Sex-Based Comparative Analysis of Outcomes Following Minimally Invasive Direct Coronary Artery Bypass: A 20-Year...

Despite the increasing adoption of minimally invasive direct coronary artery bypass (MIDCAB), data on its long-term outcomes-particularly regarding sex-based differences-remain limited. This study presents a robust 20-year analysis comparing males and females, assessing perioperative outcomes, long-term survival, and independent predictors of mortality to inform sex-sensitive clinical decision-making.

A retrospective cohort analysis of 676 patients (138 females, 538 males) undergoing MIDCAB was performed. Propensity score matching (PSM) generated balanced female and male cohorts (n = 129 each). Preoperative demographics, short-term outcomes, and long-term survival were assessed using Kaplan-Meier analysis and Cox regression modelling.

In unmatched cohorts, females exhibited significantly lower NYHA class distribution (p = 0.011) and higher atrial fibrillation prevalence (p = 0.038), with otherwise comparable comorbidities. Propensity score matching achieved cohort balance, and short-term outcomes-including 30-day mortality, stroke/TIA, and reoperation-were similar across sexes. Kaplan-Meier analysis of matched cohorts revealed no significant survival difference (log-rank p = 0.3370), though females demonstrated greater 20-year survival than males (77.6% versus 55.8%). In females, age 70-79 (HR 2.66; 95% CI: 1.02-6.95; p = 0.046) and cerebrovascular disease (HR 5.33; 95% CI: 1.49-19.03; p = 0.010) were independently associated with mortality. In males, significant predictors included diabetes (HR 1.86; 95% CI: 1.02-3.38; p = 0.042), chronic kidney disease (HR 4.92; 95% CI: 1.21-20.02; p = 0.026), pulmonary disease (HR 2.35; 95% CI: 1.20-4.60; p = 0.013), cerebrovascular disease (HR 4.77; 95% CI: 1.97-11.56; p < 0.001), and reduced left ventricular ejection fraction (HR 0.17; 95% CI: 0.06-0.43; p < 0.001).

This 20-year study, the longest to date, demonstrates that MIDCAB achieves durable and equivalent long-term survival in males and females. It highlights sex-specific predictors of mortality, emphasizing the necessity for personalized preoperative risk assessment and postoperative management.