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Canadian Journal of Cardiology

Coronary Surgery in Women and the Challenges We Face

Published:February 02, 2018DOI:https://doi.org/10.1016/j.cjca.2018.01.087

      Abstract

      This review was undertaken to understand the dynamics that have shaped our current treatment of women who undergo coronary artery bypass grafting (CABG) and summarize the current literature on surgical revascularization in women. There has been improved access to CABG over the past several decades. Despite this, compared with men, CABG in women involves fewer grafts and less frequent use of arterial grafts, the latter having improved long-term patency compared with saphenous vein grafts. We attempt to determine whether the adverse clinical profile of women, when referred for CABG is responsible for this finding. Female coronary anatomy and pathophysiology are reviewed and an attempt is made to understand how this might affect decisions of selection and outcome measures post CABG. We review the short-term, long-term, and quality of life outcomes in women. These data are taken from large databases, as well as from more recent publications. Randomized controlled trial data and meta-analytic data are used when available. Differential use of and outcomes of surgical strategies, including off-pump CABG and total arterial revascularization, are contrasted with those in men. This review shows that there continues to be widespread differences in surgical approach to coronary artery disease in female vs male patients. We provide evidence suggestive of the existence of issues specific to women that affect selection for surgical procedures and outcomes in women. More work is required to understand the reason for these differences and how to optimize sex-specific outcomes.

      Résumé

      Nous avons réalisé la présente revue pour comprendre la dynamique qui a façonné le traitement que nous offrons actuellement aux femmes qui subissent le pontage aortocoronarien (PAC) et pour résumer la littérature actuelle sur la revascularisation chirurgicale chez les femmes. Au cours des dernières décennies, l’accès au PAC s’est amélioré. En dépit de cette amélioration, le PAC chez les femmes, comparé aux hommes, nécessite moins de greffons et moins fréquemment de greffons artériels qui, par rapport aux greffons veineux saphènes, ont une meilleure perméabilité à long terme. Nous tentons de déterminer si le profil clinique défavorable des femmes lors de l’orientation vers le PAC est responsable de ce fait. Nous examinons l’anatomie et la physiopathologie des artères coronaires chez la femme et nous cherchons à comprendre comment cela peut influer sur les décisions portant sur la sélection et la mesure des résultats après le PAC. Nous passons en revue les résultats à court terme et à long terme, et les résultats liés à la qualité de vie chez les femmes. Ces données proviennent de grandes banques de données et de publications plus récentes. Des données issues d’essais cliniques à répartition aléatoire et de méta-analyses sont utilisées lorsqu’elles sont accessibles. L’utilisation de stratégies chirurgicales distinctes, dont le PAC sans pompe et la revascularisation artérielle totale, et leurs résultats sont différents de ceux des hommes. Cette revue montre que des différences importantes persistent dans l’approche chirurgicale de la coronaropathie entre les femmes et les hommes. Nous présentons des données probantes évocatrices de l’existence de questions propres aux femmes qui influent sur la sélection des interventions chirurgicales et les résultats chirurgicaux chez les femmes. D’autres travaux sont nécessaires pour comprendre les facteurs qui expliquent ces différences et la façon d’optimiser les résultats en fonction du sexe.
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      References

        • Hansen K.W.
        • Soerensen R.
        • Madsen M.
        • et al.
        Developments in the invasive diagnostic-therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study.
        BMJ Open. 2015; 5: e007785
        • Murphy M.L.
        • Hultgren H.N.
        • Detre K.
        • Thomsen J.
        • Takaro T.
        Treatment of chronic stable angina. A preliminary report of survival data of the randomized Veterans Administration cooperative study.
        N Engl J Med. 1977; 297: 621-627
      1. Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group.
        Lancet. 1982; 2: 1173-1180
        • Bolooki H.
        • Vargas A.
        • Green R.
        • Kaiser G.A.
        • Ghahramani A.
        Results of direct coronary artery surgery in women.
        J Thorac Cardiovasc Surg. 1975; 69: 271-277
        • Tyras D.H.
        • Barner H.B.
        • Kaiser G.C.
        • Codd J.E.
        • Laks H.
        • Willman V.L.
        Myocardial revascularization in women.
        Ann Thorac Surg. 1978; 25: 449-453
        • Parolari A.
        • Dainese L.
        • Naliato M.
        • et al.
        Do women currently receive the same standard of care in coronary artery bypass graft procedures as men? A propensity analysis.
        Ann Thorac Surg. 2008; 85: 885-890
        • Canadian Institute for Health Information
        Welcome to CIHI's Indicator Library.
        (Available at:) (Accessed on October 1, 2017)
        • Guru V.
        • Fremes S.E.
        • Austin P.C.
        • Blackstone E.H.
        • Tu J.V.
        Gender differences in outcomes after hospital discharge from coronary artery bypass grafting.
        Circulation. 2006; 113: 507-516
        • Kennedy R.H.
        • Kennedy M.A.
        • Frye R.L.
        • et al.
        Cardiac-catheterization and cardiac-surgical facilities: use, trends, and future requirements.
        N Engl J Med. 1982; 307: 986-993
        • Leening M.J.
        • Ferket B.S.
        • Steyerberg E.W.
        • et al.
        Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study.
        BMJ. 2014; 349: g5992
        • Kaul P.
        • Saunders L.D.
        • Roos L.L.
        • et al.
        Trends in utilization of coronary artery bypass surgery and associated outcomes: Alberta, Manitoba, and Nova Scotia.
        Am J Med Qual. 2002; 17: 103-112
        • Lansky A.J.
        • Ng V.G.
        • Maehara A.
        • et al.
        Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes.
        JACC Cardiovasc Imaging. 2012; 5: S62-72
        • Arthur H.M.
        • Campbell P.
        • Harvey P.J.
        • et al.
        Women, cardiac syndrome X, and microvascular heart disease.
        Can J Cardiol. 2012; 28: S42-S49
        • Reis S.E.
        • Holubkov R.
        • Conrad Smith A.J.
        • et al.
        Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study.
        Am Heart J. 2001; 141: 735-741
        • Ouzounian M.
        • Currie M.E.
        • Buth K.J.
        • et al.
        Myocardium at risk is associated with adverse clinical events in women but not in men, after coronary artery bypass grafting.
        Can J Cardiol. 2014; 30: 808-813
        • Dodge Jr., J.T.
        • Brown B.G.
        • Bolson E.L.
        • Dodge H.T.
        Lumen diameter of normal human coronary arteries. Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation.
        Circulation. 1992; 86: 232-246
        • Sheifer S.E.
        • Canos M.R.
        • Weinfurt K.P.
        • et al.
        Sex differences in coronary artery size assessed by intravascular ultrasound.
        Am Heart J. 2000; 139: 649-653
        • Kim S.G.
        • Apple S.
        • Mintz G.S.
        • et al.
        The importance of gender on coronary artery size: in-vivo assessment by intravascular ultrasound.
        Clin Cardiol. 2004; 27: 291-294
        • Fisher L.D.
        • Kennedy J.W.
        • Davis K.B.
        • et al.
        Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS).
        J Thorac Cardiovasc Surg. 1982; 84: 334-341
        • O'Connor G.T.
        • Morton J.R.
        • Diehl M.J.
        • et al.
        Differences between men and women in hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group.
        Circulation. 1993; 88: 2104-2110
        • Adams G.A.
        Platelet adhesion: past and present.
        in: Longenecker G.L. The Platelets: Physiology and Pharmacology. Academic Press, Inc, London1985: 15-47
        • Crosby I.K.
        • Wellons Jr., H.A.
        • Taylor G.J.
        • et al.
        Critical analysis of the preoperative and operative predictors of aortocoronary bypass patency.
        Ann Surg. 1981; 193: 743-751
        • Bjork V.O.
        • Ekestrom S.
        • Henze A.
        • Ivert T.
        • Landou C.
        Early and late patency of aortocoronary vein grafts.
        Scand J Thorac Cardiovasc Surg. 1981; 15: 11-21
        • Bolooki H.
        The controversy in clinical results among men and women after coronary bypass operation.
        J Am Coll Cardiol. 2007; 49: 1559-1560
        • Boese A.C.
        • Kim S.C.
        • Yin K.J.
        • Lee J.P.
        • Hamblin M.H.
        Sex differences in vascular physiology and pathophysiology: estrogen and androgen signaling in health and disease.
        Am J Physiol Heart Circ Physiol. 2017; 313: H524-H545
        • Tonino P.A.
        • De B.B.
        • Pijls N.H.
        • et al.
        Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.
        N Engl J Med. 2009; 360: 213-224
        • Shah T.
        • Geleris J.D.
        • Zhong M.
        • et al.
        Fractional flow reserve to guide surgical coronary revascularization.
        J Thorac Dis. 2017; 9: S317-S326
        • Edwards F.H.
        • Carey J.S.
        • Grover F.L.
        • Bero J.W.
        • Hartz R.S.
        Impact of gender on coronary bypass operative mortality.
        Ann Thorac Surg. 1998; 66: 125-131
        • Vaccarino V.
        • Lin Z.Q.
        • Kasl S.V.
        • et al.
        Gender differences in recovery after coronary artery bypass surgery.
        J Am Coll Cardiol. 2003; 41: 307-314
        • Alam M.
        • Lee V.V.
        • Elayda M.A.
        • et al.
        Association of gender with morbidity and mortality after isolated coronary artery bypass grafting. A propensity score matched analysis.
        Int J Cardiol. 2013; 167: 180-184
        • Woods S.E.
        • Noble G.
        • Smith J.M.
        • Hasselfeld K.
        The influence of gender in patients undergoing coronary artery bypass graft surgery: an eight-year prospective hospitalized cohort study.
        J Am Coll Surg. 2003; 196: 428-434
        • Swaminathan R.V.
        • Feldman D.N.
        • Pashun R.A.
        • et al.
        Gender differences in in-hospital outcomes after coronary artery bypass grafting.
        Am J Cardiol. 2016; 118: 362-368
        • Alam M.
        • Bandeali S.J.
        • Kayani W.T.
        • et al.
        Comparison by meta-analysis of mortality after isolated coronary artery bypass grafting in women versus men.
        Am J Cardiol. 2013; 112: 309-317
        • Koch C.G.
        • Khandwala F.
        • Nussmeier N.
        • Blackstone E.H.
        Gender and outcomes after coronary artery bypass grafting: a propensity-matched comparison.
        J Thorac Cardiovasc Surg. 2003; 126: 2032-2043
        • Ennker I.C.
        • Albert A.
        • Pietrowski D.
        • et al.
        Impact of gender on outcome after coronary artery bypass surgery.
        Asian Cardiovasc Thorac Ann. 2009; 17: 253-258
        • Guru V.
        • Fremes S.E.
        • Tu J.V.
        Time-related mortality for women after coronary artery bypass graft surgery: a population-based study.
        J Thorac Cardiovasc Surg. 2004; 127: 1158-1165
        • Freiheit E.A.
        • Hogan D.B.
        • Patten S.B.
        • et al.
        Frailty trajectories after treatment for coronary artery disease in older patients.
        Circ Cardiovasc Qual Outcomes. 2016; 9: 230-238
        • Humphries K.H.
        • Gao M.
        • Pu A.
        • Lichtenstein S.
        • Thompson C.R.
        Significant improvement in short-term mortality in women undergoing coronary artery bypass surgery (1991 to 2004).
        J Am Coll Cardiol. 2007; 49: 1552-1558
        • O'Connor N.J.
        • Morton J.R.
        • Birkmeyer J.D.
        • Olmstead E.M.
        • O'Connor G.T.
        Effect of coronary artery diameter in patients undergoing coronary bypass surgery. Northern New England Cardiovascular Disease Study Group.
        Circulation. 1996; 93: 652-655
        • Trienekens M.P.
        • Maas A.H.
        • Timman S.T.
        • Van Swieten H.A.
        • Noyez L.
        Sex differences in patient and procedural characteristics and early outcomes following cardiac surgery.
        J Cardiovasc Surg (Torino). 2015; 56: 817-823
        • Emmert M.Y.
        • Salzberg S.P.
        • Seifert B.
        • et al.
        Despite modern off-pump coronary artery bypass grafting women fare worse than men.
        Interact Cardiovasc Thorac Surg. 2010; 10: 737-741
        • Martin L.M.
        • Holmes S.D.
        • Henry L.L.
        • et al.
        Health-related quality of life after coronary artery bypass grafting surgery and the role of gender.
        Cardiovasc Revasc Med. 2012; 13: 321-327
        • Berndt R.
        • Panholzer B.
        • Huenges K.
        • et al.
        Impact of gender on outcome in octogenarians after coronary artery bypass grafting.
        Thorac Cardiovasc Surg. 2017; 65: 286-291
        • Roques F.
        • Nashef S.A.
        • Michel P.
        • et al.
        Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients.
        Eur J Cardiothorac Surg. 1999; 15 ([discussion 822-823]): 816-822
        • Nicolini F.
        • Vezzani A.
        • Fortuna D.
        • et al.
        Gender differences in outcomes following isolated coronary artery bypass grafting: long-term results.
        J Cardiothorac Surg. 2016; 11: 144
        • den Ruijter H.M.
        • Haitjema S.
        • van der Meer M.G.
        • et al.
        Long-term outcome in men and women after CABG; results from the IMAGINE trial.
        Atherosclerosis. 2015; 241: 284-288
        • Lewis W.R.
        • Ellrodt A.G.
        • Peterson E.
        • et al.
        Trends in the use of evidence-based treatments for coronary artery disease among women and the elderly: findings from the Get With the Guidelines quality-improvement program.
        Circ Cardiovasc Qual Outcomes. 2009; 2: 633-641
        • Sanghavi M.
        • Gulati M.
        Sex differences in the pathophysiology, treatment, and outcomes in IHD.
        Curr Atheroscler Rep. 2015; 17: 511
        • Teo K.K.
        • Cohen E.
        • Buller C.
        • et al.
        Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology/Canadian Society of Cardiac Surgery position statement on revascularization–multivessel coronary artery disease.
        Can J Cardiol. 2014; 30: 1482-1491
        • Lindquist R.
        • Dupuis G.
        • Terrin M.L.
        • et al.
        Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study.
        Am Heart J. 2003; 146: 1038-1044
        • Kendel F.
        • Dunkel A.
        • Muller-Tasch T.
        • et al.
        Gender differences in health-related quality of life after coronary bypass surgery: results from a 1-year follow-up in propensity-matched men and women.
        Psychosom Med. 2011; 73: 280-285
        • Klerman G.L.
        • Weissman M.M.
        Increasing rates of depression.
        JAMA. 1989; 261: 2229-2235
        • Sandoval Y.
        • Brilakis E.S.
        • Canoniero M.
        • Yannopoulos D.
        • Garcia S.
        Complete versus incomplete coronary revascularization of patients with multivessel coronary artery disease.
        Curr Treat Options Cardiovasc Med. 2015; 17: 366
        • Hassan A.
        • Chiasson M.
        • Buth K.
        • Hirsch G.
        Women have worse long-term outcomes after coronary artery bypass grafting than men.
        Can J Cardiol. 2005; 21: 757-762
        • Sabik 3rd, J.F.
        • Lytle B.W.
        • Blackstone E.H.
        • Houghtaling P.L.
        • Cosgrove D.M.
        Comparison of saphenous vein and internal thoracic artery graft patency by coronary system.
        Ann Thorac Surg. 2005; 79 ([discussion: 544-551]): 544-551
        • Taggart D.P.
        Current status of arterial grafts for coronary artery bypass grafting.
        Ann Cardiothorac Surg. 2013; 2: 427-430
        • Sotomi Y.
        • Onuma Y.
        • Cavalcante R.
        • et al.
        Geographical difference of the interaction of sex with treatment strategy in patients with multivessel disease and left main disease: a meta-analysis from SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) randomized controlled trials.
        Circ Cardiovasc Interv. 2017; 10: e005027
        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • et al.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        • Farooq V.
        • van Klaveren D.
        • Steyerberg E.W.
        • et al.
        Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II.
        Lancet. 2013; 381: 639-650
        • Lytle B.W.
        • Blackstone E.H.
        • Sabik J.F.
        • et al.
        The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.
        Ann Thorac Surg. 2004; 78: 2005-2014
        • Kurlansky P.A.
        • Traad E.A.
        • Dorman M.J.
        • et al.
        Bilateral internal mammary artery grafting reverses the negative influence of gender on outcomes of coronary artery bypass grafting surgery.
        Eur J Cardiothorac Surg. 2013; 44: 54-63
        • Jabagi H.
        • Tran D.T.
        • Hessian R.
        • Glineur D.
        • Rubens F.D.
        Impact of gender on arterial revascularization strategies for coronary artery bypass grafting.
        Ann Thorac Surg. 2018; 105: 62-68
        • Tabata M.
        • Grab J.D.
        • Khalpey Z.
        • et al.
        Prevalence and variability of internal mammary artery graft use in contemporary multivessel coronary artery bypass graft surgery: analysis of the Society of Thoracic Surgeons National Cardiac Database.
        Circulation. 2009; 120: 935-940
        • Kurlansky P.A.
        • Traad E.A.
        • Galbut D.L.
        • et al.
        Coronary bypass surgery in women: a long-term comparative study of quality of life after bilateral internal mammary artery grafting in men and women.
        Ann Thorac Surg. 2002; 74: 1517-1525
        • Gaudino M.
        • Taggart D.
        • Suma H.
        • et al.
        The choice of conduits in coronary artery bypass surgery.
        J Am Coll Cardiol. 2015; 66: 1729-1737
        • Taggart D.P.
        • Altman D.G.
        • Gray A.M.
        • et al.
        Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART).
        Eur Heart J. 2010; 31: 2470-2481
        • Rubens F.D.
        • Chen L.
        • Bourke M.
        Assessment of the association of bilateral internal thoracic artery skeletonization and sternal wound infection after coronary artery bypass grafting.
        Ann Thorac Surg. 2016; 101: 1677-1682
        • Takagi H.
        • Goto S.N.
        • Watanabe T.
        • et al.
        A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2014; 148: 1282-1290
        • Parasca C.A.
        • Head S.J.
        • Mohr F.W.
        • et al.
        The impact of a second arterial graft on 5-year outcomes after coronary artery bypass grafting in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery Trial and Registry.
        J Thorac Cardiovasc Surg. 2015; 150: 597-606.e592
        • Endo M.
        • Nishida H.
        • Tomizawa Y.
        • Kasanuki H.
        Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting.
        Circulation. 2001; 104: 2164-2170
        • Tatoulis J.
        • Buxton B.F.
        • Fuller J.A.
        The right internal thoracic artery: the forgotten conduit–5,766 patients and 991 angiograms.
        Ann Thorac Surg. 2011; 92: 9-15
        • Hayward P.A.
        • Buxton B.F.
        Contemporary coronary graft patency: 5-year observational data from a randomized trial of conduits.
        Ann Thorac Surg. 2007; 84: 795-799
        • Desai N.D.
        • Cohen E.A.
        • Naylor C.D.
        • Fremes S.E.
        A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts.
        N Engl J Med. 2004; 351: 2302-2309
        • Desai N.D.
        • Naylor C.D.
        • Kiss A.
        • et al.
        Impact of patient and target-vessel characteristics on arterial and venous bypass graft patency: insight from a randomized trial.
        Circulation. 2007; 115: 684-691
        • Dimitrova K.R.
        • Hoffman D.M.
        • Geller C.M.
        • et al.
        Radial artery grafting in women improves 15-year survival.
        J Thorac Cardiovasc Surg. 2013; 146: 1467-1473
        • Yanagawa B.
        • Verma S.
        • Mazine A.
        • et al.
        Impact of total arterial revascularization on long term survival: a systematic review and meta-analysis of 130,305 patients.
        Int J Cardiol. 2017; 233: 29-36
        • Gaudino M.
        • Puskas J.D.
        • Di Franco A.
        • et al.
        Three arterial grafts improve late survival: a meta-analysis of propensity-matched studies.
        Circulation. 2017; 135: 1036-1044
        • Dhurandhar V.
        • Saxena A.
        • Parikh R.
        • et al.
        Comparison of the safety and efficacy of on-pump (ONCAB) versus off-pump (OPCAB) coronary artery bypass graft surgery in the elderly: a review of the ANZSCTS database.
        Heart Lung Circ. 2015; 24: 1225-1232
        • Mack M.J.
        • Brown P.
        • Houser F.
        • et al.
        On-pump versus off-pump coronary artery bypass surgery in a matched sample of women: a comparison of outcomes.
        Circulation. 2004; 110: II1-6
        • Puskas J.D.
        • Kilgo P.D.
        • Kutner M.
        • et al.
        Off-pump techniques disproportionately benefit women and narrow the gender disparity in outcomes after coronary artery bypass surgery.
        Circulation. 2007; 116: I192-I199
        • Mack M.J.
        • Pfister A.
        • Bachand D.
        • et al.
        Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease.
        J Thorac Cardiovasc Surg. 2004; 127: 167-173