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Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112 Page 7 of 17

MAG and should be spared from its associated risks [49,50] . Evidence also suggests that epicardial lead
placement is beneficial and should be considered in patients undergoing concomitant surgery with
[3]
QRS ≥ 120 ms and LBBB, or patients requiring chronic ventricular pacing .

Despite its potential benefits, MAG remains underutilized among women. In the Society of Thoracic
Surgeon (STS) database from 2011-2019, women were significantly less likely to receive left internal thoracic
[51]
artery, bilateral internal thoracic artery (BITA), or radial grafts . Rate of increasing BITA use is higher in
men, and although propensity score matching removed significant differences in BITA and radial artery
graft use between men and women, there was still greater use of ≥ three artery MAG in men than women
(10.5% vs. 7.3%; P = 0.048) . Hesitancy towards performing MAG in women can be a result of small target
[52]
vessel and arterial conduit size, risk of sternal dehiscence with BITA, and higher preoperative risk profile .
[53]
[54]
Women are known to have worse early and late mortality, and greater risk of postoperative major adverse
cardiac and cerebrovascular events post-CABG than men . In a New York State registry study, MAG is
[55]
associated with improved survival and a lower rate of major adverse cardiac events among low-risk patients
regardless of sex. This was not seen among high-risk patients, with different risk thresholds between sexes
[56]
when the benefit of MAG is lost . In addition, a propensity-matched analysis between MAG vs. single
arterial grafting revealed lower seven-year mortality in men who received MAG (HR 0.80 [0.73-0.87]), but
not for women (HR 0.99 [0.84-1.15]) . The upcoming ROMA:Women trial (NCT03217006) will explore
[56]
the role of MAG in women; however, the joint impact of sex and LVSD remains to be established as patients
with LVEF ≤ 35% will be excluded .
[57]

Within surgical revascularization, women appear to derive disproportionately greater benefit from off-
pump CABG (OPCAB) than men for rates of postoperative death, stroke, and major cardiac events .
[58]
Adding the additional context of LVSD, OPCAB in the modern era has been associated with comparable, if
not better, early survival than on-pump CABG , with potentially higher five-year mortality, potentially due
[59]
[60]
to suboptimal longitudinal management rather than surgical strategy . The merit of OPCAB in women
with reduced LVEF remains to be explored.

Other operative considerations include addressing moderate-severe ischemic mitral regurgitation at the
time of CABG through mitral repair or replacement [61,62] , concomitant tricuspid valve repair for moderate-
[63]
severe tricuspid regurgitation , and arrhythmia surgery for atrial fibrillation (AF) for restoration of atrial
kick to complement CABG in LVEF recovery . Women have worse age-standardized mortality after
[64]
combined CABG/mitral valve surgery compared to men .
[65]
A 90-day waiting period post-revascularization is recommended before proceeding with primary prevention
implantable cardioverter-defibrillator (ICD) implantation in patients who have LVEF ≤ 35% despite
[66]
guideline-directed medical therapy (GDMT) . In a multinational European registry study on primary
prevention ICD, fewer women than men undergo ICD implantation; however, women also have lower
[67]
mortality and receive fewer appropriate ICD shocks after multivariate adjustment . In a race-based
subanalysis of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT, NCT00000609) on primary
prevention ICD for LVEF ≤ 35% in ICM and non-ischemic cardiomyopathy, survival benefits conferred by
ICD was independent of race . Furthermore, the incidence of ICD refusal and medication non-compliance
[68]
were comparable between Black and Caucasian patients , suggesting that the lower rates of specialist
[68]
consultation and ICD implantation in eligible patients who do not identify as White may be attributed to
biases in health care delivery .
[69]