The Recurring Theme of Gender Difference in Cardiac Surgical OutcomesJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 1144References: 13Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: john_ikonomidis@med.unc.eduTel: (919) 966-3381In this issue of the Journal of Cardiac Surgery,1Newell and colleagues examined contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors. The 2016-2018 Nationwide Readmissions Database was queried for all patients > 18 years of age with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. A weighted total of 2,557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens. The authors found that while there was no difference in 30-day mortality (2.1% vs 1.3%, p=0.550), 30-day readmission (7.0% vs 9.1%, p=0.222), or 30-day composite morbidity (56.8% vs 53.8%, p=0.369) between females and males respectively, on multivariable analysis, female sex was independently associated with increased risk of 30-day mortality (OR 2.65, p=0.028).Overall, this was a well study which documents a large contemporary cohort of benign cardiac tumor resections. However, perhaps the most interesting feature of this study is the finding of sex as an independent predictor of 30 day mortality after propensity matching. Cardiac surgery suffers from a gender gap in terms of its outcomes. It has been well established that for many procedures such coronary bypass surgery (CABG), aortic valve replacement, mitral valve surgery, and aortic surgery.2 For CABG, women referred for surgery are typically older than men, have a higher comorbidity (hypertension, renal failure, diabetes, peripheral vascular disease) profile, and more often present in urgent or emergent status for surgery.3 Large, risk-adjusted, propensity matched studies have documented increased mortality in women as compared with men.4-7 This difference also extends into the interventional cardiology realm, where mortality and complication rates have been shown to be higher in women following percutaneous interventions for ST-elevation myocardial infarction.8For aortic valve replacement, a Nationwide Inpatient Sample study of 166809 patients with aortic stenosis from 2003 to 2014 found that women experience higher inpatient mortality (5.6% versus 4%, P<0.001) which persisted after propensity matching (3.3% versus 2.9%, P<0.001).9 For mitral valve surgery, a randomized controlled trial of patients with severe ischemic mitral insufficiency undergoing repair versus replacement found that women had higher mortality than men (27.1% versus 17.4%, p<0.03).10 For aortic surgery, female gender was associated with a higher mortality after both aortic dissection and aortic arch repair.11,12 Reduction in surgical stress through application of minimally invasive approaches still resulted in female sex being a risk factor for higher in-hospital mortality.13 The findings of the present study add further support to the above observations, with the potential addition that, in contrast to the other disease processes described, the majority of patients presenting for surgical removal of benign cardiac tumors were likely free of either symptoms or cardiac sequelae due to the disease, but nevertheless still the gender disparity in mortality persisted.While it is obvious that the above disease processes and their related surgical remedies are quite disparate, the association with increased mortality seen in females seems to be constant. Why is this? A considerable amount has been written regarding sex bias in referral patterns for surgery and even decreased functional reserve and health profiles of women when they are referred for surgical intervention compared with men.2 With regard to these referral patterns, published guidelines directing practitioners regarding indications for surgery are, in general, based upon studies in which the majority of patients were male. Interestingly, in the present study, females made up over two thirds of the patient population.1 While this suggests that females carry a disproportionately more benign cardiac tumors amenable to surgery, the post-surgical mortality disparity remained.The exact reasons for the above disparity remain unelucidated and further work is required to eliminate the gender gap in cardiac surgical outcomes. There is considerable focus on the removal of sex bias in animal and human research, as well as the development of disease treatment guidelines that consider gender in the algorithms. Hopefully and these and other sex-balanced approaches will reveal new insights that will allow us to bring equipoise to gender-stratified cardiac surgical outcomes.
Objectives: The aim of the study is to compare the safety and efficacy of unilateral anterograde cerebral perfusion (UACP) and bilateral anterograde cerebral perfusion (BACP) for acute type A aortic dissection (ATAAD). Methods: A systematic review of MEDLINE (PubMed), Scopus, and Cochrane Library databases (last search: August 7 th, 2021) was performed according to the PRISMA statement. Studies directly comparing UACP versus BACP for ATAAD were included. Random-effects meta-analyses were performed. Results: Eight retrospective cohort studies were identified, incorporating 2416 patients (UACP: 843, BACP: 1573). No statistically significant difference was observed regarding in-hospital mortality (odds ratio [OR]:1.05 [95% Confidence Interval (95%CI):0.70-1.57]), permanent neurological deficit (PND) (OR: 0.94 [95%CI:0.52-1.70]), transient neurological deficit (TND) (OR: 1.37 [95%CI:0.98-1.92]), renal failure (OR: 0.96 [95%CI:0.70-1.32]), and re-exploration for bleeding (OR: 0.77 [95%CI:0.48-1.22]). Meta-regression analysis revealed that PND and TND were not influenced by differences in rates of total arch repair, Bentall procedure and concomitant CABG in UACP and BACP groups. Cardiopulmonary bypass time (Standard Mean Difference [SMD]:-0.11 [95%CI:-0.22, 0.44]), Cross clamp time (SMD:-0.04 [95%CI:-0.38, 0.29]) and hypothermic circulatory arrest time (SMD:-0.12 [95%CI:-0.55, 0.30]) were comparable between UACP and BACP. Intensive care unit stay was shorter in BACP arm (SMD:0.16 [95%CI:0.01, 0.31]), however, length of hospital stay was shorter in UACP arm (SMD:-0.25 [95%CI:-0.45, -0.06]). Conclusions: UACP and BACP had similar results in terms of in-hospital mortality, PND, TND, renal failure and re-exploration for bleeding rate in patients with ATAAD. ICU stay was shorter in the BACP arm while LOS was shorter in the UACP arm.
A Preliminary Argument for the Selective Use of the Robicsek WeaveJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 886References: 4Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: john_ikonomidis@med.unc.eduTel: (919) 966-3381Proper execution of median sternotomy and its subsequent closure are critical to the success of cardiac surgical outcomes. It is essential that the sternum be divided directly in the midline, and table fractures must be avoided if at all possible by avoiding excessive spreading if the sternum for exposure of the heart. Multiple methods have been described regarding primary sternal closure technique, but the conventional technique of wire circlage, either linear or figure-of-eight, has endured and is also the most cost-effective. Sternal wound complications have an incidence of 0.8% to 1.5% patients, and this number rises to as high as 8% when bilateral internal mammary artery harvest is undertaken. Further established risk factors for deep sternal wound complications include breaches in sterility in the operating room, lengthy operations, re-exploration for bleeding, undrained retrosternal hematoma, incomplete wound closure, obesity, advanced age, diabetes, chronic obstructive pulmonary disease, hospital acquired pneumonias, renal failure, requirement for dialysis, and prolonged mechanical ventilation. Mortality from sternal dehiscence and related complications ranges from 6% to 70%. It is generally felt that early treatment reduces mortality.1Deep sternal wound complications and dehiscence were once thought to be highly feared and challenging complications of cardiac surgery. Modern primary closure techniques, tissue flap coverage options, and negative pressure wound therapy have made these complications more manageable. Nevertheless, it behooves surgeons to avoid this complication due to its considerable negative clinical impact.There are many methods currently available for reconstruction of the sternum after its dehiscence, the most common of which is the sternal weave first described by Robicsek and colleagues in 1977.2 This technique is often used to reinforce the sternum with primary sternal closure in instances where the sternotomy was off the midline leaving a thin weak section of sternum on one side or where some fracturing has occurred, but has also been used as a first line for sternal reconstruction after its dehiscence from primary closure. Data are not available regarding the overall success rate of reinforcement using the Robicsek weave, but at least one multicenter, randomized controlled trial showed that in patients with an increased risk for sternal instability and wound infection after cardiac surgery, sternal reinforcement using the Robicsek technique prior to primary sternal closure did not reduce dehiscence rate.3In addition to the above, antecedent sternal weaving weave may complicate further attempts at sternal closure should dehiscence recur. In this issue of the Journal of Cardiac Surgery,4Seyrek et al. conducted a retrospective review of patients at a single institution with noninfectious sternal dehiscence (NISD) after median sternotomy who received thermoreactive nitinol clips (TRNC) for sternal closure. The authors studied 34 cases who received TRNC treatment between December 2009 and January 2020 out of 283 patients with NISD who underwent sternal refixation. These cases were divided into two groups: patients who had a previously failed Robicsek procedure before TRNC treatment (group A, n=11) and patients who had been directly referred to TRCN treatment (group B, n= 23). The results showed that the postoperative complication rate and length of hospital stay was significantly higher with use of the Robicsek weave. Further, operative time was significantly shorter and blood loss was significantly lower in patients referred for sternal refixation without having first undergone a Robicsek weave.Part of the reason for the above results may lie with the surgical requirements for performance of the Robicsek weave. Substernal and lateral dissection is required to define the margins of the sternum before placing the weave. This increases the technical difficulty of the reclosure operation and puts the patient at risk for inadvertent injury to the heart, great vessels, and other mediastinal structures. This dissection may also compromise blood flow to the sternal half. Further, intercostal arteries may be squeezed by weave as it runs anteriorly and posteriorly around the ribs, which may occlude blood supply to the sternum. This could worsen pre-existing ischemia, which would delay sternal healing, promote bacterial colonization, and cause bone necrosis and additional sternal fragmentation, thus complicating any additional closure attempts.Use of TRNC may represent an advance in sternal reconstruction therapy due to the simplicity of use and lack of requirement for a complex mediastinal dissection prior to application. The authors contend that a previously failed Robicsek procedure caused significantly higher morbidity, additional operative risk and lower success rate in later TRNC treatment of high-risk cases and hence speculate that patients at high risk for sternal separation should proceed directly to TRNC treatment. In the light of the above study, this approach seems reasonable, but a prospective trial should be considered to provide the definitive answer.