Coronary Surgery in Women and the Challenges We Face

Sex difference in outcomes after coronary artery bypass grafting: follow-up data of the Netherlands Heart Registration

OBJECTIVES

Controversies exist regarding sex differences in outcomes after coronary artery bypass grafting (CABG). This study assessed sex differences in early and mid-term outcomes after CABG and factors associated with these differences. Outcomes were based on data from the Netherlands Heart Registration (NHR).

METHODS

Data of patients undergoing CABG in the Netherlands between 2013 and 2019 were retrieved from the NHR database. Primary outcomes were early mortality, morbidity and mid-term survival. The population was divided into subgroups based on age (≥ 70 years and < 70 years). Regression analyses investigated the correlation between sex and both early and mid-term mortality.

RESULTS

This study included 41,705 male and 10,048 female patients. Median follow-up was 3.6 (1.8-4.8) years. Female patients were less likely to receive ≥ 2 arterial grafts (15.9% vs 23.2%, p < 0.001), had fewer anastomoses (3.2 ± 1.1 vs 3.5 ± 1.1, p < 0.001), higher 30-day mortality (1.9% vs 1.0%; p < 0.001) and a lower mid-term survival rate (91.3% vs 93.1%, p < 0.001). Perioperative complications, including myocardial infarction and stroke, were more common in female patients (all p < 0.001). Women aged < 70 years had a lower mid-term survival rate than men < 70 years (94.5% vs 96.0%, p < 0.001). Cox regression analysis showed that female sex was not significantly associated with mid-term mortality in the total cohort [hazard ratio (HR) 1.03; p = 0.45] but was associated with mid-term mortality in patients aged < 70 years (HR 1.19; p < 0.001).

CONCLUSIONS

Women undergoing CABG in our cohort presented with more complex risk profiles, received different surgical strategies and had worse early and mid-term outcomes compared to men. Female sex was associated with mid-term mortality only in patients < 70 years of age.

Male-female differences following concomitant coronary artery bypass grafting and aortic valve replacement surgery

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.

Sex differences in outcomes of patients undergoing on-pump coronary artery bypass grafting surgery

There are controversies regarding the impact of sex on mortality and postoperative complications in patients undergoing on-pump coronary artery bypass grafting (CABG), although some studies demonstrate comparable outcomes. This study sought to evaluate sex differences regarding risk factors associated with hospital mortality and postoperative clinical outcomes among patients undergoing isolated on-pump CABG. We conducted a retrospective observational cohort study of patients who underwent isolated on-pump CABG from January 1996 to January 2020. Patients were divided into two groups (male and female) and compared regarding preoperative characteristics, surgical technical variables, and in-hospital outcomes. All-cause mortality between groups was compared using logistic regression. Risk factors for mortality, along with their respective odds ratios (OR), were separately assessed using a logistic regression model with p-values for interaction. We analyzed 4,882 patients, of whom 31.6% were female. Women exhibited a higher prevalence of age >75 years (12.2% vs 8.3%, p<0.001), obesity (22.6% vs 11.5%, p<0.001), diabetes (41.6% vs 32.2%, p<0.001), hypertension (85.2% vs 73.5%, p<0.001), and NYHA functional classes 3 and 4 (16.2% vs 11.2%, p<0.001) compared to men. Use of the mammary artery for revascularization was less frequent among women (73.8% vs 79.9%, p<0.001), who also received fewer saphenous vein grafts (2.17 vs 2.27, p = 0.002). A history of previous or recent myocardial infarction (MI) had an impact on women's mortality, unlike in men (OR 1.61 vs 0.94, p = 0.014; OR 1.86 vs 0.99, p = 0.015, respectively). After adjusting for several risk factors, mortality was found to be comparable between men and women, with an OR of 1.20 (95% CI 0.94-1.53, p = 0.129). In conclusion, female patients undergoing isolated on-pump CABG presented with a higher number of comorbidities. Previous and recent MI were associated with higher mortality only in women. In this cohort analysis, female gender was not identified as an independent risk factor for outcome after CABG.

Coronary artery bypass surgery versus percutaneous interventions for women with multivessel coronary artery disease

OBJECTIVE

To compare outcomes in women undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery.

DESIGN

This retrospective, propensity-score matched cohort study from the New York State cardiac registry (2012-2018) included all women with multivessel coronary artery disease undergoing PCI with everolimus-eluting stents (EES) and CABG surgery. The primary outcome was all-cause mortality. The key secondary outcome was major adverse cardiac events, defined as the composite of all-cause mortality, myocardial infarction, and stroke.

RESULTS

PCI with EES was associated with a higher 6-year risk of mortality (25.75% vs 23.57%; adjusted hazard ratio [AHR], 1.29; 95% confidence interval [CI], 1.14-1.45). PCI also was associated with a higher rate of the composite outcome of death, myocardial infarction, and stroke (36.58% vs 32.89%; AHR, 1.28; 95% CI, 1.17-1.41), as well as myocardial infarction (14.94% vs 9.12%; AHR, 1.84; 95% CI, 1.56-2.17), but not stroke (7.07% vs 7.62%; AHR, 0.83; 95% CI, 0.67-1.03). Repeat revascularization rates also were higher for women undergoing PCI (21.53% vs 11.57%; AHR, 1.88; 95% CI, 1.63-2.17). There was no difference in mortality between the 2 interventions when PCI patients received complete revascularization or had noncomplex lesions and for women without diabetes.

CONCLUSIONS

For women with multivessel coronary artery disease, CABG surgery is associated with lower 6-year mortality, myocardial infarction, and repeat revascularization rates compared to PCI with EES.

Long-term mortality after isolated coronary artery bypass grafting and risk factors for mortality

BACKGROUND

Patients requiring coronary artery bypass grafting (CABG) have multiple co-morbidities which need to be considered in totality when determining surgical risks. The objective of this study is to evaluate short-term and long-term mortality rates of CABG surgery, as well as to identify the most significant risk factors for mortality after isolated CABG.

METHODS

All patients with complete dataset who underwent isolated CABG between January 2008 and December 2017 were included. Univariate and multivariate Cox regression was performed to determine the risk factors for all-cause mortality. Classification and regression tree analysis was performed to identify the relative importance of these risk factors.

RESULTS

3,573 patients were included in the study. Overall mortality rate was 25.7%. In-hospital mortality rate was 1.62% overall. 30-day, 1-year, 5-year, 10-year and 14.5-year mortality rates were 1.46%, 2.94%, 9.89%, 22.79% and 36.30% respectively. Factors associated with death after adjustment for other risk factors were older age, lower body mass index (BMI), hypertension, diabetes mellitus, chronic obstructive pulmonary disease, pre-operative renal failure on dialysis, higher last pre-operative creatinine level, lower estimated glomerular filtration rate (eGFR), heart failure, lower left ventricular ejection fraction and New York Heart Association class II, III and IV. Additionally, female gender and logistic EuroSCORE were associated with death on univariate Cox analysis, but not associated with death after adjustment with multivariate Cox analysis. Using CART analysis, the strongest predictor of mortality was pre-operative eGFR < 46.9, followed by logistic EuroSCORE ≥ 2.4.

CONCLUSION

Poorer renal function, quantified by a lower eGFR, is the best predictor of post-CABG mortality. Amongst other risk factors, logistic EuroSCORE, age, diabetes and BMI had a relatively greater impact on mortality. Patients with chronic kidney disease stage 3B and above are at highest risk for mortality. We hope these findings heighten awareness to optimise current medical therapy in preserving renal function upon diagnosis of any atherosclerotic disease and risk factors contributing to coronary artery disease.

Sex-related differences in outcome of thoracic aortic surgery

BACKGROUND

Sex-related dissimilarities' influence on outcomes following thoracic aortic surgery is poorly understood. Our aim is to examine sex-related disparities in patients undergoing thoracic aortic aneurysm (TAA).

METHODS

A total of 455 cases undergoing thoracic aortic aneurysm (TAA) surgery were consecutively enrolled between December 2009 and December 2015 in a Chinese hospital. Primary outcomes, including overall mortality and related risk factors, were evaluated. Cox regression is utilized to recognize the independent risk factor of these consequences.

RESULTS

Females, compared to males, had greater indexed aortic diameters and higher aortic transvalvular pressure differences. For the location of aortic aneurysms, females had a higher rate of aortic arch involvement, while males had a higher rate of root involvement. Females underwent less frequent complex proximal aortic operations compared with males (29.5% versus 46.9%; p < 0.001). Women and men both had a lower rate of aortic transvalvular pressure difference and LV volume index 7 days after thoracic aortic surgery. The overall mortality for the women's groups (11%) was suggestively greater compared to 4.9% for the men's groups (p = 0.026). Renal failure and aortic arch involvement were the main risk factors associated with males' survival, while maximum indexed aortic diameter and cross-clamp time were the risk factors associated with females' survival.

CONCLUSIONS

The outcome after TAA surgery was less favorable in women with significantly increased overall mortality. It highlights the need to focus on implementing personalized surgery strategies and gender-specific guidelines in treating female patients following TAA surgery.

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

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.

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

Females have an increased risk of short-term mortality after cardiac surgery compared to males: Insights from a national database

OBJECTIVES

Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males.

METHODS

Using data from National Adult Cardiac Surgery Audit, we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010 to 2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theater for bleeding, and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics.

RESULTS

Females, compared to males, had greater odds of experiencing 30-day mortality (CABG odd ratio [OR] 1.76, confidence interval [CI] 1.47-2.09, p < .001; AVR OR 1.59, CI 1.27-1.99, p < .001; MVR OR 1.37, CI 1.09-1.71, p = .006). After CABG, females also had higher rates of postoperative dialysis (OR 1.31, CI 1.12-1.52, p < .001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p = .005) and longer length of hospital stay (β 1.2, CI 1.0-1.4, p < .001) compared to males. Female sex was protective against returning to theater for postoperative bleeding following CABG (OR 0.76, CI 0.65-0.87, p < .001) and AVR (OR 0.72, CI 0.61-0.84, p < .001).

CONCLUSION

Females in the United Kingdom have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.

Long-term survival of female versus male patients after coronary artery bypass grafting

Background

Several of the most extensively used risk prediction tools for coronary artery bypass grafting outcomes include female sex as an independent risk factor for postoperative outcomes. It is not clear whether this putative increased surgical risk impacts long-term survival. This study aimed to assess sex differences in 10-year all-cause mortality.

Methods

Retrospective analysis of 5340 consecutive patients undergoing primary isolated coronary artery bypass surgery, performed from 2000 to 2015, in a Portuguese level III Hospital. The primary endpoint was all-cause mortality at ten years. We employed an overlap weighting algorithm to minimize confounding. Its target population highlights patients with the most overlap in their observed characteristics, and its corresponding estimand is the average treatment effect in the overlap population.

Results

We identified that 5340 patients underwent isolated CABG: 1104 (20.7%) were female, and 4236 (79.3%) were male. Sixteen patients were lost to follow-up (0.3%). The median follow-up time was 12.79 (IQR, 9.52–16.66) years: 12.68 (IQR, 9.48–16.54) years for the male patient group and 13.13 (IQR, 9.75–16.98) years for the female patient group. The primary endpoint of all-cause mortality at ten years occurred in 1106 patients (26.1%) in the male patient group, compared with 315 (28.5%) in the female patient group. The unweighted survival analysis for both groups reveals the worst long-term prognosis for the female cohort (hazard ratio, 1.22; 95% CI, 1.10 to 1.35; p < 0.001), while in the overlap weighted survival analysis, such long-term difference in prognosis disappears (hazard ratio, 0.98; 95% CI, 0.88 to 1.09; p = 0.693).

Conclusion

In this longitudinal, population-level analysis of patients undergoing primary, isolated CABG, we demonstrated that the female sex is not associated with increased long-term all-cause mortality compared to their male counterparts. Thus, sex should not influence the undertaking of an adequate revascularization strategy.

Impact of sex on outcomes after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Despite advances in cardiac surgery, observational studies suggest that females have poorer post-operative outcomes than males. This study is the first to review sex related outcomes following both coronary artery bypass graft (CABG) and valve surgery with or without combined CABG.

METHODS

We identified 30 primary research articles reporting either short-term mortality (in-hospital/30 day), long-term mortality, and post-operative stroke, sternal wound infection and myocardial infarction (MI) in both sexes following CABG and valve surgery with or without combined CABG. Reported adjusted odds/hazard ratio were pooled using an inverse variance model.

RESULTS

Females undergoing CABG and combined valve and CABG surgery were at higher risk of short-term mortality (odds ratio (OR) 1.40; 95% confidence interval (CI) 1.32-1.49; I² = 79%) and post-operative stroke (OR 1.2; CI 1.07-1.34; I² = 90%) when compared to males. However, for isolated AVR, there was no difference found (OR 1.19; 95% CI 0.74-1.89). There was no increased risk in long-term mortality (OR 1.04; 95% CI: 0.93-1.16; I² = 82%), post-operative MI (OR 1.22; 95%CI: 0.89-1.67; I² = 60%) or deep sternal wound infection (OR 0.92; 95%CI: 0.65-1.03, I² = 87%). No evidence of publication bias or small study effect was found.

CONCLUSION

Females are at a greater risk of short-term mortality and post-operative stroke than males following CABG and valve surgery combined with CABG. However, there is no difference for Isolated AVR. Long-term mortality is equivalent in both sexes. PROSPERO Registration: CRD42021244603.

Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care?

Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.

Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease

Background

There are relatively limited data regarding real-world outcomes in very old patients with three-vessel disease (3VD) receiving different therapeutic strategies. This study aimed to perform analysis of long-term clinical outcomes of medical therapy (MT), coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) in this population.

Methods

We included 711 patients aged ≥ 75 years from a prospective cohort of patients with 3VD. Consecutive enrollment of these patients began from April 2004 to February 2011 at Fu Wai Hospital. Patients were categorized into three groups (MT, n = 296; CABG, n = 129; PCI, n = 286) on the basis of different treatment strategies.

Results

During a median follow-up of 7.25 years, 262 deaths and 354 major adverse cardiac and cerebrovascular events (MACCE) occurred. Multivariate Cox analysis showed that the risk of cardiac death was significantly lower for CABG compared with PCI (adjusted hazard ratio [HR] = 0.475, 95% confidence interval [CI] 0.232–0.974, P = 0.042). Additionally, MACCE appeared to show a trend towards a better outcome for CABG (adjusted HR = 0.759, 95% CI 0.536–1.074, P = 0.119). Furthermore, CABG was significantly superior in terms of unplanned revascularization (adjusted HR = 0.279, 95% CI 0.079–0.982, P = 0.047) and myocardial infarction (adjusted HR = 0.196, 95% CI 0.043–0.892, P = 0.035). No significant difference in all-cause death between CABG and PCI was observed. MT had a higher risk of cardiac death than PCI (adjusted HR = 1.636, 95% CI 1.092–2.449, P = 0.017). Subgroup analysis showed that there was a significant interaction between treatment strategy (PCI vs. CABG) and sex for MACCE (P = 0.026), with a lower risk in men for CABG compared with that of PCI, but not in women.

Conclusions

CABG can be performed with reasonable results in very old patients with 3VD. Sex should be taken into consideration in therapeutic decision-making in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02067-6.

Gender Differences in Postoperative Outcomes After Cardiac Surgery

Women presenting for cardiac surgery tend to be older and have hypertension, diabetes, and overweight or underweight body mass index than men. Despite improvements in surgical techniques and medications, women have increased risk for morbidity and mortality after multiple types of cardiac surgery. Women presenting for transcatheter aortic valve replacement are older and frailer than men, and have increased risk of intraoperative complications, but lower mortality at mid- and long-term ranges compared with men. Adherence to recovery and rehabilitation from cardiac surgery is challenging for women. Solutions should focus on increased family support, and use of group exercise and activities.

[Microsurgical technique in coronary bypass surgery: possibilities, perspectives and limitations]

Microsurgical approach implies a special technique of operation under operating microscope with the use of special tools and ultra-thin atraumatic sutures. This method may be used in coronary artery bypass surgery in order to improve conventional technique, its quality and outcomes. The report summarizes information about technical features, capabilities and results of microsurgical coronary artery bypass grafting. The problem of popularizing microsurgical technologies in coronary bypass surgery is also discussed.

Recognition and treatment of ischemic heart diseases in women

Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.

Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score

Background

Prediction scoring systems for coronary artery bypass grafting (CABG) patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not yet been reported. This study was designed to develop a predictive score for in-hospital mortality for cardiogenic shock patients who received VA-ECMO after isolated CABG.

Methods

Retrospective cohort study of consecutive CABG patients supported with VA-ECMO (n = 166) at the Beijing Anzhen Hospital between February 2004 and March 2017.

Results

One hundred and six patients (64%) could be weaned from VA-ECMO, and 74 patients (45%) survived to hospital discharge. On the basis of multivariable logistic regression analyses, the pRedicting mortality in patients undergoing veno-arterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score was created with six pre-ECMO parameters: older age, left main coronary artery disease, inotropic score > 75, CK-MB > 130 IU/L, serum creatinine > 150 umol/L, and platelet count < 100 × 10⁹/L. Four risk classes, namely class I (REMEMBER score 0–13), class II (14–19), class III (20–25), and class IV (> 25) with their corresponding mortality (13%, 55%, 70%, and 94%, respectively), were identified. The area under the receiver operating characteristic curve 0.85(95% CI 0.79–0.91) for the REMEMBER score was better than those for the SOFA, SAVE, EuroSCORE, and ENCOURAGE scores in this population.

Conclusions

The REMEMBER score might help clinicians at bedside to predict in-hospital mortality for patients receiving VA-ECMO after isolated CABG for refractory cardiogenic shock. Prospective studies are needed to externally validate this scoring system.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2307-y) contains supplementary material, which is available to authorized users.