Comparable outcomes between genders in patients undergoing surgical ventricular reconstruction for ischaemic heart failure

AIMS: 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.

METHODS AND RESULTS: 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 m2 , 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/m2 , 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/m2 , 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).

CONCLUSIONS: 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.