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Gender Differences and Early Outcome after Concomitant Aortic Valve and CABG Surgery: A Nationwide Study
Mostafa M. Mokhles1, Sabrina Siregar2, Michel Versteegh2, Luc Noyez3, Bart van Putte4, Alexander BA Vonk5, Jolien W. Roos-Hesselink1, Ad JJC Bogers1, Johanna JM Takkenberg1.
1Erasmus University Medical Center, Rotterdam, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands, 3Radboud University Medical Center, Nijmegen, Netherlands, 4St Antonius Hospital, Nieuwegein, Netherlands, 5Free University Medical Center, Amsterdam, Netherlands.

OBJECTIVE Although gender-related differences in patient presentation, morbidity and mortality are well described for coronary artery bypass grafting (CABG), there is uncertainty about whether this also applies to patients undergoing concomitant aortic valve (AV) and CABG surgery. The aim of this study was to evaluate gender-related differences in patients undergoing concomitant AV and CABG surgery. METHODS All patients (N=5867, 67% males (N=3937)) that underwent AV surgery (replacement: N=5817, 99.1%; reconstruction: N=50, 0.9%) with concomitant CABG in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics, and in-hospital outcome were compared between male en female patients. RESULTS Female patients were older (mean age, 75 vs. 72 years,p<0.001) and had higher logistic EuroSCORE (median score, 8.1 vs. 5.5,p<0.001). Male patients presented more often with chronic lung disease(16.8% vs. 12.1%;p<0.001), extracardiac arteriopathy(18.9% vs. 12.9%;p<0.001), neurological dysfunction(3.5% vs. 2.3%;p<0.001), prior cardiac surgery(4.7% vs. 3.3%;p<0.001), renal disease(2.7% vs. 1.4%;p<0.001), active endocarditis(1.0% vs. 0.4%;p<0.001), moderate(21.2% vs. 15.3%;p<0.001) and poor(5.7% vs. 2.5%;p<0.001) left ventricular function. Female patients received more often stented(81.3% vs. 73.6%;p<0.001) and stentless(5.2% vs. 4.0%;p<0.001) bioprostheses. Male patients, on the other hand, received more often a mechanical prosthesis(21.7% vs. 12.3%;p<0.001). Female patients underwent more often total venous grafting(30.0% vs. 26.3%;p=0.003). In-hospital mortality was 4.1% (n=239) and higher in female compared to male patients(OR 2.00, 95%CI 1.44-2.79;p<0.001). In males, the AUC for the logistic EuroSCORE was 0.78 (95%CI 0.73-0.82) versus 0.69 (95%CI 0.63-0.74) in females. The calibration of the logistic EuroSCORE model resulted in p-values of p<0.001 and p=0.09 for males and females, respectively. CONCLUSIONS There are considerable gender differences in patient presentation, operative characteristics, and in-hospital mortality in contemporary concomitant AV and CABG surgery. The predictive value of logistic EuroSCORE is substantially better in men. This calls for the development of gender specific risk stratification models for combined AV and CABG surgery.
Table 1 Multivariate analyses of risk factors associated with in-hospital mortality in male and female patients


Characteristics

Males

Females

OR (95% CI)

p-value

OR (95% CI)

p-value
Age1.07 (1.03-1.10)<0.0011.05 (1.01-1.09)0.007
Chronic lung disease2.23 (1.42-3.50)<0.001
Extracardiac arteriopathy2.00 (1.29-3.09)0.002
Prior cardiac surgery3.80 (2.08-6.95)<0.0015.90 (2.88-12.12)<0.001
Unstable angina3.29 (1.38-7.82)0.007
LV function
Goodreference
Poor2.61 (1.37-4.99)0.004
Pulmonary hypertension2.23 (1.07-4.67)0.033
Emergent surgery3.14 (1.29-7.62)0.0125.75 (2.49-13.29)<0.001
Total venous graft1.19 (1.00-1.41)0.045
Increasing number of venous anastomosis1.26 (1.05-1.52)0.013

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