Gender differences in outcomes following cardiac surgery: implications for managing patients with mitral valve 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.

The Effect of Gender on Triple Heart Valve Surgery Outcomes; Reinforcing Women's Health

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m2, P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females (P < .001), and they had lower concomitant coronary artery bypass grafting (P = .001). Bleeding and renal failure were lower in females (P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.

Longitudinal Outcomes Following Surgical Repair of Primary Mitral Regurgitation

Degenerative mitral valve (MV) disease is the most common cause of organic mitral regurgitation (MR) in developed countries. Surgical mitral valve repair is the gold standard treatment for primary MR. Surgical mitral valve repair is associated with excellent outcomes in terms of survival and freedom from recurrent MR. As well, innovations in surgical repair techniques, including thoracoscopically and robotically assisted approaches, further reduce morbidity. Emerging catheter-based therapies may also provide advantages in select patient groups. Although the outcomes following surgical mitral valve repair are well described in the literature, longitudinal follow-up is heterogenous. Indeed, longitudinal follow-up and long-term data are vital to better advise treatment and counsel patients.

Prospective cohort study of characteristics and sex differences in elderly patients with degenerative valvular disease

OBJECTIVES

We aimed to describe the characteristics and to compare the sex differences in the clinical features and prognosis of Chinese elderly patients with senile degenerative valvular heart disease (VHD).

DESIGN

This study was a nationwide, multicentre, prospective cohort study.

SETTING

Participants were enrolled consecutively from 69 hospitals nationwide in China from September to December 2016.

PARTICIPANTS

A total of 2728 patients aged ≥60 years old with an aetiological diagnosis of moderate to severe degenerative VHD as defined by echocardiography were recruited.

MAIN OUTCOME MEASURES

The baseline data and 1-year follow-up data were collected, and disease distribution, clinical features, treatment and prognosis were compared between different sex groups.

RESULTS

Aortic disease was more common in men, and mitral disease was more common in women. Male patients were more likely to have smoking, coronary heart disease, cardiomyopathy, chronic obstructive pulmonary disease and coronary artery bypass grafting histories, while female patients had more hypertension and atrial fibrillation. The average age and left ventricular ejection fraction were significantly lower in men than in women (p<0.001), while the intervention rate (p=0.026) and total hospitalisation cost (p=0.016) of male patients were higher than those of female patients. There were no significant differences in perioperative complications, in-hospital outcomes or short and intermediate prognoses between the two groups.

CONCLUSIONS

Currently, the intervention rate of elderly patients with VHD is still not ideal, with dominant factor-patient rejection. Heart failure was the critical reason for rehospitalisation. There were some differences between men and women in the distribution, severity, clinical characteristics and interventions in senile degenerative valvular disease.

Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature

Sex and gender, among other equity-related characteristics, influence the process of care and patients’ outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.

Prediction of acute kidney injury after left ventricular assist device implantation: Evaluation of clinical risk scores

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVAD patients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the Cleveland Clinic Score (CCS), the Society of Thoracic Surgeons Score (STS), and the Simplified Renal Index Score (SRI) were evaluated. 76 patients underwent LVAD implantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stay on the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P < .01). Whereas the Thakar Score (7.43 ± 1.75 vs 6.44 ± 1.44, P = .02) and the Mehta Score (28.12 ± 15.08 vs 21.53 ± 5.43, P = .02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96 ± 1.15 vs 3.44 ± 1.05, P = .08). Using ROC analyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P = .040), 0.637 ± 0.079 (P = .792), and 0.618 ± 0.075 (P = .764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De Ritis Ratio (OR 2.67, P = .034) and MELD (OR 1.11, P = .028) were identified as predictors of postoperative RRT. Risk scores which are predictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population.

Mortality after emergency abdominal operations in premature infants

CONTEXT/BACKGROUND

To determine risk of 30-day mortality for premature infants undergoing abdominal operations during the first 2 months of life and to identify risk factors for perioperative mortality using available demographic and clinical variables of interest.

BASIC PROCEDURES

Retrospective descriptive analysis of premature infants (gestational age less than or equal to 36weeks) undergoing abdominal operations during the first 2 months of life using the American College of Surgeon's National Surgical Quality Improvement Project Pediatric (NSQIP-P, 2012-2015) database. A stepwise logistic regression model incorporating multiple demographic and clinical factors was constructed to identify independent predictors of 30-day mortality.

FINDINGS

A total of 1554 premature infants were identified who underwent abdominal operations during the first 2 months of life. Unadjusted 30-day mortality ranged from 31% for infants born <24weeks gestational age to 4.9% for those born at 35-36weeks. Increased gestational age corresponded to decreased risk of mortality but week-by-week was not independently predictive of mortality in multivariate modeling. Female sex (aOR 1.51, 95% C.I. 1.08-2.10, p=0.014), inotrope support (aOR 3.46, 95% C.I. 2.43-4.92, p<0.001), ventilator use (aOR 2.86, 95% C.I. 1.56-5.25, p<0.001) and American Society of Anesthesiologists (ASA) class 3 (aOR 4.14, 95% C.I. 1.58-10.81, p=0.004) at time of operation were all associated with significantly increased risk of 30-day mortality. On stepwise logistic regression incorporating only those variables with statistical significance, female sex, inotrope, and ventilator support retained statistical significance.

CONCLUSIONS

Premature infants undergoing abdominal operations during the first 2 months of life have expectedly high risk of 30-day mortality. Female sex, inotrope, and ventilator support are independently associated with increased risk of mortality and can be incorporated into a model where, if present, risk of mortality is greater than 14.2%.

LEVEL OF EVIDENCE

Level III.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation

BACKGROUND

Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics.

METHODS AND RESULTS

We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers.

CONCLUSIONS

We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.

Outcomes in patients undergoing complex cardiac repairs with cross clamp times over 300 minutes

BACKGROUND

Long cross clamp times have been associated with poor clinical outcomes, yet some patients require extremely long ischemic times to repair complex surgical problems. The purpose of this study was to examine short and mid-term survival and to identify risk factors for mortality and morbidity in patients with cross clamp times greater than or equal to 300 min.

METHODS

Review of our institution's Society of Thoracic Surgeons database identified 202 patients who underwent surgical procedures necessitating aortic cross clamp times 300 min or greater between 2001 and 2012. Short-term (30-day) clinical outcomes were derived from this database and survival was assessed utilizing the Social Security Death Index. Univariate and multivariate analyses were used to determine the relationship between independent variables and mortality and postoperative outcomes.

RESULTS

The average age of the patients was 69.5 ± 10.6 (mean ± standard deviation) years and the mean ejection fraction was 52 ± 12 %. 70.3 % of patients were male. Mean cross clamp time was 346 ± 45 min, and total bypass time was 421 ± 70 min. Thirty-day mortality was 12.4 %. The incidence of bleeding and stroke were 6.4 % and 4.0 % respectively. Prolonged ventilation occurred in 26.7 % of patients, and incidence of renal failure was 10.4 %. One, three, five, and seven year survival of the patients who survived the first 30 days post-surgery was 91.9 %, 83.2 %, 75.6 % and 65.7 % respectively. Proportional hazards analysis determined that the statistically significant hazard ratios for mid-term mortality for female gender, age, and prolonged postoperative ventilation were 2.11, 1.04 and 2.72, respectively (p < 0.05 for each).

CONCLUSIONS

Cardiac procedures requiring extremely long ischemic times have significant early mortality and morbidity. However, mid-term survival in the patients who survive is good. Decision-making regarding operability in complex cases should allow for long ischemic times.