Background: Femal sex and heart failure (HF) are traditionally considered poor prognostic factors for surgery. However, the influence of patient sex on outcomes following cardiac surgery is proving controversial and the current guidelines are lacking in providing specific indications.
Purpose: We aimed to investigate the association of sex on outcomes of a large, single-center population with ischemic left ventricular dysfunction undergoing coronary artery bypass grafting (CABG) plus surgical ventricular reconstruction (SVR) with or without mitral valve surgery.
Methods: From July 2001 to June 2017, 648 patients (111 women [17%] and 537 men [83%]) with previous myocardial infarction, LV remodeling and HF were referred to our Center for cardiac surgery. Follow-up continued through June 2018. All patients underwent SVR; CABG was performed in 582 patients (90%) and mitral valve surgery in 200 patients (30%). Primary outcome was defined the time to death from any cause, including death within 30 days. Secondary outcome included death from any cause at 30 days or hospitalization for any cause.
Results: At baseline, women were older (67.7±9.56 versus 63.9±9.43, P<0.0001) with lower body surface area (1.69±0.15 versus 1.87±1.15, P<0.0001). Women had more diabetes (40 (36%) versus 126 (24%), P=0.005), less tabagic habit (42 (37.8%) versus 397 (73.9%), P<0.0001) and higher NYHA class (class III/IV, 73 (65.7%) versus 257 (47.8%), P=0.0006), without any significant difference in medical therapy. At baseline echocardiographic evaluation, the diastolic diameter (59,7±10.26 mm versus 65.73±8.85 mm, P<0.0001), the systolic diameter (46.81±11.76 mm versus 52.53±10.22 mm, P<0.0001) and the end-diastolic volume index (109.33±36.50 ml/m2 versus 118. 95±37.52 ml/m2) were lower in women, but not the ejection fraction (31.02%±8.71 versus 32.10%±7.99, P=0.150). Women had a higher rate of anterior remodeling (101 (90.9%) versus 425 (79.1%)), while the rate of posterior remodeling was lower (7 (6.3%) versus 89 (16.5%), all P=0.0129), although without differences in the degree of mitral valve insufficiency (P=0.761 for grade 0 to 4) and mitral surgery (P=0.3985). Overall, mortality within 30 days occurred in 43 patients (6.64%), 12 women (10.81%) and 31 men (5.77%) (P=0.0522). Over a median follow-up of 9.8 years all-causes deaths occurred in 269 patients (41.64%), without significant difference between women (51, 45.9%) and men (218, 40.7%, P=0.3120). In addition, hospitalizations (247, 41.6%) were not statistically different (40.40% versus 41.9%, P=0.7825) between sexs. At Kaplan-Meier analysis, the probability of all-cause death at 5 and 10 years was 0.25 [0.21–0.28] and 0.45 [0.41–0.50] (Log-rank=0.241) (Figure).
Conclusions: In a “ real world ” of ischemic HF population undergoing complex cardiac surgery, outcomes for women and men are equivalent. Albeigt older and more symptomatic for HF, women have not to be denied cardiac surgery.