Are there gender differences in patients with acute type A aortic dissection?

Authors have nothing to disclose with regard to commercial support. Authors have nothing to disclose with regard to commercial support. We read with great interest the recent article of Fukui and colleagues,1Fukui T. Tabata M. Morita S. Takanashi S. Gender differences in patients undergoing surgery for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2015; 150: 581-587.e1Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar who investigated the sex differences in patients undergoing surgery for acute type A aortic dissection (ATAAD), which was poorly investigated previously. Fukui and colleagues1Fukui T. Tabata M. Morita S. Takanashi S. Gender differences in patients undergoing surgery for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2015; 150: 581-587.e1Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar must be congratulated for their relatively low operative mortality and for shedding light on the important issue of the impact of sex on preoperative characteristics and postoperative outcomes in patients undergoing surgery for ATAAD. They pointed out that there were no differences in early mortality, late reoperation, or late mortality between male and female patients. Multivariate logistic regression analyses also demonstrated that female sex was not an independent predictor of operative mortality. In addition, they addressed the findings that serious preoperative conditions, including myocardial ischemia, brain ischemia, and shock or tamponade, were independent predictors of operative mortality and that the prevalences of these conditions were not significantly different between the sexes, with only shock or tamponade tending to be more frequent in female patients (27.8% vs 20.5%; P = .0701). Nevertheless, this well-illustrated investigation is deserving of additional comments, particularly with respect to the differences in preoperative characteristics of ATAAD between male and female patients. The sex-related differences that are seen after cardiovascular surgery may be related to a sex-specific clustering of preoperative characteristics.2Shah S.V. Kruse J. Andrei A.C. Li Z. Malaisrie S.C. Knight B.P. et al.Gender differences in outcomes after surgical ablation of atrial fibrillation.J Thorac Cardiovasc Surg. 2016; 151: 391-398.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Considering the impact of preoperative characteristics, especially serious conditions, on operative mortality risk for patients with ATAAD, generalized ischemia (shock or hypotension),3Augoustides J.G. Geirsson A. Szeto W.Y. Walsh E.K. Cornelius B. Pochettino A. et al.Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification.Nat Clin Pract Cardiovasc Med. 2009; 6: 140-146Crossref PubMed Scopus (127) Google Scholar, 4Danielsson E. Zindovic I. Bjursten H. Ingemansson R. Nozohoor S. Generalized ischaemia in type A aortic dissections predicts early surgical outcomes only.Interact Cardiovasc Thorac Surg. 2015; 21: 583-589Crossref PubMed Scopus (7) Google Scholar critical organ-specific ischemias (ie, mesentery, coronary, and cerebral ischemias),5Di Eusanio M. Patel H.J. Nienaber C.A. Montgomery D.M. Korach A. Sundt T.M. et al.Patients with type A acute aortic dissection presenting with major brain injury should we operate on them?.J Thorac Cardiovasc Surg. 2013; 145: S213-S221Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 6Di Eusanio M. Trimarchi S. Patel H.J. Hutchison S. Suzuki T. Peterson M.D. et al.Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390.e1Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 7Chien T.M. Cheng Q.H. Chen C.W. Yu C.P. Chen H.M. Chen Y.F. Modification of Penn classification and its validation for acute type A aortic dissection.Am J Cardiol. 2014; 114: 497-499Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar and cardiac tamponade8Gilon D. Mehta R.H. Oh J.K. Januzzi Jr., J.L. Bossone E. Cooper J.V. et al.Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection.Am J Cardiol. 2009; 103: 1029-1031Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar have been repeatedly demonstrated as independent predictors of operative mortality by a number of investigators. As Fukui and colleagues1Fukui T. Tabata M. Morita S. Takanashi S. Gender differences in patients undergoing surgery for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2015; 150: 581-587.e1Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar pointed out, there was only a single study dealing with sex-related differences in patients undergoing repaired ATAAD, which used data from the International Registry of Acute Aortic Dissection.9Nienaber C.A. Fattori R. Mehta R.H. Richartz B.M. Evangelista A. Petzsch M. et al.International Registry of Acute Aortic Dissection. Gender-related differences in acute aortic dissection.Circulation. 2004; 109: 3014-3021Crossref PubMed Scopus (333) Google Scholar The sex-related differences of preoperative characteristics have thus not been clearly defined, although Fukui and colleagues1Fukui T. Tabata M. Morita S. Takanashi S. Gender differences in patients undergoing surgery for acute type A aortic dissection.J Thorac Cardiovasc Surg. 2015; 150: 581-587.e1Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar have attempted to start filling this gap through their analysis of their experience. We studied the sex disparities in 202 patients (61 women, 30.2%; 141 men, 69.8%) undergoing surgery for ATAAD from 1997 to 2015. Demographic characteristics, clinical presentations, and outcomes are shown in Table 1. Women had significantly higher percentages of major cerebral injury (coma or stroke; 18.0% vs 7.8%; P = .032), shock or hypotension (37.7% vs 17.0%; P = .002), cardiac tamponade (37.7% vs 17.0%; P = .002), and 30-day mortality (23.0% vs 10.6%; P = .022) compared with their male counterparts. According to the International Registry of Acute Aortic Dissection analysis,9Nienaber C.A. Fattori R. Mehta R.H. Richartz B.M. Evangelista A. Petzsch M. et al.International Registry of Acute Aortic Dissection. Gender-related differences in acute aortic dissection.Circulation. 2004; 109: 3014-3021Crossref PubMed Scopus (333) Google Scholar clinical presentations of pericardial effusion (38.6% vs 28.6%, P = .001), congestive heart failure (9.1% vs 5.4%; P = .03), coronary artery compromise (10.8% vs 6.9%; P = .05), and coma or altered mental status (13.0% vs 9.0%; P = .05) occurred more commonly in women. In addition, surgical mortality for ATAAD was significantly higher among female than male patients (31.9% vs 21.9%; P = .013).9Nienaber C.A. Fattori R. Mehta R.H. Richartz B.M. Evangelista A. Petzsch M. et al.International Registry of Acute Aortic Dissection. Gender-related differences in acute aortic dissection.Circulation. 2004; 109: 3014-3021Crossref PubMed Scopus (333) Google Scholar Finally, recent evidence10Afifi R.O. Sandhu H.K. Leake S.S. Rice R.D. Azizzadeh A. Charlton-Ouw K.M. et al.Determinants of operative mortality in patients with ruptured acute type A aortic dissection.Ann Thorac Surg. 2016; 101: 64-71Abstract Full Text Full Text PDF Scopus (16) Google Scholar also demonstrates that female sex was strongly correlated with ruptured ATAAD (odds ratio, 1.89; 95% confidence interval, 1.05-3.39; P = .033). Moreover, a prospective population-based study from the Oxford Vascular Study11Howard D.P. Banerjee A. Fairhead J.F. Perkins J. Silver L.E. Rothwell P.M. Oxford Vascular Study. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control 10-year results from the Oxford Vascular Study.Circulation. 2013; 127: 2031-2037Crossref PubMed Scopus (429) Google Scholar indicated that a higher portion (61.1%) of out-of-hospital cardiac arrest (ie, immediately fatal) after the incidence of acute type A dissection were women. More research is therefore needed in this area to further define the sex-related differences in patients with acute type A aortic dissection.Table 1Demographic characteristics, clinical presentations, and postoperative outcomes in patients with acute type A aortic dissectionNTotal202Women61Men141P valueDemographic characteristics Age (y, mean ± SD)58.95 ± 11.9764.25 ± 10.6456.65 ± 11.82<.001 Age ≥70 y42 (21.9%)20 (34.5%)22 (16.4%).012 Hypertension163 (80.7%)48 (78.7%)115 (81.6%).635 Diabetes mellitus22 (10.9%)10 (16.4%)12 (8.5%).099 Asthma or COPD21 (10.8%)7 (11.5%)14 (9.9%).741 CVA15 (7.4%)5 (8.2%)10 (7.1%).783 CAD13 (6.4%)5 (8.2%)8 (5.7%).502Clinical presentation Coma or stroke22 (10.9%)11 (18.0%)11 (7.8%).032 Shock or hypotension47 (23.3%)23 (37.7%)24 (17.0%).002 Cardiac tamponade47 (23.3%)23 (37.7%)24 (17.0%).002 Aortic rupture14 (6.9%)7 (11.5%)7 (5.0%).100 AR (grade 3 or 4)73 (36.1%)24 (39.3%)49 (34.8%).605 CPR before operation13 (6.4%)7 (11.5%)6 (4.3%).055 Any pulse deficit44 (21.8%)11 (18.0%)33 (23.4%).396Postoperative outcome Initial 24-h bleeding >1500 mL23 (14.7%)14 (13.0%)9 (18.8%).593 Reoperation during hospitalization17 (8.2%)13 (9.0%)4 (6.3%).326 30-d mortality29 (14.4%)14 (23.0%)15 (10.6%).022Values are presented as number with percentage unless otherwise stated. SD, Standard deviation; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; CAD, coronary artery disease; AR, aortic regurgitation; CPR, cardiopulmonary resuscitation. Open table in a new tab Values are presented as number with percentage unless otherwise stated. SD, Standard deviation; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; CAD, coronary artery disease; AR, aortic regurgitation; CPR, cardiopulmonary resuscitation. Gender differences in patients undergoing surgery for acute type A aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 150Issue 3PreviewThe impact of gender on preoperative characteristics and postoperative outcomes in patients undergoing surgery for acute type A aortic dissection rarely has been investigated. Full-Text PDF Open ArchiveGender differences in acute type a aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 6PreviewWe appreciate Shih and colleagues' interest and comments on our article.1 Sex-related differences in patients undergoing repair of acute type A aortic dissection (AAAD) should be of great interest, given the important public health implications of understanding sex differences in outcomes after AAAD repair. However, only 1 previous study has focused on sex-related differences in patients undergoing surgical repair of AAAD using data from the International Registry of Acute Aortic Dissection (IRAD). Full-Text PDF Open Archive