Reduced Long-Term Relative Survival in Females and Younger Adults Undergoing Cardiac Surgery: A Prospective Cohort Study.
OBJECTIVE
To assess long-term survival and mortality in adult cardiac surgery patients.


METHODS
8,564 consecutive patients undergoing cardiac surgery in Trondheim, Norway from 2000 until censoring 31.12.2014 were prospectively followed. Observed long-term mortality following surgery was compared to the expected mortality in the Norwegian population, matched on gender, age and calendar year. This enabled assessment of relative survival (observed/expected survival rates) and relative mortality (observed/expected deaths). Long-term mortality was compared across gender, age and surgical procedure. Predictors of reduced survival were assessed with multivariate analyses of observed and relative mortality.


RESULTS
During follow-up (median 6.4 years), 2,044 patients (23.9%) died. The observed 30-day, 1-, 3- and 5-year mortality rates were 2.2%, 4.4%, 8.2% and 13.8%, respectively, and remained constant throughout the study period. Comparing observed mortality to that expected in a matched sample from the general population, patients undergoing cardiac surgery showed excellent survival throughout the first seven years of follow-up (relative survival ≥ 1). Subsequently, survival decreased, which was more pronounced in females and patients undergoing other procedures than isolated coronary artery bypass grafting (CABG). Relative mortality was higher in younger age groups, females and patients undergoing aortic valve replacement (AVR). The female survival advantage in the general population was obliterated (relative mortality ratio (RMR) 1.35 (1.19-1.54), p<0.001). Increasing observed long-term mortality seen with ageing was due to population risk, and younger age was independently associated with increased relative mortality (RMR per 5 years 0.81 (0.79-0.84), p<0.001)).


CONCLUSIONS
Cardiac surgery patients showed comparable survival to that expected in the general Norwegian population, underlining the benefits of cardiac surgery in appropriately selected patients. The beneficial effect lasted shorter in younger patients, females and patients undergoing AVR or other procedures than isolated CABG. Thus, the study identified three groups that need increased attention for further improvement of outcomes.
Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Department of Cardiothoracic Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway.
Tone Bull
TB
Enger
Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Clinic of Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway.
Hilde
H
Pleym
Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Department of Cardiothoracic Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway.
Roar
R
Stenseth
Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Department of Cardiothoracic Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway.
Guri
G
Greiff
Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Clinic of Cardiothoracic Surgery, St. Olavs University Hospital, Trondheim, Norway.
Alexander
A
Wahba
Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.|Department of Immunology and Transfusion Medicine, St. Olavs University Hospital, Trondheim, Norway.
Vibeke
V
Videm
Eur J Cardiothorac Surg. 2012 Apr;41(4):734-44; discussion 744-5
22378855
Heart. 2002 Apr;87(4):395-400
11907022
Circulation. 2003 Mar 11;107(9):1271-7
12628947
J Am Coll Cardiol. 2000 Mar 1;35(3):747-56
10716479
Neth Heart J. 2012 Mar;20(3):110-7
22311176
J Am Coll Cardiol. 2013 Feb 26;61(8):837-48
23428216
Stat Med. 1996 Feb 28;15(4):361-87
8668867
Circulation. 2000 May 30;101(21):2497-502
10831524
Ann Thorac Surg. 2001 Dec;72(6):2033-7
11789789
Circulation. 2001 Oct 30;104(18):2205-9
11684632
Comput Methods Programs Biomed. 2006 Mar;81(3):272-8
16510208
Circulation. 2012 Mar 27;125(12):1491-500
22361330
Interact Cardiovasc Thorac Surg. 2012 Nov;15(5):825-32
22833511
Eur J Cardiothorac Surg. 2013 Jan;43(1):253-4
23148067
Eur Heart J. 1994 Sep;15(9):1204-11
7982420
Comput Biol Med. 2007 Dec;37(12):1741-9
17582396
J Cardiothorac Vasc Anesth. 2003 Oct;17(5):585-93
14579211
J Thorac Cardiovasc Surg. 2003 Dec;126(6):1707-11
14688676
Ann Thorac Surg. 2009 Feb;87(2):463-72
19161761
Interact Cardiovasc Thorac Surg. 2015 Nov;21(5):598-603
26265068
Ann Thorac Surg. 1997 Aug;64(2):437-44
9262590
Ann Card Anaesth. 2015 Apr-Jun;18(2):138-42
25849679
Acta Anaesthesiol Scand. 2011 Mar;55(3):313-21
21288212
Acta Anaesthesiol Scand. 2012 Feb;56(2):190-9
22091558
Eur J Cardiothorac Surg. 1997 Mar;11(3):539-46
9105821
Tidsskr Nor Laegeforen. 2012 Jan 24;132(2):147-51
22278269
Acta Anaesthesiol Scand. 2015 Jul;59(6):796-806
25762219
J Cardiothorac Vasc Anesth. 2015 Apr;29(2):311-9
25529438
Ann Thorac Surg. 2011 Feb;91(2):506-13
21256302
Eur J Cardiothorac Surg. 1997 Jan;11(1):81-91
9030794
Acta Anaesthesiol Scand. 2014 May;58(5):539-48
24628133
Tidsskr Nor Laegeforen. 2015 May 05;135(8):768-70
25947599
Eur J Anaesthesiol. 2013 Nov;30(11):704-12
24067536
Eur J Anaesthesiol. 2012 Mar;29(3):143-51
22228238
Br J Anaesth. 2015 Jan;114(1):53-62
25240162
Ann Thorac Surg. 2006 Mar;81(3):793-9
16488675
Rev Esp Cardiol. 2011 Jun;64(6):463-9
21497978
J Am Coll Cardiol. 1990 Jun;15(7):1493-9
2345229
Circulation. 2012 May 22;125(20):2423-30
22547673