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 a dult patients undergoing orthotopic cardiac transplantation was undert aken at the Columbia-Presbyterian Medical Center. Methods and Results The study population consisted of 379 patients (75 women, 304 men) gre ater than or equal to 18 years of age who survived for greater than or equal to 48 hours after undergoing orthotopic cardiac transplantation between March 1985 and March 1999. The following were analyzed: incid ence of death and treated rejection episodes, donor and recipient cyto megalovirus (CMV) matches, use of OKT3 induction therapy, and donor an d recipient HLA mismatches. Women 49+/-12 years old and men 47+/-12 ye ars old were characterized by differences in race and diagnosis. Women were more likely to be nonwhite (P<.01) and have idiopathic cardiomyo pathy than were men (P<.01). A trend toward an increase in first-year rejection frequency was seen in women compared with men (P=.08). Overa ll actuarial survival was significantly reduced in women after transpl antation (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 on ly CMV(+) donor status and the use of OKT3 induction therapy affected survival in women. Multivariate analysis revealed a marked reduction i n survival in female recipients of CMV(+) donors given OKT3 induction therapy. At 36 months, only 25% of women were still alive compared wit h 86% of women with neither risk factor (P<.001). Even without OKT3 in duction there was markedly reduced survival in women with mismatched C MV status, ie, CMV(-) recipients of CMV(+) donors; 17% survival after 36 months versus 86% in women who were CMV(+) recipients (P<.05). Alth ough 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 th at 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 OK T3 induction therapy. (3) Multivariate analysis reveals that women are at even greater risk for death when receiving hearts from CMV(+) dono rs in conjunction with OKT3 induction therapy. (4) In the absence of O KT3 use, the greatest risk of death occurs in CMV(-) women transplante d with CMV(+) donor hearts. (5) When female to male survival curves ar e compared, factors that influenced survival in women did not appear t o be problematic in men.