Thursday, February 22

Heart surgery that is unsafe for older women

Last Thanksgiving, Cynthia Mosson had been up all day in her kitchen in Frankfort, Indiana, preparing dinner for nine o’clock. She was almost done—the ham in the oven, the dressing ready—when she suddenly felt the need to sit down.

“I started to hurt my left shoulder,” Ms. Mosson, 61, said. “It got really intense and started going down my left arm.” She became sweaty and pale and told her family: “I think I’m having a heart attack.”

An ambulance took her to hospital where doctors confirmed she had suffered a mild heart attack. They said her tests revealed severe blockages in all of her coronary arteries and told her, “You’re going to need open-heart surgery,” Ms. Mosson recalled.

When these patients enter an operating room, what happens next has a lot to do with their gender, a recent study reported in JAMA Surgery. The study bolstered years of research by showing that male and female patients can have very different outcomes following an operation called coronary artery bypass.

CABG (pronounced like vegetable) restores blood flow by taking arteries from patients’ arms or chest and veins from their legs and using them to bypass blocked blood vessels.

“It’s the most common heart operation in the United States,” and it happens 200,000 to 300,000 times a year, said Dr. Mario Gaudino, a cardiothoracic surgeon at Weill Cornell Medicine and lead author of the study.

25 to 30% of patients undergoing CABG are women. How are they doing? Dr. Gaudino and his colleagues found that the death rate from CABG, while low, is much higher for women (2.8%) than men (1.7%).

Analyzing the results of approximately 1.3 million patients (average age: 66 years) from 2011 to 2020, researchers also determined that after CABG, approximately 20% of men had complications that included stroke, kidney failure, surgery repeated, sternum infections and prolonged ventilation. use and hospital stays. Among women, more than 28% did so.

Of these complications, “many are relatively minor and resolve on their own,” Dr. Gaudino said. But recovery from sternal wound infections can take months, he noted, and “if you have a stroke, that can affect you for a long time.” Although outcomes improved for both sexes over the decade, the gender gap remained.

The study “should be regarded as an explosion in the sky for all doctors who care for women,” an accompanying editorial reads. Yet to cardiac researchers, the results sounded familiar.

“This is something we’ve known since the 1980s,” said Dr. C. Noel Bairey Merz, a cardiologist and researcher at Cedars-Sinai Medical Center. Heart disease, he pointed out, remains the leading cause of death for American women.

With CABG, “the general assumption was that things were getting better because technology, knowledge, skills and training were improving,” he said. Seeing gender inequality persist “is very disappointing”.

Several factors help explain these differences. Women are three to five years older than men when they undergo bypass surgery, in part because “we recognize coronary heart disease more easily and earlier in men,” Dr. Gaudino said. “Men have the classic presentation that we study in medical school. Women have different symptoms.” These can include fatigue, shortness of breath, and back or stomach pain.

Fewer than 20% of patients enrolled in clinical trials were women, so “what we were taught is essentially based on research in men,” he added.

Partly because they are older – about 40% are over 70 – women are more likely than men to develop health problems such as diabetes, hypertension and vascular conditions, “all factors that increase risk in heart surgery,” he said Doctor Gaudino. . They also have smaller, more fragile blood vessels, which can make surgery more complex.

The disparities also affect other forms of cardiac treatment and surgery. Women have worse outcomes than men five years after receiving a stent, a 2020 review of randomized trials reported.

They are “less likely to be prescribed and take statins, and particularly less likely to take high-intensity statins, which are the most life-saving,” Dr. Bairey Merz said. “The list goes on and on.”

When CABG works well, the results can seem miraculous. Rhonda Skaggs, 68, underwent a quadruple bypass in July 2022 and spent 12 days in intensive care before returning home to Brooksville, Florida. Six months passed before she returned to work at a Home Shopping Network outlet.

“Now, you would never know that I had open heart surgery,” he said. “I take 10,000 steps a day. I teach line dance classes twice a week. I have my life back.”

But Susan Leary, 71, a retired New York teacher who now lives in Fuquay-Varina, North Carolina, is facing a second procedure after bypass surgery at Duke University last month.

“Women are less likely to have all the vessels that need to be bypassed,” said her cardiothoracic surgeon, Dr. Brittany Zwischenberger, co-author of the call-to-arms editorial in JAMA Surgery.

A few years earlier, Ms. Leary had sought a procedure to reduce “nasty” varicose veins in her legs; now she was missing vital blood vessels for the graft. “How did I know I would need some of those veins for my heart?” she said.

He underwent a double bypass, instead of the triple bypass he needed, which represents an “incomplete revascularization.”

“It may contribute to poorer outcomes and future interventions,” Dr. said. Zwischenberger. “Fortunately, she is a candidate for a stent” for the blocked third artery, which involves inserting a mesh tube into the vessel to widen it. The procedure is scheduled for next month.

Advocates for better care for women argue that surgical risks can be reduced.

Dr. Lamia Harik, a cardiothoracic surgery fellow at Weill Cornell Medicine, and her colleagues found that nearly 40 percent of women’s mortality during CABG results from interoperative anemia. (Their study is in press.)

This occurs when operating teams administer fluids to thin patients’ blood during the procedure, allowing them to use the large cardiopulmonary bypass machine (“the pump”) that keeps the blood oxygenated and thin while surgeons perform the graft.

“This is something modifiable,” Dr. Harik said. For women, surgeons might use smaller pumps or reduce the volume of fluid added, or both.

To learn more, Dr. Gaudino and other researchers have begun enrolling women, and only women, in two new clinical trials. The international ROMA study, the first all-female surgical study, will examine two CABG techniques to see which produces better results; the federally funded Recharge study will compare stenting with CABG

“In the past, many surgeons thought this was inevitable,” Dr. Gaudino said of the differences between the sexes. “Maybe they won’t disappear, but they can be minimized.”

Ms Mosson said her surgeons were satisfied with the results of her quadruple bypass, although she was briefly readmitted to hospital with fluid in her lungs. She has begun a three-times-a-week cardiac rehabilitation program, recommended for patients who have undergone bypass surgery, and has found that her endurance is improving.

She still has to deal with the psychological consequences of her heart attack and surgery, as Ms. Skaggs did and as Ms. Leary still does. They describe shock – none had a history of heart disease – depression and anxiety. “I’m still struggling with the fear of it happening again,” Ms. Mosson said.

One antidote, for Mrs. Leary, was Roma recruitment; Duke is among the clinical trial sites. He jumped at the opportunity to sign up.

“Let me be a part of it,” he said. “Maybe my daughter will need this information someday.”