Gender and sex differences in the outcomes of modern coronary surgery: the main results of the Coronary Revascularization Outcomes Within Necessary Sex And Gender Aspects (CROWN-SAGA) study

Aim. To conduct an in-depth comparative analysis of the impact of preoperative profile and range of surgical techniques in coronary artery bypass grafting (CABG) surgery on shortand long-term outcomes in women and men.

Material and methods. This retrospective and prospective single-center CROWNSAGA study (NCT06749171) includes a sample of 400 patients (200 women and 200 men) who underwent CABG in the period from January 2016 to July 2023 at the Sukhanov Federal Center for Cardiovascular Surgery (Perm). The patients included in the study were divided into groups by sex followed by propensity score matching (PSM) analysis, as well as into stratum of surgical techniques — on-pump coronary artery bypass grafting (ONCAB), off-pump coronary artery bypass grafting (OPCAB), no-touch aorta technique (NTA), minimally invasive multiple coronary artery bypass grafting (MICSCAB). Furthermore, the impact of multiple arterial grafting (MAG), total arterial revascularization (TAR), composite and sequential grafting on outcomes was analyzed for each sex. The primary endpoint was a composite of allcause mortality, myocardial infarction (MI), stroke or transient ischemic attack (TIA) and repeat revascularization (major adverse cardiovascular and cerebrovascular events, MACCE) during the long-term follow-up. The secondary endpoint was allcause mortality during the long-term follow-up.

Results. Median follow-up duration was 50 (1^st (Q1) and 3^rd (Q3) quartiles: 30; 72) months: 54,5 (33; 75,8) in women and 46 (22; 71) in men. Women had less favorable preoperative profile compared to men. Short-term in-hospital outcomes were comparable between women and men in terms of mortality (2,5% vs 3,5%) and MACCE (1% vs 1,5%). Over long-term follow-up, the incidence of MACCE was 21,2% in women and 16,2% in men (hazard ratio (HR) =1,15 [95% confidence interval (CI): 0,72; 1,82], p=0,557) and the incidence of death was 11,1% in women and 10,2% in men (HR =0,94 [95% CI: 0,51; 1,72], p=0,83). Female cohort had higher risks of MI (HR =6,66 [95% CI: 0,83; 53,28], p=0,038), revascularization (HR =4,11 [95% CI: 1,18; 14,32], p=0,016) and stroke (HR =1,24 [95% CI: 0,59; 2,6], p=0,567). In the all off-pumps strata (OPCAB, NTA, MICSCAB) compared with ONCAB, risk of adverse long-term outcomes was higher among all patients in regard to both MACCE (HR =1,54 [95% CI: 0,95; 2,49], p=0,08) and death (HR =2,17 [95% CI: 1,14; 4,14], p=0,016). No significant difference was observed in longterm MACCE and death rates between women or men when comparing ONCAB, OPCAB, MICSCAB and NTA stratum, except for a significant lower risk of death in men with ONCAB compared to OPCAB (HR =0,28 [95% CI: 0,09; 0,91], p=0,03). The use of graft imaging revealed an increased risk of graft occlusion in women, whereas following off-pump CABG the risk of any occlusion was significantly higher in both sexes compared to ONCAB. Predictor of long-term MACCE and death for women was use of composite grafts, while for men — ejection fraction (EF) £40%, age >70 years, and off-pump CABG. At last follow-up, the persistence of health complaints was significantly higher among female patients versus male patients.

Conclusion. Women overall have less favorable outcomes following surgical myocardial revascularization compared with men. The impact of different surgical bypass techniques on postoperative outcomes varies between women and men. A differential sex-gender approach should be employed in the selection of the optimal surgical technique for CABG, with the objective of improving patient outcomes following myocardial revascularization.

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