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LETTER TO THE EDITOR

There Are More Important Risk Factors That May Influence The Outcome in Female AVR Patients

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

1. Duncan AI, Lin J, Koch CG, Gillinov AM, Xu M, Starr NJ. The impact of gender on in-hospital mortality and morbidity after isolated aortic valve replacement. Anesth Analg 2006;103:800–8[Abstract/Free Full Text]
2. Rohde LE, Zhi G, Aranki SF, Beckel NE, Lee RT, Reimold SC. Gender-associated differences in left ventricular geometry in patients with aortic valve disease and effect of distinct overload subsets. Am J Cardiol 1997;80:475–80[Web of Science][Medline]
3. Mangano DT, Layug EL, Wallace A, Tateo I. Multicenter Study of Perioperative Ischemia Research Group. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996;335:1713–20[Abstract/Free Full Text]
4. Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn JD, Baars HF, Yo TI, Trocino G, Vigna C, Roelandt JR, van Urk H. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 1999;341:1789–94[Abstract/Free Full Text]
5. Kaneko T, Saito Y, Hikawa Y, Yasuda K, Makita K. Dose-dependent prophylactic effect of nicorandil, an ATP-sensitive potassium channel opener, on intra-operative myocardial ischaemia in patients undergoing major adnominal surgery. Br J Anaesth 2001;86:332–7[Abstract/Free Full Text]
6. De Hert SG, ten Broecke PW, Mertens E, Van Sommeren EW, De Blier IG, Stockman BA, Rodrigus IE. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients. Anesthesiology 2002;97:42–9[Web of Science][Medline]
7. Taylor NE, O’Brien S, Edwards FH, Peterson ED, Bridges CR. Relation between race and mortality and morbidity after valve replacement surgery. Circulation 2005;111:1305–12[Abstract/Free Full Text]
8. Erdogan HB, Kayalar N, Ardal H, Omeroglu SN, Kirali K, Guler M, Akinci E, Yakut C. Risk factors for requirement of permanent pacemaker implantation after aortic valve replacement. J Card Surg 2006;21:211–5[Web of Science][Medline]

This article has been cited by other articles:

				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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Ishikawa, S. Search for Related Content PubMed PubMed Citation Articles by Ishikawa, S.