Mitral Repair vs Replacement for Degenerative Mitral Regurgitation in Patients Aged ≥65 Years.

BACKGROUND: The benefits of mitral valve repair vs replacement are well documented. However, survival benefits in the elderly population are more controversial. In this novel lifetime analysis, we hypothesize that survival benefits for valve repair vs replacement in the elderly are sustained throughout the patient's lifetime. METHODS: From January 1985 through December 2005, 663 patients, aged ≥65 years with myxomatous degenerative mitral valve disease underwent primary isolated mitral valve repair (n = 434) or replacement (n = 229). Propensity score matching was used to balance variables potentially related to outcome. RESULTS: Follow-up was complete in 99.1% of mitral repair and 99.6% of mitral replacement patients. In matched patients, perioperative mortality was 3.9% (9 of 229) for repair and 10.9% (25 of 229) for replacement (P = .004). Survival estimates (95% confidence limits) from 29-year follow-up for matched patients were 54.6% (48.0%, 61.1%) and 11.0% (6.8%, 15.2%) at 10 years and 20 years for repair patients, and 34.2% (27.7%, 40.7%) and 3.7% (1%, 6.4%) for replacement patients, respectively. Median survival (95% confidence limits) was 11.3 years (9.6, 12.2 years) for repair patients compared with 6.9 years (6.3, 8.0 years) for replacement patients (P < .001). CONCLUSIONS: This study demonstrates that although the elderly population is prone to multiple comorbidities, survival benefits of isolated mitral valve repair vs replacement are sustained throughout the patient's lifetime.

Long-Term Survival Benefits of Porcine versus Pericardial Bioprostheses in Elderly Patients Undergoing Isolated Aortic Valve Replacement: A 32-Year Study.

BACKGROUND: The elderly population is growing at an unprecedented rate. Aortic valve disease increases with age. Bioprostheses are the valves of choice for older patients; however, the optimal tissue valve remains undetermined. The purpose of this investigation was to perform a life-of-patient survival comparison of the prototypical porcine and pericardial prostheses in elderly patients. METHODS: The study population (N = 1480) consisted of patients 65 years of age and older who underwent isolated aortic valve replacement from 1990 through 2005 with a Carpentier-Edwards Porcine (n = 650) or Pericardial (n = 830) bioprosthesis. Propensity score-matched groups were created. RESULTS: Valve selection was not associated with operative mortality. Survival estimates at 10 years were better for Pericardial (41.8%; 95% CI: 37.9 to 45.7) than Porcine (32.6%; 95% CI: 28.8 to 36.3); and 5.2% (95% CI: 3.2 to 7.1) versus 2.0%; (95% CI: 0.8 to 3.2) at 20 years (p < 0.001). E-value analysis found minimal influence of unknown study confounders. Factors associated with long-term mortality were porcine valve (p < 0.001), age (p < 0.001), diabetes mellitus (p < 0.001), preop renal insufficiency (p < 0.001), peripheral artery disease (p = 0.011), congestive heart failure (p = 0.003), New York Heart Association Class III or IV (p = 0.004), surgical history-reoperation (p = 0.012), transient ischemic attack (p = 0.009), prolonged ventilation (p = 0.010), postop renal insufficiency (p < 0.001), and atrial fibrillation (p = 0.009). The indexed Effective Orifice Area (EOAi) was assessed and did not influence observed long-term survival differences. CONCLUSIONS: This unusual lifetime study provided substantial evidence for the superiority of the pericardial over the porcine bioprosthesis in the aortic position in elderly patients. It demonstrated enhanced long-term survival benefits for elderly patients without any increase in perioperative mortality. It is intended to inform future investigation into aortic valve design.

Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit.

BACKGROUND: Extensive evidence documents a survival benefit for bilateral internal mammary artery (BIMA) grafting compared with single internal mammary artery (SIMA) grafting for patients with advanced coronary artery disease. However, controversy continues to exist regarding the incremental benefit of broadly applied BIMA grafting in elderly patients. METHODS: Retrospective analysis was conducted of 4,503 consecutive isolated coronary artery bypass grafting operations (SIMA, n = 2,340 and BIMA, n = 2,163) performed from 1972 to 1994. Multivariate analysis was used to created propensity score-matched groups of SIMA (n = 1,063) and BIMA (n = 1,063) to compare patients 65 years of age and older, and 70 years of age and older (n = 612), with similar baseline characteristics. Survival status was obtained by periodic follow-up, query of the US National Death Index, and other Internet searches, and was 99.6% complete. RESULTS: The propensity score-matched groups experienced similar perioperative mortality and morbidity. Survival benefits were found for BIMA versus SIMA grafting across both age categories. Actuarial curves after 23,593 patient-years of follow-up (mean BIMA = 11.7 years; 6 weeks to 33.1 years; mean SIMA = 10.5 years; 6 weeks to 30.7 years) demonstrated improved long-term survival for BIMA versus SIMA patients at 12 years (51.0 ± 1.5% versus 39.0 ± 1.5%) and at 24 years (3.5 ± 0.7% versus 4.5 ± 0.7%; p < 0.001). Similarly, in matched groups of patients age 70 and older, overall survival was also enhanced with BIMA grafting (p = 0.005). CONCLUSIONS: Advanced age should not be a contraindication for BIMA grafting. Long-term follow-up clearly demonstrates that BIMA grafting when broadly applied in elderly patients results in improved long-term survival over SIMA grafting.

Bilateral internal mammary artery grafting reverses the negative influence of gender on outcomes of coronary artery bypass grafting surgery.

OBJECTIVES: Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been clearly defined. METHODS: A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, [SIMA]; 1886 bilateral IMA, [BIMA]) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete. RESULTS: Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790). CONCLUSIONS: When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery.

Bilateral internal mammary artery grafting enhances survival in diabetic patients: a 30-year follow-up of propensity score-matched cohorts.

BACKGROUND: The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus SIMA grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. METHODS AND RESULTS: Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching with the propensity score was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years; mean, 8.9 years) determined long-term survival. There was no difference in operative mortality, sternal wound infection, or total complications between matched SIMA and BIMA groups (operative mortality, 10 of 414 [2.4%] versus 13 of 414 [3.1%]; P=0.279; sternal wound infection, 7 of 414 [1.7%] versus 13 of 414 [3.1%]; P=0.179); total complications, 71 of 414 [17.1%] versus 71 of 414 [17.1%]; P=1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival: SIMA, 9.8 years versus BIMA, 13.1 years; P=0.001). Use of BIMA was found to be associated with late survival on Cox regression (P=0.003). CONCLUSION: Compared with SIMA grafting, BIMA grafting in propensity score-matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality.

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up.

OBJECTIVE: Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. METHODS: Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. RESULTS: There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). CONCLUSIONS: Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

Location of the second internal mammary artery graft does not influence outcome of coronary artery bypass grafting.

BACKGROUND: Although the use of two internal mammary arteries (IMA) in coronary artery bypass graft surgery has been associated with improved patient survival and clinical status, the optimal use of the second IMA graft remains controversial. We, therefore, explored clinical outcomes in a large cohort of patients undergoing bilateral IMA grafting. METHODS: Between February 1972 and May 1994, 2,215 consecutive patients underwent bilateral IMA grafting. The second IMA was used to revascularize the left coronary system (LCS) in 1,479 and the right coronary system (RCS) in 736 patients. Propensity score optimal matching algorithm was used to create the matched LCS group (n=730) and RCS group (n=730). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8; 96.7% complete) was performed. Multivariable analyses were performed to determine correlates of operative mortality and late mortality. Patient clinical status and Short Form-36 scores of late survivors were compared. RESULTS: There was no difference in either operative mortality or late survival between LCS and RCS patients, in either unmatched or matched groups. Operative mortality unmatched was LCS 38 of 1,479 (2.6%) versus RCS 20 of 736 (2.7%; p=0.837). For matched groups, it was LCS 13 of 730 (1.8%) versus RCS 20 of 736 (2.7%; p=0.284). Median survival in unmatched patients was LCS 15.8 years versus RCS 16.1 years (p=0.803); for matched patients, it was LCS 16.1 years versus RCS 16.1 years (p=0.671). Site of second IMA was not associated with either operative mortality or late survival on multivariable analysis. At follow-up, both groups demonstrated excellent clinical outcomes, with 98.4% of LCS patients and 96.8% of RCS patients in Canadian Cardiovascular Society class I or II, and no significant difference in either the physical (p=0.142) or mental (p=0.542) health summary scores on the Short Form-36. CONCLUSIONS: Use of two IMA grafts demonstrates excellent long-term results with no demonstrable difference in outcome between RCS and LCS patients.

Eighteen-year follow-up demonstrates prolonged survival and enhanced quality of life for octogenarians after coronary artery bypass grafting.

OBJECTIVE: Octogenarians comprise the fastest growing population segment. Numerous reports have documented improved accomplishment of coronary artery bypass grafting in this high-risk cohort. But what is the quality of life after surgery, and how sustainable are the clinical benefits? METHODS: Sequential cross-sectional analyses were performed on 1062 consecutive patients 80 years old and older who underwent isolated on-pump coronary artery bypass grafting at a single institution from 1989 to 2001. After mean follow-up of 3.4 years (1 month-12.6 years), the Short Form 36 quality of life survey was administered to all survivors. Late follow-up for survival was performed after a mean 5.6 years (1 month-17.9 years). Multivariate analyses assessed risk factors associated with operative mortality, Short Form 36 self-assessment, and late survival. RESULTS: Mean age at operation was 83.1±2.8 years (range, 80-99 years). Overall in-hospital mortality was 9.7%, decreasing progressively to 2.2% during the course of the study. At midterm follow-up, 97.1% of patients were in Canadian Cardiovascular Society class I or II; Short Form 36 scores were comparable to age-adjusted norms in both physical and mental health summary scores. Actuarial survivals were 42.2%±1.5% at 7 years and 9.9%±1.4% at 14 years. Median survival was 5.9 years; 5.2 years for male patients and 6.7 for female patients (P=004). CONCLUSIONS: The risk of coronary artery bypass grafting for octogenarians now rivals that of a younger population. Midterm quality of life and long-term survival approach those of the general population.

Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups.

BACKGROUND: The value of the left internal mammary artery (LIMA) graft is well established. However, the incremental value of a second IMA graft is controversial. Despite reports of improved survival with bilateral IMA (BIMA) grafting, the Society of Thoracic Surgeons reports its use in 4% of coronary artery bypass graft operations. We report the influence of BIMA vs SIMA grafting on hospital and late mortality in comparable groups. METHODS: Retrospective review was conducted of 4584 consecutive isolated coronary artery bypass graft operations (2369 SIMA and 2215 BIMA) performed from 1972 to 1994. The influence of the second IMA was assessed by multivariate analyses of risk factors associated with hospital and late mortality and by propensity score analysis that compares patients with similar baseline characteristics for receiving a second IMA graft. All patients were monitored clinically to assess outcomes. RESULTS: Hospital mortality was 4.5% for SIMA vs 2.6% for BIMA patients (p = 0.001). When stratified by propensity score to undergo BIMA grafting, no difference in hospital mortality was found. Multivariate analyses showed SIMA grafting was significantly associated with late but not hospital mortality. Survival curves after 52,572 patient-years of follow-up (mean, 11.5 years; range, 6 weeks to 32 years) demonstrated improved long-term survival for BIMA vs SIMA patients in all quintiles except those with the greatest propensity for SIMA, wherein late survival was comparable between groups. In matched groups, survival favored BIMA patients (p = 0.001). CONCLUSIONS: BIMA grafting offers a long-term survival advantage over SIMA grafting in propensity-matched groups.

Transaortic repair of the mitral valve in patients undergoing aortic valve replacement.

OBJECTIVE: We retrospectively evaluated the results of edge-to-edge (Alfieri) repair of the mitral valve via a transaortic approach in patients undergoing aortic valve replacement (AVR) and who had significant mitral regurgitation (MR). METHODS: From July 2000 to June 2006, 13 patients underwent edge-to-edge repair of the mitral valve via a transaortic approach with concomitant AVR. Patients were considered eligible for the transaortic Alfieri repair if the preoperative transesophageal echocardiogram indicated that the MR jet originated in the middle portion (A2/P2 segments) of the mitral valve. A postoperative transesophageal echocardiogram and follow-up transthoracic echocardiograms were obtained. RESULTS: There was no operative mortality. There was a significant improvement in the median MR grade from 3 (interquartile range [IQR], 2-4) preoperatively to 1 (IQR, 1-1) postoperatively (P < .0001). The ejection fraction (EF) remained stable, with mean preoperative and postoperative EFs of 44.2% + or - 14.9% and 46.27% + or - 11.6%, respectively (P = .4). No mitral stenosis was noted in any of the patients following edge-to-edge repair. Follow-up transthoracic echocardiograms obtained at a mean of 12.5 months postoperatively (range, 1-34 months) showed a median MR grade of 1 (IQR, 1-2) with no worsening compared with immediately postoperatively (P = .4). CONCLUSION: Transaortic edge-to-edge repair of the mitral valve in patients undergoing AVR is feasible. The postoperative improvement in MR was maintained at the midterm follow-up.

The valve of choice in elderly patients and its influence on quality of life: a long-term comparative study.

BACKGROUND AND AIM OF THE STUDY: Mechanical heart valves are preferred for younger patients in order to avoid valve structural deterioration, but bioprosthetic valves are favored for older patients to avoid long-term anticoagulation. With increasing patient longevity, controversy persists regarding the valve of choice in the 65- to 75-year-old population. With improving patient survival, long-term quality of life (QOL) is a critical element in helping to resolve this controversy. METHODS: A retrospective analysis was conducted of 1,104 consecutive patients, aged 65-75 years, who underwent valve replacement between July 1976 and December 1999. Valves implanted were either a Carpentier-Edwards (CE) porcine bioprosthesis (596 patients) or a St. Jude Medical (SJM) mechanical valve (508 patients), with and without concomitant coronary artery bypass grafting. QOL was assessed using the Short Form (SF-36) Health Survey for both groups at the time of follow up, which was 98.2% complete. Comparable patient groups were analyzed within quintiles by propensity score analysis. RESULTS: Operative mortality was 9.4% (n = 56) for CE patients, and 5.3% (n = 27) for SJM patients (p = 0.014). Propensity score analysis revealed no significant difference in operative mortality between groups in any of the five quintiles. Actuarial survival for hospital survivors favored SJM patients (p = 0.005). However, when compared within quintiles, there was no significant difference between groups. QOL summary scores were significantly higher for physical health (p = 0.007) for SJM patients, but similar between valve groups for mental health. Comparison within quintiles revealed no significant difference between the groups in either area. CONCLUSION: When comparing the outcomes of mechanical versus bioprosthetic valve replacement, considerable care must be exercised to ensure the clinically relevant similarity of groups. When evaluating comparable patient groups, there was no advantage in either survival or QOL for patients aged 65-75 years receiving a CE or SJM valve.

The influence of coronary artery disease on quality of life after mechanical valve replacement.

BACKGROUND AND AIM OF THE STUDY: Coronary artery disease (CAD) is known to impact negatively on long-term survival following valve replacement (VR). However, its influence on quality of life (QOL) remains undefined in patients with mechanical VR. METHODS: A total of 318 consecutive patients undergoing VR with the St. Jude Medical (SJM) mechanical valve were matched for age and gender with 318 patients who had VR (SJM valve) and coronary artery bypass grafting (VR+CABG). The VR group comprised 197 men and 121 women; the VR+CABG group also comprised 197 men and 121 women. The mean age of all patients was 66.0 +/- 8.0 years (range: 40-87 years). The Short Form-36 (SF-36) health survey was administered to all survivors at follow up examination. RESULTS: Operative mortality was comparable between groups (4.7% for VR, 7.5% for VR+CABG; p = 0.186). Hospital complications were also similar, except for reoperation for bleeding (p = 0.049). The mean follow up was 6.0 years for VR patients and 4.7 years for VR+CABG patients. Actuarial survival was significantly better in VR patients than VR+CABG patients (79.4 +/- 2.4% versus 75.0 +/- 2.7% at five years; 58.6 +/- 4.3% versus 47.5 +/- 4.5% at 10 years; p = 0.018). The equality of survival distribution was significantly different (p = 0.008). Multivariate analysis identified CABG as a predictor of late mortality (p = 0.003) but not of late QOL. QOL was similar on the eight health scales and physical health (44.5 +/- 10.3 versus 45.5 +/- 10.7) and mental health (52.4 +/- 9.8 versus 52.5 +/- 10.1) summary components, respectively. Age (p = 0.004), time from surgery to SF-36 administration (p = 0.007) and gender (p = 0.029), but not CABG, were significantly associated with QOL as assessed by the SF-36. CONCLUSION: CAD is a predictor of late mortality after mechanical VR. However, provided CABG is performed concomitantly with VR, the patient's longterm QOL appears to return to that expected for the general population.

Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians.

BACKGROUND: Despite well-established benefits of arterial (ART) grafting, surgeons have been reluctant to use this conduit in octogenarians. This study explores the influence of arterial revascularization on operative and long-term outcomes of coronary artery bypass grafting surgery. METHODS: A retrospective analysis was conducted of 987 consecutive patients 80 years of age or older who underwent isolated coronary artery bypass grafting between January 1989 and November 2000. Patients with saphenous vein graft only (SVG; n = 574) were compared with those receiving arterial and saphenous vein grafts (ART+SVG; n = 413). Mean follow-up for SVG patients was 3.8 years (range, 4 months to 12.6 years) and 98.6% complete, and mean follow-up was 3.1 years for ART+SVG patients (range, 2 months to 11.2 years) and 97.3% complete. RESULTS: Patients with SVG had a significantly higher (p = 0.009) operative mortality (11.1% versus 6.3%) and significantly longer postoperative length of stay (12.9 versus 10.7 days; p = 0.002) than ART+SVG recipients. More ART+SVG than SVG patients were free of all postoperative complications (290 of 413; 70.2% versus 372 of 574; 64.8%; p = 0.086). Multivariable analysis identified SVG as an independent predictor of operative mortality (p = 0.014) and late mortality (p = 0.040). When patients were matched by equivalent propensity scores to receive SVG only, operative mortality was higher for SVG patients in four of the five quintiles. At 10 years, 97.0% +/- 1.2% of SVG and 92.9% +/- 3.7% of ART+SVG current survivors were free of all late major adverse cardiac events (p = 0.565), and 95.5% of SVG patients and 97.5% of ART+SVG patients were in Canadian class 1 or 2 (p = 0.162). On the SF-36 quality-of-life assessment, ART+SVG patients scored significantly higher than both SVG patients and age-adjusted normal subjects. Physical health summary component scores were 36.8 +/- 11.0 for SVG and 41.0 +/- 10.3 for ART+SVG (p = 0.001). Mental health summary scores were comparable for the two groups. CONCLUSIONS: Arterial grafting confers an operative survival benefit, and an enhanced long-term quality of life in elderly patients.

Coronary bypass surgery in women: a long-term comparative study of quality of life after bilateral internal mammary artery grafting in men and women.

BACKGROUND: Coronary bypass surgery carries a higher operative mortality and less favorable long-term clinical benefits for women than men. The impact of arterial revascularization on long-term results, including quality of life (QOL) in women, compared with men, has not been clearly defined. METHODS: A retrospective analysis was performed comparing 261 consecutive women patients from a single surgical practice receiving bilateral internal mammary artery (IMA) and supplemental vein grafts between January 1972 and October 1994 with a computer-matched cohort of 261 men undergoing bilateral IMA surgery during the same time period. Univariate analysis confirmed the homogeneity of the two groups based on multiple preoperative variables. The SF-36 QOL assessment tool was completed for all patients at follow-up, which ranged from 1 month to 25 years, with a mean follow-up of 9.1 years for women and 8.6 years for men. RESULTS: There was no significant difference in operative mortality, nor in the incidence of any of 10 postoperative complications evaluated. The actuarial survival at 15 years was 53.7% +/- 4.8% for women and 50.9% +/- 5.6% for men (p = 0.218). At follow-up, 97.0% of women and 94.3% of men were free of angina and in Canadian Cardiovascular Society (CCS) class I or II. The need for reoperation (1.8% vs 1.9%) and PTCA (4.8% vs. 3.2%) was comparable in both groups. However, a higher rate of late myocardial infarction was found in women than men (1.8% vs 0.6, p = 0.021). The long-term event-free survival was found to be no different in men than women (p = 0.084). QOL as measured by the SF-36 was compared with the general population corrected for age and gender. Men and women scored as well or better than the general population in a majority of the eight health scales. Moreover, with regard to the health summary scores, men scored significantly higher (p = 0.001) in physical health, whereas women scored significantly higher (p = 0.011) in mental health when compared with age-adjusted norms. CONCLUSIONS: Men and women undergoing coronary revascularization using bilateral internal mammary artery conduits experience comparable outcomes, excellent long-term results, and enjoy a QOL comparable to or better than the general population as measured by the SF-36.