.001) but not repeat revascularization (IRR: 0.99, 95% CI: 0.76-1.29, P = 0.95). The use of the off-pump technique or multiple arterial grafts was not associated with the primary outcome.

CONCLUSIONS

Females undergoing CABG are at higher risk for operative and late mortality as well as postoperative events including major adverse cardiac events, myocardial infarction and stroke.

PROSPERO REGISTRATION

CRD42020187556.

Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: A secondary analysis of the GOPCABE trial

OBJECTIVE

Female sex is considered a significant risk in cardiac surgery and is included in the majority of scores for risk assessment. However, the evidence is controversial and older women undergoing cardiac surgery have not specifically been investigated. We assessed the influence of female sex on surgical risk (30-day mortality) in a secondary analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass grafting in the Elderly (GOPCABE) trial, comparing on- to off-pump) and also evaluated its impact on risk prediction from commonly used risk scores.

METHODS

We performed logistic regression analyses on the GOPCABE trial population, where patients were randomized to either on- or off-pump CABG. The study was performed in 12 cardiac surgery centers in Germany and analyzed 2394 patients having undergone CABG at age ≥75 years (1187 on-pump, 1207 off-pump). Of the 2394 patients, 755 (32%) were women. The logistic EuroSCORE and the German KCH score were calculated as expected (E) mortality and values were compared to observed (O) 30-day mortality (O/E ratio).

RESULTS

There was no difference in mortality or major cardiovascular adverse events after 30 days between men and women for both on- and off-pump CABG (men: on- vs. off-pump OR = 0.90, 95%-CI: [0.63;1.27]; women: on- vs. off-pump OR = 1.07, 95%-CI: [0.62;1.87]). Therefore, groups were combined for further analyses. Both men and women had considerable and similar comorbidities. Expected mortality was significantly higher for women than for men (logistic EuroSCORE: 8.88±6.71% vs. 7.99±6.69%, p = 0.003; KCH score: 4.42±3.97% vs. 3.57±3.65%, p = 0.001). However, observed mortality rates (O) tended to be even lower in women (2.1% vs. 3.0%). The O/E ratio was closer to 1 in men than in women (0.84 vs. 0.47). Excluding female sex from the risk models increased O/E ratio to 0.69.

CONCLUSIONS

Female sex is not a risk factor in coronary bypass surgery in the GOPCABE population. The result is the same for on- and off-pump surgery. Since female sex is a component of most risk scores, the findings may identify a potential inaccuracy in current surgical risk assessment, specifically for elderly women.

TRIAL REGISTRATION

Clinicaltrials.gov GOPCABE trial No. NCT00719667.

Female Gender and Differences in Outcome after Isolated Coronary Artery Bypass Graft Surgery: Does Age Play a Role?

Introduction

Female gender is a known risk factor for early and late mortality after coronary artery bypass graft surgery (CABG). Higher age of women at operation may influence outcome, since age per se is also an important risk factor. The purpose of our study was to analyze possible gender differences in outcome after isolated CABG in different age groups to delineate the impact of female gender and age.

Methods

All patients over 60 years of age undergoing isolated CABG at our department during 2001 and 2011 were included and categorized by age into sexagenarians (2266, 16.6% women), septuagenarians (2332, 25.4% women) and octogenarians (374, 32% women) and assessed by gender for 30-day and 180-day mortality.

Results

Thirty-day mortality was significantly higher in women only amongst septuagenarians (7.1 vs. 4.7%, p = 0.033). Same differences apply for 180-day mortality (12.3 vs. 8.2%, p = 0.033) and estimated one-year survival (81.6 ± 4.2 vs. 86.9 ± 2.2%, p = 0.001). Predictive factors for 30-day mortality of septuagenarian were logistic EuroSCORE (ES) (p = 0.003), perioperative myocardial infarction (MI) (p<0.001), pneumonia (p<0.001), abnormal LV-function (p<0.04) and use of LIMA graft (p<0.001), but not female gender. However, female gender was found to be an independent predictor for 180-day mortality (HR 1.632, p = 0.001) in addition to ES, use of LIMA graft, perioperative MI, pneumonia and abnormal LV function (HR 1.013, p = 0.004; HR 0.523, p<0.001; HR 2.710, p<0.001; HR 3.238, p<0.001; HR 2.013, p<0.001).

Conclusion

Women have a higher observed probability of early death after CABG in septuagenarians. However, female gender was not found to be an independent risk factor for 30-day, but for 180-day survival. Therefore, reduction of high impact risk factors such as perioperative MI and enhancement of LIMA use should be future goals. In view of our findings, decision for surgical revascularization should not be based on gender.

Gender's impact on outcome in coronary surgery with minimized extracorporeal circulation

BACKGROUND

The role of female gender in cardiac surgery is still controversial. We examined the impact of gender on mortality after coronary artery bypass grafting (CABG) with minimized extracorporeal circulation (MECC).

METHODS

Between January 2004 and May 2009, 1,662 patients (439 females, 1,223 males) underwent CABG with MECC at the University Medical Center Regensburg. Perioperative data were retrospectively analyzed; primary end point was in-hospital mortality.

RESULTS

At operation, women were older, had a higher prevalence of diabetes and impaired renal function, and underwent more often non-elective surgery. Unadjusted mortality was significantly lower for men and than for women (2.3 vs. 5.7%; p = 0.001). Risk-adjusted mortality rates were derived by stepwise logistic regression. The final model reduced the gender-related mortality gap from 147 to 32%. Goodness of fit and discriminatory performance (AUC = 0.83) were good. Female gender, however, could not be identified as an independent risk factor for adverse outcome (OR 1.6; 95% CI 0.8-3.4). Risk-adjusted mortality was calculated as 4.9% in females and 2.6% in males. Low body surface area (<1.66 m(2)) was associated with excess mortality in females.

CONCLUSIONS

Gender-related disparity in outcome still remains present after surgery with minimized extracorporeal circulation. However, female gender per se is not an independent risk factor for in-hospital mortality, but close attention should be paid on modifiable risk factors.

Female gender and the risk for death after cardiac surgery in septuagenarians and octogenarians: a retrospective observational study

BACKGROUND

In elderly patients, the impact of gender on outcome after cardiac surgery is a debated topic of ongoing relevance.

OBJECTIVE

This study assessed the hypothesis that, among septuagenarians and octogenarians, women have poorer outcomes compared with men after cardiac surgery.

METHODS

For this retrospective observational study, the electronic medical records of patients who underwent cardiac surgery between January 2006 and August 2009 at Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany, were reviewed. The primary end points were the proportions of women and men with in-hospital and 30-day mortality, and postoperative morbidity was considered a secondary end point.

RESULTS

The records of 598 patients were reviewed (274 female [137 septuagenarians, 162 octogenarians; mean (SD)] age, 77.8 [4.8] years]; 324 male [137 septuagenarians, 162 octogenarians; mean age, 78.3 [4.8] years]; all, P = NS). At baseline, the gender groups differed significantly with respect to mean logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE) (used for calculating expected mortality) (11.9% in women, 9.9% in men; P = 0.007), rate of diabetes mellitus did not reach statistical significance ([statistical significance was considered at P < 0.05] 12.4% vs 7.4%; P = 0.052), rate of renal dysfunction (51.5% vs 28.6%; P < 0.001), proportion undergoing isolated valve surgery (43.1% vs 24.7%, respectively; P < 0.0001), and perfusion technique (conventional [83.2% vs 69.4%] vs minimized [16.8% vs 30.6%] extracorporeal circulation) (P < 0.0001). In-hospital mortality (7.3% vs 5.6%; P = 0.404) and 30-day mortality (8.0% vs 5.9%; P = 0.332) were not significantly different between genders. There were no significant differences in mortality with respect to age group. On multivariate analysis, age and female gender were not found to be independent risk factors for early mortality. The between-gender differences in postoperative morbidity, including central neurologic event (P = 0.412), need for dialysis (P = 0.491), and respiratory insufficiency (P = 1.00), were nonsignificant, as were median durations of intensive care unit stay (P = 0.68) and hospital stay (P = 0.52) stay.

CONCLUSION

In septuagenarians and octogenarians, female gender was not associated with increased risks for morbidity and mortality after cardiac surgery.