ABSTRACT
During the time when coronary artery bypass graft (CABG) surgery was first gaining widespread acceptance, several prominent heart centers found an increased operative mortality in women undergoing the procedure.1-5 Over the following years, this finding has been substantiated in numerous studies.6-13 Initially this gender difference in CABG mortality was attributed to the smaller coronary vessels of women and the attendant technical difficulty in creating anastomoses to these small vessels.5,11,14-16 In more recent years, this logic has been challenged and other explanations have been offered. In particular, it has been shown that women present for CABG with more compelling comorbid conditions as compared with men,7-11,17,18 women are less likely to receive internal mammary artery (IMA) conduits,8,11,17-22 and women receive fewer bypass grafts overall.8,17,21,22 Several groups have reported a referral bias causing women to present for revascularization at a later stage in the disease process as compared with men.6,17,18,23-25
While some have investigated reasons for the excess mortality in women, others have challenged the true existence of this excess mortality. Of the groups reporting higher unadjusted CABG mortality rates in women, several have shown that statistical risk adjustment reveals an insignificant difference in mortality between risk-matched men and women.11-13,26 Still other groups have shown no significant gender difference in mortality even when using raw, unadjusted data.17,21,22,27
These facts illustrate the extraordinarily controversial nature of gender issues in coronary artery surgery. Fortunately, the welcome rise in scientific and public interest in women’s health over the last decade has done much to address these important controversies. While some aspects remain unresolved, there are some facts that have emerged to become well-accepted in all quarters.
