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J Thorac Cardiovasc Surg 2004;127:1193-1195
© 2004 The American Association for Thoracic Surgery

Brief communication

Effect of gender on bridging to transplantation and posttransplantation survival in patients with left ventricular assist devices

Jeffrey A. Morgan, MDa, Alan D. Weinberg, MSa, Karen W. Hollingsworth, BSa, Margaret R. Flannery, ANPa, Mehmet C. Oz, MDa, Yoshifumi Naka, MD, PhDa,*

a Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA

Received for publication May 12, 2003; accepted for publication May 16, 2003.

* Address for reprints: Yoshifumi Naka, MD, PhD, Columbia University, College of Physicians and Surgeons, 177 Fort Washington Ave, Milstein Hospital 7GN-435, New York, NY, USA 10032
yn33{at}columbia.edu

Studies have demonstrated sex differences in survival after various cardiac procedures, with superior survival for male over female patients.1 This might be due to a lower threshold to diagnose and aggressively treat heart disease in male patients, resulting in female patients presenting with more advanced pathology and systemic manifestations.2 This study was designed to analyze our bridge-to-transplant experience since the beginning of our program. Our primary goal was to determine the effect of sex on survival while on support, rates of successful bridging to transplantation, and posttransplantation survival.

Patients and methods

We retrospectively reviewed our experience with Thoratec Heartmate assist devices from August 1990 through September 2002. One hundred ninety-one (80.9%) male patients and 45 (19.1%) female patients underwent implantation. This included 52 pneumatic (40 male and 12 female patients), 17 dual-lead vented electric (15 male and 2 female patients), and 167 single-lead vented electric (136 male and 31 female patients) devices. Preimplantation left ventricular assist device (LVAD) scores, determined on the basis of a patient's presenting degree of clinical stability and shown to correlate with survival on LVAD support in multivariate analysis, were calculated for male and female patients.3 The study was performed in accordance with institutional guidelines.

Data were represented as frequency distributions and percentages. Values of continuous variables were expressed as means ± SD. Continuous variables were compared by using independent samples t tests, whereas categoric variables were compared by using {chi}2 tests. Kaplan-Meier analysis was used to calculate long-term survival. Significant predictors of survival were identified by using multivariate Cox proportional hazard models. All data were analyzed with SPSS 11.5 software.

Results

Demographics
Clinical characteristics of male and female patients are outlined in Table 1. There was no significant difference in age, race, or cause of heart failure (P = not significant). Male patients had a significantly higher body surface area than female patients (2.0 ± 0.2 vs 1.8 ± 0.2 kg/m2, P < .001). LVAD implantation scores were significantly higher for female patients than male patients (6.4 ± 3.1 vs 4.2 ± 3.2, P = .020). Median support time was similar between the groups (51.5 days [0-541 days] for male patients and 46.0 [0-397 days] for female patients, P = .412).


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  		TABLE 1. Clinical characteristics of male and female LVAD recipients

 
Survival on LVAD and transplantation rate
Survival on LVAD support was significantly higher for male patients than for female patients (78.5% [n = 150] vs 62.2% [n = 28], P = .022). Successful bridging to transplantation was also significantly higher for male patients than for female patients (72.8% [n = 139] vs 57.8% [n = 26], P = .048).

Posttransplantation survival
Male patients demonstrated significantly improved posttransplantation survival, with actuarial survival at 1, 3, and 5 years of 90.4%, 86.6%, and 85.2%, respectively, versus 87.8%, 74.3%, and 50.9%, respectively, for female patients (P = .010, Figure 1). However, when comparing male and female patients with similar LVAD implantation scores, there was no significant difference in survival (P = not significant).



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  		Figure 1. Posttransplantation survival for male and female patients.

 
Predictors of survival
For univariate analysis, significant predictors of survival included sex (P = .001), cause of heart failure (P = .003 for idiopathic cardiomyopathy and P = .048 for other), and LVAD score (P < .001), with a trend toward significance in age (P = .080).

The only significant predictor of overall survival in multivariate analysis was LVAD score (odds ratio, 1.214; 95% confidence interval, 1.119-1.316; P < .001). Patients with low LVAD implantation scores (0-4) demonstrated improved survival over patients with medium scores (5-7), whose survival was superior to that of patients with high scores (8-10; P < .001). Sex was not an independent predictor of survival (odds ratio, 0.724; 95% confidence interval, 0.641-0.852; P = .124).

Discussion
In our study male patients demonstrated superior survival while receiving mechanical assistance, a higher rate of successful bridging to transplantation, and improved survival after transplantation. LVAD preimplantation scores were significantly higher for female patients, indicating that female patients presented in a more advanced state of heart failure. This is consistent with studies that have demonstrated a significant delay in the preliminary suspicion, performance of diagnostic studies, and therapeutic intervention for women with heart failure.4,5 The multivariate analysis supports the notion that higher LVAD scores in female patients and not sex in and of itself accounted for inequities in outcome between male and female patients. Furthermore, after adjustment for LVAD score, there was no significant difference in outcome between the sexes. Additional evaluation of the causes for disproportionate survival between male and female patients is warranted.

Limitations of this study include those related to a retrospectively performed analysis. Data were obtained by means of chart review, which is limited by access and accuracy of the data. Additionally, data from our overall institutional experience were evaluated, which included pneumatic, dual-lead vented electric, and single-lead vented electric devices, although there have been changes in criteria for device implantation, selection of candidates, and the devices themselves. However, we pursued this approach because of the relatively small number of patients in each individual device category and the lack of statistical power and because the criteria for device implantation have always been similar for male and female patients.

References

  1. Steingart RM, Packer M, Hamm P, Coglianese ME, Gersh B, Geltman EM, et al. Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators. N Engl J Med. 1991;325(4):226–230[Abstract]
  2. Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med. 1991;325(4):221–225[Abstract]
  3. Rao V, Oz MC, Flannery MA, Catanese KA, Argenziano M, Naka Y. Revised screening scale to predict survival after insertion of a left ventricular assist device. J Thorac Cardiovasc Surg. 2003;125(4):855–862[Abstract/Free Full Text]
  4. Roger VL, Farkouh ME, Weston SA, Reeder GS, Jacobsen SJ, Zinsmeister AR, et al. Sex differences in evaluation and outcome of unstable angina. JAMA. 2000;283(5):646–652[Abstract/Free Full Text]
  5. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association Writing Group. Circulation. 1997;96(7):2468–2482[Free Full Text]



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