According to the American Heart Association, more than 42 million women are affected with some form of cardiovascular disease that is responsible for 2,935,000 hospitalizations and 419,730 deaths every year (Roger).¹ This is about 1 death per minute among women, which makes cardiovascular disease the leading cause of death in US women nationally (Roger).¹ Heart disease causes more deaths in women than cancer, lung disease, and Alzheimer disease combined (Roger).¹ Coronary artery disease, valvular heart disease, congestive heart failure, and aortic aneurysms account for the majority of cardiovascular disease and related deaths in women (Roger).¹ Cardiac surgery is an effective treatment for many patients afflicted with these disorders.

CORONARY ARTERY BYPASS GRAFTING

Approximately 500,000 patients undergo coronary artery bypass grafting (CABG) surgery in the United States annually; however, only 25% of these surgeries are performed in women (Roger).¹

Coronary artery disease usually manifests differently in women than in men. Symptoms in women are usually subtle, leading to delays in diagnosis and presentation at more advanced stages (Blankstein).² For example, after a myocardial infarction women present more often with heart failure and cardiogenic shock symptoms, and they more frequently require support with intra-aortic balloon pumps or with inotropic drugs (Blankstein).² In addition, women have a higher prevalence of diabetes and other risk factors associated with adverse outcomes after CABG such as renal failure, stage III or IV heart failure, and valvular heart disease (Blankstein).²

CABG surgery is not only performed less often in women but is also performed differently. The left internal mammary artery (LIMA) bypass to the left anterior descending coronary artery is used less often than in men (Blankstein).² This is particularly relevant since LIMA bypass (Figure 5-1) has been associated with the best long-term primary patency rate and with improved long-term survival (Edwards).³ Women have smaller coronary arteries, leading to a lower number of bypass grafts performed per patient and to incomplete revascularization. Incomplete revascularization has been associated with adverse long-term outcomes (Edwards).³ Early outcomes after CABG are also less favorable in women. Women have an increased incidence of perioperative morbidity and mortality compared to men. The 30-day mortality in women can be about twice that of men (4.2% vs 2.2%) (Blankstein).²

MITRAL VALVE SURGERY

Mitral valve disease is the most common valvular lesion in the United States (Roger).¹ According to the Framingham study, the prevalence of moderate or severe mitral regurgitation is 15.5% in adult men and 4.2% in women (Singh)⁴ (Figure 5-2). Isolated mitral stenosis is more common in women (Roger).¹ Mitral stenosis occurs secondary to rheumatic heart disease and its prevalence has significantly decreased in the developed world (Roger).¹

Mitral valve disease may present with heart failure symptoms, atrial fibrillation, chest pain, and hemoptysis.

The treatment for the majority of patients with degenerative severe mitral valve regurgitation is mitral valve repair. Mitral valve repair is safe, effective, and durable. It reestablishes valve competency and improves the patient’s life expectancy. Restoration of the competency of the mitral valve is achieved by resection of the flail leaflet segment or by insertion of artificial chordae tendineae. The repair is reinforced by the insertion of an annuloplasty ring (Figure 5-3). This procedure can be performed in a minimally invasive manner through a right mini-thoracotomy or mini-sternotomy. Mitral valve replacement is rarely required. Operative mortality after mitral valve repair is increased for younger women compared to younger men and is believed to be related to hormonal effects (Song).⁵ Percutaneous mitral valvuloplasty has become the preferred treatment for mitral stenosis (Figure 5-4).