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Male-female differences following concomitant coronary artery bypass grafting and aortic valve replacement surgery
Rebecca Krey1, Moritz Jakob1,2, Matthias Karck1
1Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.
Insights
Female patients undergoing combined coronary artery bypass grafting and aortic valve replacement surgery face higher mortality rates. This disparity is particularly pronounced in septuagenarians, highlighting potential sex-based differences in risk and treatment.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Sex-Based Medicine
Background:
- Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) carry significant perioperative risks.
- Clinical risk scores often indicate increased mortality for combined CABG and AVR, particularly in female patients.
- Understanding sex-based differences in outcomes is crucial for optimizing patient care.
Purpose of the Study:
- To investigate sex-based differences in short-term outcomes following combined CABG and AVR.
- To stratify outcomes by age groups to identify specific risk factors.
- To analyze the impact of preoperative characteristics and surgical factors on mortality and major adverse events.
Main Methods:
- Retrospective analysis of 1963 patients undergoing combined CABG and AVR between 2001 and 2021.
- Patients were stratified into four age groups: ≤59, 60-69, 70-79, and ≥80 years.
- Primary endpoints included 30- and 180-day mortality; secondary endpoints assessed risk factors, sex impact, and major adverse events.
Main Results:
- Female patients exhibited significantly higher 30- and 180-day mortality rates (8.3% vs. 4.2% and 15.8% vs. 9.4%, respectively).
- Mortality remained significantly higher for females in the 70-79 age group (septuagenarians).
- Female sex, advanced age, diabetes mellitus, and lower ejection fraction (<30%) were correlated with increased mortality; infrequent use of internal mammary artery grafts was associated with worse outcomes.
Conclusions:
- Sex disparities in baseline characteristics may contribute to delayed surgical intervention in female patients.
- Inherent risk profiles and potentially less aggressive surgical strategies (e.g., fewer internal mammary artery grafts) may explain outcome differences, especially in older female patients.
- Further research is needed to address sex-specific factors influencing outcomes after combined CABG and AVR.
Aims:
Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male-female differences in short-term outcome stratified by age groups.
Methods And Results:
All patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59 years and younger (n = 127), 60-69 (n = 471), 70-79 (n = 1070), and 80 years and older (n = 295). The primary end points of this study were 30 and 180 days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180 days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P < 0.01; 15.8% vs. 9.4%, P < 0.01). Stratified by age groups, 30 and 180 days mortality remained significantly higher in septuagenarians (9.6% vs. 2.5%, P < 0.01; 16.3% vs. 7.7%, P < 0.01). Females were significantly older, had better preserved left ventricular function, and higher incidence of diabetes mellitus compared with male patients in this subgroup (P < 0.01; P = 0.01; P < 0.01). Additionally, females received significantly less internal mammary artery (IMA) conduits (P < 0.01). Female sex (OR: 3.33, 95% CI: [1.76-6.31]; 1.93, [1.22-3.06]), higher age (1.28, [1.13-1.45]; 1.16, [1.06-1.26]), diabetes mellitus (1.93, [1.03-3.60]; 1.70, [1.08-2.67]) and LVEF <30% (3.26, [1.48-7.17]; 2.23, [1.24-4.02]) were correlated with 30 and 180 days mortality, respectively. Upon multivariable testing, sex (1.77, [1.21-2.58]) and LVEF <30% (3.71, [2.39-5.76]) remained independent predictors for major adverse postoperative events. Infrequent use of IMA grafts was associated with increased 30 and 180 days mortality as well as adverse events (0.47, [0.25-0.87]; 0.46, [0.29-0.72]; 0.61, [0.42-0.88]).
Conclusions:
Sex disparities in baseline characteristics may delay operative intervention in female patients. The inherent risk profiles might be responsible for outcome differences in septuagenarians.
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