Reply to Sankar et al.

The suggestion by Sankar et al. [1, 2] is well considered and timely given emerging data on the differences in outcomes of coronary revascularization based on gender and race. This could not be included in our analysis due to limitations of database.

The authors agree that there are a number of biological, socio-economic and cultural factors that account for variations in outcomes between genders. Jawitz et al. [3] reported lower rates of guideline-based revascularization (use of internal thoracic artery, multiple arterial grafts and complete revascularization) in the STS database (2011–2019) among 1.2 million patients. They were underrepresented 1:4 for surgical revascularization. Females are more likely to have atypical symptoms, present late, and have higher co-morbidities and a referral bias (both personal and physician) for further investigations and surgery. Biologically, females especially elderly have uniquely higher cardiovascular risk due to diabetes and hypertension, depression, autoimmune disease and radiotherapy for breast cancer treatment. The postmenopausal milieu (low progesterone) increases the risk of atherosclerosis, cardiac disease, innate resistance, infection, osteoporosis and general frailty, thus increasing perioperative risks of cardiac surgery.

Perceived biases in strategies and care delivery as in the Society of Thoracic Surgery database may not completely explain the differences in outcomes [4]. Gaudino et al. [5] found that multiple arterial grafting reduced mortality only among low-risk men (adjusted hazard ratio, 0.80; 95% CI, 0.73–0.87) but neither in low- or high-risk women (adjusted hazard ratio, 0.99; 95% CI, 0.84–1.15). Surgeon inexperience with arterial grafting remains high (<4% multi-arterial grafting in the USA and the UK). Even experienced surgeons may not embark on a technically challenging guideline-based operation with arterial grafts if conduits and targets are small or diffusely diseased or there are significant co-morbidities including age and frailty in female patients. Focussed studies and further efforts are certainly needed to address biases in care delivery and narrow the gap in cardiovascular disease outcomes between genders.

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