Sex-Specific Outcome after Ascending Aortic Surgery in Moderate Hypothermic Circulatory Arrest

Abstract

Background Historically, female patients had worse outcome undergoing heart surgery. No recent data exist on gender-specific outcome after moderate hypothermic circulatory arrest (MHCA). The aim of this large retrospective analysis was to investigate gender disparity in patients undergoing elective surgery of ascending aorta in MHCA at 24°C.

Methods We conducted a retrospective review of 905 (33.3% female) cases of elective heart surgery in MHCA for ascending aortic aneurysm (90.9%) or severely calcified aorta (12.5%) between 2001 and 2015. Furthermore, 299 female and 299 male patients matched by propensity score were compared. Patients with dissection of the aorta were excluded.

Results Women were older (68.4 ± 9.9 vs. 65.8 ± 11.6 years; p = 0.002), had higher logistic EuroSCORE I (18.4 [11.7; 29.2] vs. 12.3% [7.4; 22.6]; p < 0.001), and significantly shorter cardiopulmonary bypass (CPB) time (132 [105; 175] vs. 150 [118; 192] minutes; p < 0.001), while mean MHCA time was longer (15 [13; 19] vs. 14 [12; 17] minutes; p = 0.003). Surgical procedures were less complex in women and they were treated more frequently by isolated supracoronary ascending aorta replacement (61 vs. 54%; p = 0.046). Postoperatively, men showed a higher incidence of neurologic complications (7.0 vs. 3.3%; p = 0.03). The 30-day mortality (women 4.9% vs. men 3.9%; p = 0.48) did not differ significantly, likewise after statistical matching (4.7 vs. 2.3%; p = 0.120). Age, CPB time, and blood transfusion, but not female gender, were risk factors for mortality in multivariable regression analysis.

Conclusion This study supports the hypothesis that female gender is not associated with increased short-term mortality or perioperative adverse events in elective aortic surgery in MHCA.

Keywords

aortic valve - aortic root - cardiopulmonary bypass - CPB - hypothermia - circulatory arrest

Ethics Approval

The study was approved by our Institutional Review Board and accordingly individual patient consent was waived due to the retrospective nature of this study.

^* Both authors contributed equally to this work.

Publikationsverlauf

Eingereicht: 12. März 2019

Angenommen: 23. August 2019

Artikel online veröffentlicht:
11. Oktober 2019

• References

• 1 Benjamin EJ, Virani SS, Callaway CW. et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2018 Update: a report from the American Heart Association. Circulation 2018; 137 (12) e67-e492
• 2 Timmis A, Townsend N, Gale C. et al; ESC Scientific Document Group. European Society of Cardiology: cardiovascular disease statistics 2017. Eur Heart J 2018; 39 (07) 508-579
• 3 Sampson UK, Norman PE, Fowkes FG. et al. Global and regional burden of aortic dissection and aneurysms: mortality trends in 21 world regions, 1990 to 2010. Glob Heart 2014; 9 (01) 171-180.e10
• 4 Coady MA, Rizzo JA, Hammond GL. et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms?. J Thorac Cardiovasc Surg 1997; 113 (03) 476-491 , discussion 489–491
• 5 Albornoz G, Coady MA, Roberts M. et al. Familial thoracic aortic aneurysms and dissections--incidence, modes of inheritance, and phenotypic patterns. Ann Thorac Surg 2006; 82 (04) 1400-1405
• 6 Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006; 114 (24) 2611-2618
• 7 Hogue Jr CW, Murphy SF, Schechtman KB, Dávila-Román VG. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999; 100 (06) 642-647
• 8 Ennker IC, Albert A, Pietrowski D, Bauer K, Ennker J, Florath I. Impact of gender on outcome after coronary artery bypass surgery. Asian Cardiovasc Thorac Ann 2009; 17 (03) 253-258
• 9 Puskas JD, Kilgo PD, Kutner M, Pusca SV, Lattouf O, Guyton RA. Off-pump techniques disproportionately benefit women and narrow the gender disparity in outcomes after coronary artery bypass surgery. Circulation 2007; 116 (11, Suppl): I192-I199
• 10 Blackstone EH. Comparing apples and oranges. J Thorac Cardiovasc Surg 2002; 123 (01) 8-15
• 11 Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat 2011; 10 (02) 150-161
• 12 Hogue Jr CW, Barzilai B, Pieper KS. et al. Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report. Circulation 2001; 103 (17) 2133-2137
• 13 Arif R, Farag M, Gertner V. et al. Female gender and differences in outcome after isolated coronary artery bypass graft surgery: does age play a role?. PLoS One 2016; 11 (02) e0145371
• 14 den Ruijter HM, Haitjema S, van der Meer MG. et al; IMAGINE Investigators. Long-term outcome in men and women after CABG; results from the IMAGINE trial. Atherosclerosis 2015; 241 (01) 284-288
• 15 Guida P, Mastro F, Scrascia G, Whitlock R, Paparella D. Performance of the European System for Cardiac Operative Risk Evaluation II: a meta-analysis of 22 studies involving 145,592 cardiac surgery procedures. J Thorac Cardiovasc Surg 2014; 148 (06) 3049-57.e1
• 16 Kallenbach K, Kojic D, Oezsoez M. et al. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre experience with 548 patients. Eur J Cardiothorac Surg 2013; 44 (02) 337-345
• 17 Erbel R, Aboyans V, Boileau C. et al; ESC Committee for Practice Guidelines; The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
• 18 Kamiya H, Hagl C, Kropivnitskaya I. et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007; 133 (02) 501-509
• 19 Tian DH, Wan B, Bannon PG. et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2 (02) 148-158
• 20 Vallabhajosyula P, Jassar AS, Menon RS. et al. Moderate versus deep hypothermic circulatory arrest for elective aortic transverse hemiarch reconstruction. Ann Thorac Surg 2015; 99 (05) 1511-1517
• 21 Yoo JS, Kim JB, Joo Y. et al. Deep hypothermic circulatory arrest versus non-deep hypothermic beating heart strategy in descending thoracic or thoracoabdominal aortic surgery. Eur J Cardiothorac Surg 2014; 46 (04) 678-684
• 22 Lai DT, Robbins RC, Mitchell RS. et al. Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection?. Circulation 2002; 106 (12, suppl 1): I218-I228
• 23 Ad N, Holmes SD, Massimiano PS. et al. Operative risk and preoperative hematocrit in bypass graft surgery: role of gender and blood transfusion. Cardiovasc Revasc Med 2015; 16 (07) 397-400
• 24 Mehta RH, Castelvecchio S, Ballotta A, Frigiola A, Bossone E, Ranucci M. Association of gender and lowest hematocrit on cardiopulmonary bypass with acute kidney injury and operative mortality in patients undergoing cardiac surgery. Ann Thorac Surg 2013; 96 (01) 133-140
• 25 Noimark D. Predicting the onset of delirium in the post-operative patient. Age Ageing 2009; 38 (04) 368-373
• 26 Arnaoutakis GJ, Vallabhajosyula P, Bavaria JE. et al. The impact of deep versus moderate hypothermia on postoperative kidney function after elective aortic hemiarch repair. Ann Thorac Surg 2016; 102 (04) 1313-1321