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Department of Anesthesiology; Tokyo Medical and Dental University; Graduate School of Medicine; Tokyo, Japan; ishikawa.mane{at}tmd.ac.jp
To the Editor:
Although a recent paper (1) describing the impact of gender on mortality and morbidity after aortic valve replacement (AVR) led to the conclusion that there was no greater than a 2.5-fold increase in risk for females compared with males using 1:1 matching by propensity score I suggest that the important additional risk factors should be taken into consideration to determine the impact of gender on outcome.
First, the severity of aortic diseases was not compared between females and males. As the authors stated in the Discussion section, female patients with aortic stenosis develop greater left ventricular wall thickness (2). Thus, it is not surprising that myocardial preservation during cardiopulmonary bypass may be suboptimal in female patients with severe aortic stenosis. Second, as perioperative factors, agents that potentially have cardioprotective effects [e.g., ß-blockers (3,4), nicorandil (5)] may have influenced the cardiac morbidity after AVR. Regarding general anesthetics, sevoflurane has been shown to have a better cardioprotective effect compared with propofol (6).
Third, there is a possibility that race is a significant predictor of some complications after isolated AVR. Taylor et al. (7) recently reported that black race was associated with an increased risk of prolonged ventilation, postoperative stay >14 days, and reoperation for bleeding after AVR.
Lastly, it may be more technically difficult for surgeons to perform AVR in female patients than in male patients. Female gender is known as one of the independent risk factors for permanent pacemaker implantation after AVR (8). Placement of sutures after extensive debridement of valve leaflets may have damaged the conduction system. I hope quantitative scoring will be performed by surgeons regarding technical difficulties in future studies.
The greater the number of important risk factors included for matching female and male pairs, the closer we will come to the conclusion that there is no gender-related risk regarding isolated AVR surgery.
REFERENCES
This article has been cited by other articles:
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  A. Duncan and C. Koch There Are More Important Risk Factors That May Influence The Outcome in Female AVR Patients Anesth. Analg., August 1, 2007; 105(2): 542 - 542. [Full Text] [PDF]
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