Correlation between Sex and Prognosis of Acute Aortic Dissection in the Chinese Population

Sex-related differences in clinical characteristics and in-hospital outcomes of patients in acute type A aortic dissection

OBJECTIVE

The aim of this study was to investigate sex-related differences in the clinical characteristics and hospital outcomes of patients undergoing surgery for acute type A aortic dissection (AAAD).

METHODS

This study was a retrospective study. Patients who underwent surgery for AAAD at the Department of Cardiac Surgery, Fujian Medical University Union Hospital, from January 2014 to March 2023 were consecutively included. Data was extracted from electronic medical records. The primary outcome measure was in-hospital mortality, and secondary outcome measures included new-onset postoperative arrhythmia (POA), acute kidney injury (AKI), hepatic dysfunction, neurological complications, gastrointestinal hemorrhage, ICU length of stay, and hospital length of stay. Patients were divided into two groups based on sex, and data analysis was performed using SPSS 25.0 software.

RESULTS

A total of 1137 subjects were included, with 863 males (75.9%) and 274 females (24.1%). There were statistically significant differences in age and BMI between the two groups (P < 0.05). There was no statistically significant difference in the incidence of pain at the onset between the two groups, but chest tightness in females was higher than in males (22.6% vs. 13.8%). Regarding primary outcomes, the in-hospital mortality rate was 11.1% for males and 10.6% for females (P = 0.803). There were no statistically significant differences between the groups in ICU days, length of hospitalization, neurological complications, or liver dysfunction (P > 0.05). The rate of POA in females was 4.7%, higher than in males (2.2%), but AKI and gastrointestinal hemorrhage were both higher in males than in females (P < 0.05). Multivariate analysis showed that age, white blood cell (WBC) counts, lactic acid, operation duration and prolonged mechanical ventilation (PMV) increased the risk of in-hospital mortality in male patients. Hypertension, WBC counts, lactic acid, and PMV increased the risk of in-hospital mortality in female patients.

CONCLUSION

Despite significant baseline characteristic differences between male and female AAAD patients, there were no significant differences in onset symptoms. The in-hospital mortality rates were similar between male and female patients, but the risk factors for in-hospital mortality differed.

Sex disparities in patients with acute aortic dissection: A scoping review

Disparities in outcomes for patients with cardiovascular disease and those undergoing cardiac or vascular operations are well-established. These disparities often span several dimensions and persist despite advancements in medical and surgical care; sex is among the most pervasive. Specifically, females sex has been implicated as a predictor of poor outcomes in both patients with acute type A aortic dissections (ATAADs) and type B aortic dissections (TBADs). For instance, one study, using the International Registry of Acute Aortic Dissection database, found that females with acute aortic dissection-including ATAAD and TBAD that were either medically or surgically managed-had 40% higher odds of in-hospital mortality than men. Notably, both types of acute aortic dissections affect men more commonly than females and can be life-threatening without prompt, appropriate treatment. The underlying mechanisms for these disparities are unclear but are thought to be multifactorial. The association of sex with patterns of disease and outcomes in patients with ATAAD or TBAD remains unclear, with conflicting reports from different studies. Thus, we sought to review the literature regarding sex disparities in patients with ATAAD and TBAD.

Sex differences in long-term outcomes following surgery for acute type A aortic dissection: a systematic review and meta-analysis

Background

Recent reports on sex differences in long-term outcomes after surgery for acute type A aortic dissection (ATAAD) are conflicting. We aimed to aggregate updated data on long-term survival and reoperation stratified by sex.

Methods

A literature search was conducted using Medline, Embase, and Cochrane Central. Studies reporting sex-stratified long-term survival and/or reoperation following surgery for ATAAD between January 1, 2000, to March 15, 2023 were included. Preoperative characteristics, intraoperative variables, and early perioperative outcomes were meta-analyzed using a random effects model and pooled risk ratio (RR) with men as the reference group. Individual patient-level data for long-term outcomes was reconstructed to generate sex-specific pooled Kaplan-Meier curves to assess long-term survival and freedom from reoperation.

Results

A total of 15 studies with 7,608 male and 3,989 female patients were included in this analysis. Female patients were older, had higher rates of hypertension, and had less previous cardiac surgery. Intraoperatively, women received less extensive repairs with lower rates of aortic valve replacement and total arch replacement, and higher rates of hemiarch replacement. There were no sex differences for in-hospital/30-day mortality [risk ratio (RR), 1.18; 95% confidence interval (CI): 0.96, 1.45; P=0.12], stroke (RR, 1.07; 95% CI: 0.90, 1.28; P=0.46), and early reoperation (RR, 0.90; 95% CI: 0.75, 1.09; P=0.28). Female patients had lower long-term survival overall (P<0.001) and amongst survivors at 1-year (P=0.014). Overall survival at 5-year was 82.4% in men and 78.1% in women, and at 10-year was 68.1% for men and 63.4% in women. Male patients had higher rates of long-term reoperation (P<0.001). Freedom for reoperation at 5-year was 88.4% in men vs. 93.1% in women.

Conclusions

Though perioperative early outcomes have equalized between the sexes following surgery for ATAAD, differences remain in long-term survival and reoperation.

From Fibromuscular Dysplasia to Arterial Dissection and Back

Fibromuscular dysplasia (FMD) is an idiopathic and systemic non-inflammatory and non-atherosclerotic arterial disease. Fifteen to 25% of patients with FMD present with arterial dissection in at least one arterial bed. Conversely, a substantial number of patients with renal, carotid, and visceral dissection have underlying FMD. Also, while few patients with FMD develop coronary artery dissection, lesions suggestive of multifocal FMD have been reported in 30-80% of patients with spontaneous coronary artery dissection (SCAD), and the relation between these two entities remains controversial. The frequent association of FMD with arterial dissection, both in coronary and extra-coronary arteries raises a number of practical and theoretical questions: (i) Are FMD and arterial dissections two different facets of the same disease or distinct though related entities? (ii) Is SCAD just a manifestation of coronary FMD or a different disease? (iii) What is the risk and which are predictive factors of developing arterial dissection in a patient with FMD? (iv) What proportion of patients who experienced an arterial dissection have underlying FMD, and does this finding influence the risk of subsequent arterial complications? In this review we will address these different questions using fragmentary, mostly cross-sectional evidence derived from large registries and studies from Europe and the United States, as well as arguments derived from demographics, clinical presentation, imaging, and when available histology and genetics. From there we will derive practical consequences for nosology, screening and follow-up.

Clinical analysis of 908 patients with aortic dissection under different Stanford types: A cross-sectional study

This study aims to investigate the difference of clinical characteristics and risk factors in aortic dissection (AD) of patients with 2 Stanford subtypes. A retrospective analysis was conducted on 908 patients admitted to Tongji Hospital from July 2019 to January 2021, and the aortic computed tomography angiography was used to clearly diagnose the artery dissection. Patient basic information as well as blood test indicators containing leukocytes, neutrophils, lymphocytes, hemoglobin, myoglobin, hypersensitive cardiac troponin, γ-glutamyl transferase, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, ultrasensitive C-reactive protein, glucose were recorded and analyzed. There was no significant difference in gender, heart rate, smoking history, hypertension history and diabetes history between the 2 groups (P > .05), however, compared with type A patients, type B patients were older, and had a significantly higher frequency of alcohol consumption (P < .05); On laboratory tests, type A patients had significantly higher mean leukocytes and neutrophils (P < .05), and significantly lower frequency of reduced hemoglobin than type B patients (P < .05), although there was no statistical difference in lymphocyte, γ-glutamyl transferase, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein and glucose counts between the 2 groups. Additionally, type A patients had a significantly higher number of abnormal myoglobin, hypersensitive cardiac troponin and ultrasensitive C-reactive protein test results than type B patients (P < .05). The receiver operating characteristic curve analysis showed that the area under the curve for each parameter was 0.605 (0.538-0.673) for hemoglobin, 0.610 (0.543-0.677) for leukocytes and 0.627 (0.561-0.693) for neutrophils. Understanding the relevant clinical indicators and risk factors of patients with different types of AD can provide a new perspective to assist the classification and diagnosis of AD and a basis for effective and rational treatment.

Sex differences in acute type A aortic dissection: a systematic review and meta-analysis

INTRODUCTION

The objective of this study is to provide a comprehensive comparison of outcomes following acute type A aortic dissection (ATAAD) repair in males and females.

EVIDENCE ACQUISITION

PubMed, Medline, and Web of Science were systematically searched by two authors for studies published from January 1^st, 2000, to May 10^th, 2021. Overall, 2405 articles were screened, and 16 were included in this review. Meta-analysis of the compiled data was performed.

EVIDENCE SYNTHESIS

Pooled estimates indicated no difference in operative (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.59-1.67, P=0.99, I²=52%), in-hospital (OR 0.78, 95% CI 0.56-1.08; P=0.13, I²=57%), and 30-day mortality (OR 1.09, 95% CI 0.83-1.43, P=0.52, I²=45%) between the sexes. However, males had significantly reduced 5-year mortality rates (OR 0.71, 95% CI 0.51-1.00, P=0.05, I²=45%). There was no difference between sexes in rates of postoperative stroke (OR 1.07, 95% CI 0.86-1.33, P=0.54, I²=0%), atrial fibrillation (OR 0.99, 95% CI 0.82-1.19, P=0.92, I²=0%), as well as mesenteric or limb ischemia (OR 0.73, 95% CI 0.22-2.43, P=0.61, I²=77%; OR 0.83, 95% CI 0.30-2.30, P=0.72, I²=76%, respectively). Males did experience significantly increased rates of acute renal failure and reoperation (OR 1.35, 95% CI 1.16-1.56, P=0.0001, I²=29%; OR 1.40, 95% CI 1.09-1.81, P=0.010, I²=42%).

CONCLUSIONS

Composite analysis indicates that early mortality does not differ between the sexes; however, late outcomes favor males. Differences in preoperative presentation and subsequent procedure selection between the sexes likely contribute to the disparity in late outcomes. Decision-making for surgical treatment of ATAAD should account for sex-specific risk factors.

Gender Differences in Acute Aortic Dissection

Cardiovascular disease (CVD) represents the most important cause of mortality and morbidity worldwide. There is heterogeneity in the epidemiology and management of CVD between male and female patients. In the specific case of acute aortic dissection (AAD), women, at the time of diagnosis, are older than men and complain less frequently of an abrupt onset of pain with delayed presentation to the emergency department. Furthermore, a history of hypertension and chronic obstructive pulmonary disease is more common among women. In type A AAD, women more often experience pleural effusion and coronary artery compromise, but experience less neurological and malperfusion symptoms. They undergo less frequent surgical treatment and have higher overall in-hospital mortality. Conversely, in type B AAD no significant differences were shown for in-hospital mortality between the two genders. However, it should be highlighted that further studies are needed in order to develop AAD gender specific preventive, diagnostic and therapeutic strategies.

Analysis of racial disparities in acute type A aortic dissection repair at a rural tertiary academic medical center

BACKGROUND

To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center.

METHODS

There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant.

RESULTS

Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m² ) (all p values < .006). There were no significant differences in type of repair or intraoperative variables. A logistic regression analysis showed AAs had an increased rate of postoperative acute renal failure not requiring hemodialysis when compared to NHWs (20.8% vs. 10.6%, p value = .042). Thirty-day mortality was not significantly different (15.7% vs. 13.4%) nor was 1-year survival (78% vs. 79%) in AAs and NHWs, respectively.

CONCLUSIONS

Despite AAs having more medical comorbidities at presentation, there were no differences in short- and intermediate-term survival. In our catchment of 1.8 million people, AAs appear to undergo ATAAD repair at a disproportionate rate versus NHWs. These findings may alter strategies for surveillance and prevention of aortic disease in this high-risk population.

Epidemiology of aortic dissection

Aortic dissection remains a highly morbid diagnosis. The treatment of aortic dissection has undergone several paradigm shifts since it was first understood. However, despite the robust research in treatment, the epidemiology of aortic dissection is limited. In this review, we discuss the historical perspectives of aortic dissection with a review of risk factors and presentation. We review the trends in incidence during the past 40 years, with consideration for sex, race, and ethnicity in admission. We further focus our discussion of the classically described Type B aortic dissection treatment. Lastly, we review the impact of long-term events, readmissions, cost assessments, and quality of life studies of patients with aortic dissection. Care for those with aortic dissection remains a long-term challenge for providers and a multispecialty approach is needed for complete patient management.

Gender Difference is Associated with Short-Term Outcomes in Non-Surgically Managed Acute Aortic Dissection Patients with Hypertension: A Retrospective Cohort Study

Background

The management of acute aortic dissection (AAD) has improved; however, the outcomes related to different gender with short-term outcomes in non-surgically managed AAD with hypertension are still limited. Our objective was to explore gender-differences in association with short-term outcomes of patients comorbid with hypertension in non-surgically managed AAD.

Methods

This is an observational retrospective single-center cohort. We analyzed the data from the Second Xiangya Hospital of Central South University (2014-2018). The data on demographics, clinical presentation, chronic comorbidities, laboratory testing, imaging studies, and treatment were analyzed for all patients. Univariate and multiple analyses were used to test gender-difference associated with short-term outcomes of patients with hypertension in non-surgically managed AAD.

Results

In total, 288 patients were enrolled in this study, of whom 238 (82.63%) were male and 50 (17.37%) were females. About 74% of female patients were dead in-hospital, which was more than male patients (56.3%). Female patients with diabetes mellitus were more than male patients (14% vs 2.94%), while male patients with smoking were significant higher than female patients (36.55% vs 8%). In the full model (model 3), after adjusting for confounding variables, the female AAD patients were more likely to have worse short-term outcomes (OR=3.60, 95% CI=1.41 to 9.60).

Conclusion

Female patients were more likely to have worse outcomes in non-surgically managed AAD patients with hypertension. Large numbers of investigations are required to further explore this relationship.

Gender-related differences in patients with acute aortic dissection type A

OBJECTIVE

Acute aortic dissection type A can occur in both genders at any age. Our aim was to report differences in presentation, treatment, and outcome in female and male patients with acute aortic dissection type A.

METHODS

Between July 2006 and June 2015, 56 centers participating in the German Registry for Acute Aortic Dissection Type A reported on a total of 3380 patients. As many as 1234 (37%) were women and 2146 (63%) were men. We compared their clinical features and events occurring within 30 days after surgery.

RESULTS

Women were significantly older than male patients (65.5 ± 12.7 years vs 59.2 ± 13.3 years; P < .001). Aortic dissection extended down to the abdominal aorta in 43% men and 39% women (P = .01). Visceral (4.9% vs 7.3%; P = .006) and renal malperfusion (7.7% vs 10.6%; P = .006) were more frequently diagnosed in men. Aortic roots were replaced more frequently in men (22% vs 18%; P < .001). Different aortic arch repair strategies were distributed similarly in both genders. The incidence of new hemiplegia or hemiparesis was also similar in men and women (P = .24). Thirty-day mortality did not differ between women and men (16.3% vs 16.6%; P = .18). In a logistically mixed-effect model, gender revealed no influence on 30-day mortality (odds ratio, 1.15; 95% confidence interval, 0.92-1.44; P = .21).

CONCLUSIONS

Aortic dissection type A occurs almost twice as frequently in men. Women develop aortic dissection later in life. Despite women and men presenting at different ages and exhibiting varying dissection and malperfusion patterns, and the fact that men undergo complex proximal aortic repair more frequently, outcomes are similar in both genders.

Type 2 diabetes mellitus reduces clinical complications and mortality in Stanford type B aortic dissection after thoracic endovascular aortic repair: A 3-year follow-up study

BACKGROUND

Previous studies have demonstrated that type 2 diabetes mellitus (T2DM) is negatively correlated with the occurrence of aortic dissection (AD). This study aimed to investigate the effects of T2DM on the prognosis of Stanford type B AD (STBAD) patients after thoracic endovascular aortic repair (TEVAR).

METHODS

STBAD patients (n = 141) who underwent TEVAR received an oral glucose tolerance test (OGTT) and were divided into a normal glucose (NG, n = 55) group, an abnormal glucose tolerance (AGT, n = 48) group and a T2DM (n = 38) group according to the results of the OGTT. Data on mortality, clinical complications, left ventricular (LV) remodeling and aortic remodeling were collected during the 3-year follow-up.

RESULTS

Lower mortality and fewer clinical complications after TEVAR were found in the T2DM group than in the NG group. Multivariate linear regression analysis showed that 2-hour postprandial glucose (Glu-2h) was negatively correlated with mortality and the occurrence of clinical complications in STBAD patients after TEVAR. In addition, better LV remodeling, larger true lumen areas and smaller false lumen areas in both the proximal aortas and abdominal aortas were observed in the T2DM group than in the NG group. Furthermore, no significant differences in mortality or clinical complications after TEVAR were found between the NG group and the AGT group or between the T2DM group and the AGT group.

CONCLUSION

During the 3-year follow-up period, mortality and clinical complications in STBAD patients after TEVAR were significantly reduced in the T2DM group. For STBAD patients who undergo TEVAR, properly relaxing of blood glucose control requirements may be beneficial for their prognosis.

Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience

Background

Repair of acute type A aortic dissection (ATAAD) is a complex and emergent cardiovascular surgery that is associated with high perioperative morbidity and mortality. Each cannulation strategy has different benefits and drawbacks during cardiopulmonary bypass. Using a retrospective study design, we aimed to clarify the safety and efficacy of right axillary artery cannulation in combination with femoral artery cannulation compared to single arterial cannulation for ATAAD repair.

Methods

From January 2007 to July 2017, 476 adult patients underwent ATAAD repair at a single institution. Patients were classified into groups according to their cannulation strategy: the double arterial cannulation (DAC) group (n = 377; 79.2%) or single arterial cannulation (SAC) group (n = 99; 20.8%). Preoperative demographics, surgical information, and postoperative recovery were compared between both groups. Survival and freedom from reoperation rates were analyzed using the Kaplan-Meier actuarial method.

Results

Demographics, comorbidities, and surgical procedures were generally homogenous between the two groups, except for sex, age, and rate of extensive aortic repair. Patients who underwent DAC had lower in-hospital mortality (13.5% vs. 25.3%; P = 0.005) and lower incidence of malperfusion-related complications (18.8% vs. 30.3%; P = 0.011) than those who underwent SAC. During multivariate analysis, SAC was identified as an in-hospital mortality predictor (odds ratio, 2.81; 95% confidence interval, 1.52–5.17; P = 0.001), as were preoperative ventilator support, intraoperative extracorporeal membrane oxygenation installation, and postoperative malperfusion-related complications. Three-year cumulative survival and freedom from reoperation rates were 74.8% and 85.3% for the DAC group and 62.6% and 81.1% for the SAC group, respectively (P = 0.010 and 0.430, respectively).

Conclusions

With acceptable short- and mid-term outcomes, DAC is effective and safe for establishing cardiopulmonary bypass during ATAAD repair.