The heart surgery that is not so safe for older women

Last Thanksgiving, Cynthia Mosson spent all day in her kitchen in Frankfort, Indiana, preparing dinner for nine people. She was almost done – the ham in the oven, the dressing made – when she suddenly felt the need to sit down.

“I started hurting in my left shoulder,” said Ms Mosson, 61. “It became very intense and it started running down my left arm.” She became sweaty and pale and told her family, “I think I'm having a heart attack.”

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

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

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

“It is the most common heart surgery in the United States,” performed 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.

Twenty-five to thirty percent of CABG patients are women. How are they doing? The mortality rate for CABG, while low, is much higher for women (2.8 percent) than for men (1.7 percent), Dr. Gaudino and his colleagues.

Analyzing results from approximately 1.3 million patients (average age: 66) between 2011 and 2020, researchers also found that after CABG, approximately 20 percent of men developed complications, including strokes, kidney failure, repeat surgeries, infections of the the sternum and prolonged ventilation. use and hospital stay. Among women, more than 28 percent did so.

Of these complications, “many are relatively minor and resolve on their own,” said Dr. Gaudino. But recovery from a sternal wound infection can take months, he noted, and “if you have a stroke, you can be in pain for a long time.” Although outcomes for both genders improved over the past decade, the gender gap persisted.

The study 'should be regarded as an exploding flame in the sky for all physicians who care for women' an accompanying editorial said. Still, the results sounded familiar to heart researchers.

“We've known this since the 1980s,” said Dr. C. Noel Bairey Merz, a cardiologist and researcher at Cedars-Sinai Medical Center. Heart disease, she emphasized, remains the leading cause of death for American women.

With CABG, “the general assumption was that things got better because the technology, the knowledge, the skills and the training all improved,” she said. It is very disappointing to see that gender inequality persists.

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 artery disease more easily and earlier in men,” said Dr. Gaudino. “Men have the classic presentation that we study in medical school. Women have different symptoms.” These may include fatigue, shortness of breath, and pain in the back or abdomen.

Less than 20 percent 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 percent are over 70 — women are more likely than men to have health problems such as diabetes, high blood pressure and vascular disease, “all factors that increase the risk of heart surgery,” said Dr. Gaudino. . They also have smaller, more fragile blood vessels, which can make surgeries more complex.

The differences affect other forms of heart treatment and surgery too. Women have worse outcomes than men five years after receiving a stent, in 2020 assessment of randomized trials reported.

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

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

“You'd never know I had open-heart surgery,” she said. “I walk 10,000 steps a day. I teach line dancing lessons twice a week. I have my life back.”

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

“Women are less likely to bypass all the blood vessels that need to be bypassed,” says 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 shrink the “ugly-looking” varicose veins in her legs; now she lacked viable blood vessels for transplantation. “How did I know I would need some of those veins for my heart?” she said.

She had a double bypass, instead of the triple bypass she needed, which amounts to “incomplete revascularization.”

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

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

Dr. Lamia Harik, a cardiothoracic surgery researcher at Weill Cornell Medicine, and her colleagues have found that nearly 40 percent of deaths among women during CABG result from interoperative anemia. (Their study is in the press.)

That happens when surgical 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 flowing while surgeons perform the transplant.

“This is something that can be changed,” Dr. Harik said. For women, surgeons may use smaller pumps or reduce the volume of fluid added, or both.

To find out more, Dr. Gaudino and other researchers began enrolling women, and only women, in two new clinical trials. The international ROMA study, the first surgical trial in women only, will investigate two CABG techniques to see which produces better results; the federally funded Recharge trial will compare stent placement with CABG

“In the past, many surgeons thought this was inevitable,” said Dr. Gaudino on the differences between the sexes. “They may not disappear, but they can be minimized.”

Ms Mosson said her surgeons were pleased with the results of her quadruple bypass, although she was briefly readmitted to hospital due to fluid in her lungs. She started with one three times a week cardiac rehabilitation programrecommended for patients who have undergone bypass surgery and find that her endurance improves.

She is still dealing with the psychological aftermath of her heart attack and surgery, as Ms. Skaggs did and Ms. Leary still does. They describe shock – none had a history of heart disease – depression and anxiety. “I still struggle with the fear that it will happen again,” Ms Mosson said.

One antidote, for Mrs. Leary, was recruited for ROMA; Duke is one of the clinical trial sites. She seized the opportunity to register with both hands.

“Let me be part of it,” she said. “Maybe one day my daughter will need this information.”