Increased early mortality in women undergoing cardiac transplantation.
BACKGROUND
To evaluate factors that explain sex differences affecting mortality after cardiac transplantation, a retrospective analysis of adult patients undergoing orthotopic cardiac transplantation was undertaken at the Columbia-Presbyterian Medical Center.


RESULTS
The study population consisted of 379 patients (75 women, 304 men) > or = 18 years of age who survived for > or = 48 hours after undergoing orthotopic cardiac transplantation between March 1985 and March 1992. The following were analyzed: incidence of death and treated rejection episodes, donor and recipient cytomegalovirus (CMV) matches, use of OKT3 induction therapy, and donor and recipient HLA mismatches. Women 49 +/- 12 years old and men 47 +/- 12 years old were characterized by differences in race and diagnosis. Women were more likely to be nonwhite (P < .01) and have idiopathic cardiomyopathy than were men (P < .01). A trend toward an increase in first-year rejection frequency was seen in women compared with men (P = .08). Overall actuarial survival was significantly reduced in women after transplantation (P < .05). At 36 months, female actuarial survival was 64 +/- 7% versus 76 +/- 3% for men (P < .05). The majority of patients in this study did not receive CMV prophylaxis. Univariate analysis revealed that only CMV(+) donor status and the use of OKT3 induction therapy affected survival in women. Multivariate analysis revealed a marked reduction in survival in female recipients of CMV(+) donors given OKT3 induction therapy. At 36 months, only 25% of women were still alive compared with 86% of women with neither risk factor (P < .001). Even without OKT3 induction there was markedly reduced survival in women with mismatched CMV status, ie, CMV(-) recipients of CMV(+) donors; 17% survival after 36 months versus 86% in women who were CMV(+) recipients (P < .05). Although at this institution during the study time period, CMV prophylaxis was not routinely employed and OKT3 induction was selectively used in higher-risk patients, conclusions regarding differences in outcome that are sex dependent are valid.


CONCLUSIONS
(1) Women are at risk for reduced actuarial survival up to 3 years after cardiac transplantation. (2) Univariate analysis shows that women are selectively at risk for death when receiving hearts from CMV(+) donors and after receiving OKT3 induction therapy. (3) Multivariate analysis reveals that women are at even greater risk for death when receiving hearts from CMV(+) donors in conjunction with OKT3 induction therapy. (4) In the absence of OKT3 use, the greatest risk of death occurs in CMV(-) women transplanted with CMV(+) donor hearts. (5) When female to male survival curves are compared, factors that influenced survival in women did not appear to be problematic in men.
Wechsler
M E
ME
Cardiovascular Clinical Pharmacology Laboratory, College of Physicians and Surgeons, Columbia University, New York, NY.
Giardina
E G
EG
Sciacca
R R
RR
Rose
E A
EA
Barr
M L
ML
D000206:Actuarial Analysis; D003586:Cytomegalovirus Infections / Q000453:epidemiology*; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology*; D016027:Heart Transplantation / Q000401:mortality*; D006650:Histocompatibility Testing; D006801:Humans; D007165:Immunosuppression Therapy; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016853:Muromonab-CD3 / Q000627:therapeutic use*; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D016019:Survival Analysis; D013997:Time Factors; D014019:Tissue Donors
D016853:Muromonab-CD3