Women see worse outcomes after thoracic aortic surgery

Women see worse outcomes than men after thoracic aortic surgery requiring hypothermic circulatory arrest (HCA), researchers reported in the Feb. 26 edition of Circulation.

A study of 1,653 patients—30.1 percent of them women—found female sex was an independent predictor of not only in-hospital mortality, but also of stroke and a Society of Thoracic Surgeons-defined composite endpoint of death or major morbidity. The research, spearheaded by Jennifer Chung, MD, MSc, aimed to analyze sex differences in high-risk thoracic surgery in an attempt to better tailor treatments for individual patients.

“Thoracic aortic surgery remains an area in which a substantial opportunity exists for improving perioperative outcomes,” Chung and her co-authors wrote. “A personalized approach to female and male patients may prove to be an important strategy for improving overall surgical outcomes.”

Patients in Chung et al.’s study all underwent thoracic aortic surgery with HCA between 2002 and 2017 at one of 10 institutions included in the Canadian Thoracic Aortic Collaborative. The researchers’ primary outcomes, aside from in-hospital mortality and stroke, were a composite of renal failure, deep sternal wound infection, reoperation and prolonged ventilation.

The team found women who underwent thoracic aortic surgery with HCA were on average older than men (66 years old compared to 61 years) and had more hypertension and renal failure. But they also had less coronary disease, less previous cardiac surgery and higher mean ejection fraction than men.

Men experienced longer cross-clamp and cardiopulmonary bypass times than women, but the sexes saw similar durations of circulatory arrest, methods of cerebral perfusion, nadir temperatures, rates of hemiarch and rates of total arch repair. When it came to aortic root reconstruction, though, including aortic root replacement, Ross or valve-sparing root operations, women saw a 29 percent prevalence compared to men’s 45 percent.

In all, more women than men died after their procedures (11 percent vs. 7.4 percent), experienced stroke (8.8 percent vs. 5.5 percent) and experienced the Society of Thoracic Surgeons-defined composite endpoint for mortality or major morbidity (31 percent vs. 27 percent). In multivariable analyses, female sex was associated with 1.81-fold increased odds of death, 1.9-fold increased odds of stroke and 1.4-fold increased odds of experiencing the composite endpoint.

“A striking outcome gap between the women and men undergoing thoracic aortic surgery was demonstrated in this large multicenter study,” Chung and co-authors wrote.

“Taken together, our data suggest that aortic surgery is being performed on female patients later in the disease process, which may present technical challenges resulting from smaller body size and increased tissue fragility. Such technical factors may explain the outcome gap as well as the more limited repairs in women we have demonstrated.”