Castelvecchio Serenella, Milani Valentina, Volpe Marianna, Citarella Michele, Ambrogi Federico, Boveri Sara, Saitto Guglielmo, Garatti Andrea, Menicanti Lorenzo
Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy.
Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy.
ESC Heart Fail. 2021 Feb;8(1):291-299. doi: 10.1002/ehf2.13039. Epub 2020 Nov 10.
Female sex and heart failure (HF) are considered poor prognostic factors for surgery. We aimed to investigate the association between sex and surgical outcomes in patients with ischaemic HF undergoing surgical ventricular reconstruction and coronary artery bypass grafting.
From July 2001 to June 2017, 648 patients [111 women (17%) and 537 men (83%)] were referred to our centre. Follow-up continued through June 2018. All patients underwent surgical ventricular reconstruction; coronary artery bypass grafting was performed in 582 patients (90%). Primary outcome was defined as all-cause mortality. Secondary outcome included all-cause mortality or all-cause hospitalization. Women were older (70 vs. 65 years, P < 0.0001) with lower body surface area (1.70 vs. 1.86 m , P < 0.0001). Women had more diabetes (36% vs. 24%, P = 0.005) and a higher New York Heart Association classification (Class III/IV 65.7% vs. 47.8%, P = 0.0006), without any significant difference in medical therapy except for a higher use of oral antidiabetic agents in women (P = 0.029). At baseline, the left ventricular (LV) end-diastolic volume index was significantly lower in women [median 107.06 (80.6-127.81) vs. 113. 04 (94.33-135.52) mL/m , P = 0.0078] but not the LV end-systolic volume index (ESVI) [median 73.45 (51.93-96.79) vs. 77.03 (60.33-95.71) mL/m , P = 0.1393] and the ejection fraction (median 31% vs. 32%, P = 0.150). Women had a higher rate of anterior remodelling (90.9% vs. 79.1%, P = 0.0129), without evidence of differences in mitral valve insufficiency (P = 0.761 for Grade 0 to 4) and mitral surgery (P = 0.810). After surgery, the percentage of reduction in LV ESVI was higher in women than in men (median ΔLV ESVI -42.06 vs. -31.99, P = 0.0003). 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-cause mortality occurred in 269 patients (41.64%), without significant difference between women (45.9%) and men (40.7%). There was no evidence of difference of all-cause death between sexes (log-rank = 0.2441). When considering mortality and first hospitalization as competing events, Gray's test showed no difference of cumulative incidence functions (all-cause hospitalization, all-cause death, and combined endpoint) according to sex (P = 0.909, P = 0.445, and P = 0.429, respectively).
In this study, long-term outcomes for women and men with ischaemic HF undergoing complex cardiac surgery were equivalent. Albeit older and more symptomatic, women should not be denied this type of cardiac surgery.
女性性别和心力衰竭（HF）被认为是手术预后不良的因素。我们旨在研究接受外科心室重建和冠状动脉搭桥术的缺血性HF患者的性别与手术结果之间的关联。
2001年7月至2017年6月，648例患者[111例女性（17%）和537例男性（83%）]被转诊至我们中心。随访持续至2018年6月。所有患者均接受了外科心室重建；582例患者（90%）进行了冠状动脉搭桥术。主要结局定义为全因死亡率。次要结局包括全因死亡率或全因住院。女性年龄较大（70岁对65岁，P<0.0001），体表面积较低（1.70对1.86 m²，P<0.0001）。女性患糖尿病的比例更高（36%对24%，P=0.005），纽约心脏协会分级更高（III/IV级65.7%对47.8%，P=0.0006），除女性口服抗糖尿病药物使用比例较高外（P=0.029），药物治疗无显著差异。基线时，女性左心室（LV）舒张末期容积指数显著较低[中位数107.06（80.6 - 127.81）对113.04（94.33 - 135.52）mL/m²，P=0.0078]，但左心室收缩末期容积指数（ESVI）[中位数73.45（51.93 - 96.79）对77.03（60.33 - 95.71）mL/m²，P=0.1393]和射血分数（中位数31%对32%，P=0.150）无显著差异。女性前壁重塑发生率较高（90.9%对79.1%，P=0.0129），二尖瓣关闭不全（0至4级，P=0.761）和二尖瓣手术（P=0.810）无差异。术后，女性LV ESVI降低百分比高于男性（中位数ΔLV ESVI -42.06对 -31.99，P=0.0003）。30天内死亡43例患者（6.64%）：12例女性（10.81%）和31例男性（5.77%，P=0.0522）。中位随访9.8年，269例患者（41.64%）发生全因死亡，女性（45.9%）和男性（40.7%）之间无显著差异。两性之间全因死亡无差异证据（对数秩检验=0.2441）。将死亡率和首次住院视为竞争事件时，Gray检验显示根据性别累积发生率函数（全因住院、全因死亡和联合终点）无差异（P分别为0.909、0.445和P=0.429）。
在本研究中，接受复杂心脏手术的缺血性HF女性和男性的长期结局相当。尽管女性年龄较大且症状更明显，但不应拒绝这类女性进行心脏手术。
