Sex-based outcomes in surgical repair of acute type A aortic dissection: A meta-analysis and meta-regression

Gender Differences in Acute Type A Aortic Dissection: A Comprehensive Review and Meta-Analysis

We aimed to undertake a meta-analysis of cohort studies to evaluate gender-based differences for patients with acute type A aortic dissection. A systematic search was performed across PubMed, Embase, and Cochrane Library (2000 to 2023) for studies reporting gender-related discrepancies in clinical presentation, in-hospital management, and/or outcomes. Study effects were assessed using mean difference or risk ratio (RR) as aggregated estimates. Besides, individual patient-level data on survival were reestablished to form gender-related Kaplan-Meier curves to evaluate long-term survival outcome. The study protocol was registered in PROSPERO (ID: CRD42024524125). The 21 studies were analyzed, comprising 6,728 women and 12,839 men. Women had lower risks of postoperative acute kidney injury (RR 0.85; 95% confidence interval [CI] 0.72 to 1.00, p = 0.049) and reoperation (RR 0.89; 95% CI 0.81 to 0.99, p = 0.024) but a higher perioperative mortality (RR 1.11; 95% CI 1.03 to 1.18, p = 0.005) than men. In addition, the overall survival was poorer in women (p <0.001), with 10-year survival rates of 66.5% for men and 60.0% for women. In conclusion, acute type A aortic dissection presents gender differences, with women facing higher perioperative and long-term mortality despite lower acute kidney injury and reoperation risks, suggesting a need for tailored management and prevention strategies.

Real World Sex Differences in Patients Undergoing Ascending Aortic Aneurysm Surgery-A Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data

Background: Men are known to have a higher incidence of acute cardiovascular events, while women are recognized for their increased mortality following diagnosis or intervention for these conditions. The aim of this study is to explore the sex differences in clinical profiles and outcomes of patients undergoing ascending aortic aneurysm (AscAA) surgery. Methods: A PRISMA compliant literature search and data extraction were conducted using PubMed, EMBASE, and SCOPUS. Observational cohort or retrospective registries that compared a defined number of male and female adults undergoing ascending aortic surgery for AscAA were included. Data analysis was conducted in compliance with Cochrane methods. Results: A total of 11 unique studies met the inclusion criteria, from which 13636 patients were included, with a distribution of 9124 males (67%) and 4512 females (33%). Overall, 91% underwent elective surgery. Male patients had significantly lower 30-day mortality, (RR: 0.68, 95% Cl [0.57, 0.81], p < 0.0001) and shorter stays in the intensive care unit, with a mean difference (MD) of -0.48 days ([-0.84, -0.13], p = 0.008). Males were significantly younger at the time of surgery (MD: -3.94 years, 95% CI [-5.58, -2.31], p < 0.00001). Male patients had significantly more frequent concomitant CABG (21% vs. 14.5%; p < 0.0001), while females had more frequent isolated supra-coronary ascending aortic replacement (22% vs. 36%; p = 0.004). Female patients who underwent AscAA surgery had significantly lower long-term survival (HR: 1.25, [1.05, 1.50], p = 0.013). Conclusions: Women undergo surgery for AscAA at older ages and face greater mortality. The disparities in preoperative age and timing of surgery between males and females can be explained by differences in comorbidity profiles and the need for concomitant surgery.

The relationship of sex and aortic diameter at the time of acute type A aortic dissection

Objective

Evaluate sex differences in patients undergoing repair of acute type A aortic dissection (ATAAD).

Methods

Sex-stratified, single-center cohort study of patients undergoing ATAAD repair from 1997 to 2022. The primary outcome was aortic diameter at time of presentation with ATAAD. Secondary outcomes were mortality, myocardial infraction, stroke, hemodialysis, tracheostomy, re-exploration for bleeding, a composite of major adverse events, and long-term survival.

Results

In 390 consecutive patients (150 women), men were younger than women (61.0 years; interquartile range [IQR], 50-70 years vs 70.5 years; IQR, 59-78 years; P < .001), had higher body mass index (28.6; IQR, 25.1-32.3 vs 25.4; IQR, 21.9-29.2; P < .001), more frequent peripheral vascular disease (11.7% vs 4.7%; P = .03), renal insufficiency (36.7% vs 22%; P = .003), malperfusion (34.2% vs 18.7%; P = .007), and smoking history (65% vs 44%; P < .001). There was no sex difference in median aortic diameter at the time of ATAAD (men: 5.3 cm; IQR, 4.9-6.1 cm and women: 5.2 cm; IQR, 4.6-5.9 cm; P = .12) even when adjusted for body mass index (men: 5.7 cm; IQR, 5.4-6.1 cm and women: 5.4 cm; IQR, 5.4-6.1 cm; P = .19). There was no sex difference in mortality (4.6% vs 6.0%; P = .70), major adverse events, or 10-year survival (50.3% vs 58.5%; P = .13). On multivariable analysis, there was no interaction between aneurysm size and sex (interaction P = .62). Sex was not associated with major adverse events (odds ratio, 0.75; 95% CI, 0.07-7.39; P = .81).

Conclusions

There was no sex difference in aneurysm size at the time of presentation of ATAAD, even after adjustment for body mass index, and no interaction between aneurysm size and sex, suggesting that aortic diameter remains a reasonable criterion for intervention irrespective of sex.

Sex disparities in the risk of urgent dialysis following acute aortic dissections in Japan

The global outcome of acute aortic dissection (AD) remains poor, with a high risk of the need for urgent dialysis. This study aimed to clarify the association between sex and the requirement for urgent dialysis within 30 days after admission among patients with AD. This study included 79,998 cases who were hospitalized due to AD in Japan from 2010 to 2020 using an administrative claims database. The association between the risk of urgent dialysis and sex was investigated using the Fine and Gray model. Patients were classified into two groups based on the Stanford classification: type A AD (TAAD) and type B AD (TBAD). The lower subdistribution hazard ratio (SHR) in women was observed in both groups: TAAD (SHR: 0.58, 95% confidence interval [CI]: 0.54-0.62); TBAD (SHR: 0.49, 95% CI: 0.41-0.58). Our study revealed that women had a lower risk of requiring urgent dialysis than men in TAAD and TBAD.

Sex-based outcomes after thoracic endovascular aortic repair: a systematic review and meta-analysis

OBJECTIVE

As it remains unclear whether there are sex-based differences in clinical outcomes after thoracic endovascular aortic repair (TEVAR), this meta-analysis aimed to evaluate differences in early outcomes and overall survival between female and male patients who underwent TEVAR.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Central databases were searched for eligible studies published through June 10, 2023, that reported sex-based differences in clinical outcomes after TEVAR. The primary outcome was operative mortality; second outcomes included stroke, spinal cord ischemia, acute kidney injury, hospital length of stay, and overall survival. Patient characteristics, operative data, and early outcomes were aggregated using the random-effects model, presenting pooled risk ratio (RR) or standardized mean difference along with their corresponding 95% confidence intervals (CIs). Overall survival was assessed by reconstructing individual patient data to generate sex-specific pooled Kaplan-Meier curves. This study was registered in PROSPERO (CRD42023426069).

RESULTS

Of the 1785 studies retrieved, 14 studies met all eligibility criteria, encompassing a total of 17,374 patients, comprising 5026 female and 12,348 male patients. Female patients were older, had a smaller maximum aortic diameter, had lower rates of smoking and coronary artery disease, and had higher rates of anemia. Intraoperatively, female patients were more likely to use iliac conduits and require blood transfusions. There were no sex-based differences in operative mortality (RR: 1.12, 95% CI: 0.90-1.40; P = .309), stroke (RR: 1.14, 95% CI: 0.95-1.38; P = .165), spinal cord ischemia (RR: 1.33, 95% CI: 0.83-2.14; P = .234), acute kidney injury (RR: 0.78, 95% CI: 0.52-1.17; P = .228), and hospital length of stay (standardized mean difference: 0.09, 95% CI: -0.03 to 0.20; P = .141). Pooled Kaplan-Meier estimates showed a worse overall survival in female patients compared with male patients (87.2% vs 89.8% at 2 years, log-rank P = .001).

CONCLUSIONS

Among patients treated by TEVAR, female sex was not associated with increased risk of operative mortality or major morbidity. However, female patients exhibited a lower overall survival after TEVAR compared with male patients.

Operative Mortality After Type A Aortic Dissection Surgery: Differences Based on Sex and Age

Background

There is controversy regarding sex differences in short-term mortality in acute type A aortic dissection (ATAAD).

Objectives

This study aimed to investigate the impact of sex differences on 30-day operative mortality after ATAAD surgery and to determine if other covariates modify the association.

Methods

Consecutive patients (N = 5670) with surgically repaired ATAAD were identified from the multicenter China 5A study. The primary outcome was operative mortality. The age dependency was modeled using a cubic spline curve.

Results

There were 1,503 females (26.5%) and 4,167 males (73.5%). Females were older and had a lower percentage of comorbidities compared with males. Females had higher mortality compared to males (10.2% vs 8.2%, P = 0.019); however, there was no difference after propensity analyses (adjusted OR: 1.334 [95% CI: 0.918-1.938]). There was an interaction with sex and age (P interaction = 0.035): older age was associated with higher odds of operative mortality among females (OR: 1.045 [95% CI: 1.029-1.061]) compared with males (OR: 1.025 [95% CI: 1.016-1.035]). The risk of mortality for males and females appears to diverge at 55 years of age (P interaction = 0.019): females under 55 years of age had similar odds to males (OR: 0.852 [95% CI: 0.603-1.205]) but higher odds when over 55 years (OR: 1.420 [95% CI: 1.096-1.839]) compared to males.

Conclusions

Under the age of 55 years, females have similar odds of operative mortality compared with males; however, over the age of 55 years females have higher odds than males. Understanding differences in risk allows for individualized treatment strategies. (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy; NCT04398992).

Long-term sex-based outcomes after surgery for acute type A aortic dissection: Meta-analysis of reconstructed time-to-event data

BACKGROUND

The influence of sex on outcomes of surgery for acute type A aortic dissection remains incompletely characterized. We sought to evaluate post-procedural survival in the follow-up of females versus males.

METHODS

We carried out a systematic review with meta-analysis of Kaplan-Meier-derived time-to-event data from studies published by June 2023 in the following databases: PubMed/MEDLINE, EMBASE, Web of Science and CENTRAL/CCTR (Cochrane Controlled Trials Register).

RESULTS

Twelve studies met our eligibility criteria, including 11,696 patients (3753 females; 7943 males). The mean age ranged from 41.2 to 72.6 years with low prevalence of bicuspid aortic valve (ranging from 0.0% to 12.0%) and connective tissue disorders (ranging from 0.8% to 7.3%). We found a considerable prevalence of coronary artery disease (ranging from 12.1% to 21.1%) and malperfusion (ranging from 20.0% to 46.3%). At 10 years, females undergoing surgery had a significantly higher risk of all-cause mortality compared with males (HR 1.25, 95%CI 1.14-1.38, P ​< ​0.001).

CONCLUSION

In the follow-up of patients undergoing surgery for type A aortic dissection, females presented poorer overall survival in comparison with males.

Sex Differences in DeBakey Type I/II Acute Aortic Dissection Outcomes: The Tokyo Acute Aortic Super-network

Background

Sex differences in the clinical presentation and outcomes of DeBakey type I/II (Stanford type A) acute aortic dissection (AAD) remain unclear.

Objectives

The authors aimed to determine the impact of sex on the clinical presentation and in-hospital outcomes of surgically or medically treated patients with type I/II AAD.

Methods

We studied 3,089 patients with type I/II AAD enrolled in multicenter Japanese registry between 2013 and 2018. The patients were divided into 2 treatment groups: surgical and medical. Multivariable logistic regression was used to examine the association between sex and in-hospital mortality.

Results

In the entire cohort, women were older and more likely to have hyperlipidemia, previous stroke, altered consciousness, and shock/hypotension at presentation than men. Women had higher proportions of intramural hematomas and type II dissections than men. In the surgical group (n = 2,543), men had higher rates of preoperative end-organ malperfusion (P = 0.003) and in-hospital mortality (P = 0.002) than women. Multivariable analysis revealed that male sex was associated with higher in-hospital mortality after surgery (OR: 1.71; 95% CI: 1.24-2.35; P < 0.001). In the medical group (n = 546), women were older and had higher rates of cardiac tamponade (P = 0.004) and in-hospital mortality (P = 0.039) than men; no significant association between sex and in-hospital mortality was found after multivariable adjustment (OR: 0.95; 95% CI: 0.56-1.59; P = 0.832).

Conclusions

Male sex was associated with higher in-hospital mortality for type I/II AAD in the surgical group but not in the medical group. Further research is needed to understand the mechanisms responsible for worse surgical outcomes in men.

Impact of body mass index on perioperative mortality of acute stanford type A aortic dissection: a systematic review and meta-analysis

BACKGROUND

Obesity may increase perioperative mortality of acute Stanford type A aortic dissection (ATAAD). However, the available evidence was limited. This study aimed to systematically review published literatures about body mass index (BMI) and perioperative mortality of ATAAD.

METHODS

Electronic literature search was conducted in PubMed, Medline, Embase and Cochrane Library databases. All observational studies that investigated BMI and perioperative mortality of ATAAD were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Meta-regression analysis was performed to assess the effects of different clinical variables on BMI and perioperative mortality of ATAAD. Sensitivity analysis was performed to determine the sources of heterogeneity. Egger's linear regression method and funnel plot were used to determine the publication bias.

RESULTS

A total of 12 studies with 5,522 patients were eligible and included in this meta-analysis. Pooled analysis showed that perioperative mortality of ATAAD increased by 22% for each 1 kg/m2 increase in BMI (OR = 1.22, 95% CI: 1.10-1.35). Univariable meta-regression analysis indicated that age and female gender significantly modified the association between BMI and perioperative mortality of ATAAD in a positive manner (meta-regression on age: coefficient = 0.04, P = 0.04; meta-regression on female gender: coefficient = 0.02, P = 0.03). Neither significant heterogeneity nor publication bias were found among included studies.

CONCLUSIONS

BMI is closely associated with perioperative mortality of ATAAD. Optimal perioperative management needs to be further explored and individualized for obese patient with ATAAD, especially in elderly and female populations.

TRIAL REGISTRATION

PROSPERO (CRD42022358619). BMI and perioperative mortality of ATAAD.

Sex Differences in Thoracic Aortic Disease and Dissection: JACC Review Topic of the Week

Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.

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

BACKGROUND

In acute aortic dissection (AAD) sex heterogeneity reports are not exhaustive and in part even conflicting.

AIMS

To explore sex differences in clinical features, management, and outcomes among patients with type A AAD.

METHODS AND RESULTS

A systematic review and meta-analysis of the literature were conducted for studies (2004-2022) reporting type A AAD sex differences. Among the 1938 studies retrieved, 16 (16 069 patients, 7142 women, and 8927 men) fulfilled all eligibility criteria. Data were aggregated used the random-effects model as pooled risk ratio and mean difference. Due to information reported by considered manuscripts, analysis were performed only among surgically treated type A AAD patients. At the time of hospital presentation type A AAD women were older than men but had lower body mass index (BMI), body surface area (BSA), and creatinine plasma levels. Active smoking, bicuspid aortic valve, and previous cardiac surgery were less common in women while diabetes mellitus was more frequent. Furthermore, women experienced more frequently pericardial effusion/cardiac tamponade than men. Interestingly, in-hospital surgical mortality did not differ between sexes [risk ratio (RR), 1.02; 95% confidence interval (CI), 0.53-1.99; P = 0.95], whereas 5 (RR 0.94; 95% CI: 0.92-0.97; P < 0.001) and 10-year survival (RR 0.82; 95% CI: 0.74-0.92; P = 0.004) was higher among men. A descriptive analysis of in-hospital outcomes among medically treated type A AAD patients confirmed prohibitive high mortality for both sexes (men 58.6% vs. women 53.8%, P = 0.59).

CONCLUSIONS

A female sex phenotype appears to be evident in type A AAD implying the need for a personalized management patient approach along with tailored preventive strategies.

PROSPERO REGISTRY ID

CRD42022359072.

Is female sex impactful in the pathophysiology, presentation, management, and outlook of type A acute aortic dissection?

Acute aortic dissection (AAD) is the most common acute aortic syndrome. It is a life-threatening condition and surgical emergency associated with high mortality if not treated promptly. While it is well established that cardiovascular disease recognises different pathophysiological pathways between men and women, there is limited evidence of sex differences in AAS, especially in type A AAD. According to a recent synthesis of clinical studies on gender differences in type A AAD, women were found to have different baseline characteristics, presentation and outcomes, and thus sex should be considered relevant for diagnosis, risk-stratification and management of type A AAD.

Female Sex Is Not an Independent Risk Factor for Poor Prognosis of Patients with Acute Type A Aortic Dissection Undergoing Surgery

Background and Aim of the Study. The effects of sex on the prognosis of patients with acute type A aortic dissection (ATAAD) have still remained controversial. This study aimed to explore the sex differences in outcomes of ATAAD patients undergoing surgery. Methods. Data of patients with ATAAD who were operated in our center from 2010 to 2018 were retrospectively collected. Data on pre-, intra-, and postoperative courses were analyzed. Propensity score weighting was performed to balance the baseline characteristics. Multivariable logistic regression was used to assess predictors of early mortality in overall female and male patients. Results. A total of 1448 patients were enrolled, including 352 (24.3%) female patients and 1096 (75.7%) male patients. Females were significantly older than males (56.0 vs. 47.8 years, P < 0.001 ). Dissection was less extensive (Fuwai Ct: 85.8% vs. 91.3%, P = 0.003 ) and malperfusion syndrome was less frequently diagnosed (Penn Ab: 19.3% vs. 29.7%, P < 0.001 ) in females. Males experienced more aortic root replacement (Bentall: 14.2% vs. 24.9%, P < 0.001 ) and total arch replacement combined with frozen elephant trunk (56.8% vs. 75.8%, P < 0.001 ) with the prolonged operation time (6.1 vs. 6.4 hours, P = 0.001 ). In contrast, early mortality was higher in females (9.4% vs. 6.1%, P = 0.036 ). No differences were found in long-term survival and reoperation rates. After propensity score weighting, sex suggested no influence on both early and long-term outcomes. Cardiopulmonary bypass time was an independent risk factor for early mortality in both overall and sex-related populations according to the multivariable logistic regression. Conclusions. In ATAAD, different presentations and surgical strategies were noted in male and female patients. However, there were no significant differences in early and long-term outcomes between sexes after propensity score weighting.

Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study

BACKGROUND

Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition.

METHODS

A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score.

RESULTS

633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491-1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561-1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133-1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361-319.017) were significantly associated with increased operative mortality.

CONCLUSIONS

The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.

Gender differences in acute aortic syndromes

PURPOSE OF REVIEW

Acute aortic syndromes include acute aortic dissection, intramural hematoma, and penetrating aortic ulcer, and are associated with high mortality and morbidity. This review focuses on recent findings and current understanding of gender-related and sex-related differences in acute aortic syndromes.

RECENT FINDINGS

Large international and national registries, population studies, and multicentre national prospective cohort studies show evidence of sex differences in acute aortic syndromes. Recent studies of risk factors, aorta remodelling, and genetics provide possible biological basis for sex differences. The 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management of Aortic Disease revise recommendations for surgical management for aortic root and ascending aorta dilatation, which could impact outcome differences between the sexes.

SUMMARY

Acute aortic syndromes affect men more frequently than women. The prevalence of acute aortic syndromes and prevalence of many risk factors rise sharply with age in women leading to higher age at presentation for women. Times from symptom onset to presentation and presentation to diagnosis are delayed in female patients. Females with type A dissection are also more commonly treated conservatively than male counterparts. These factors likely contribute to higher early mortality and complications in women.

Acute renal failure after acute type A aortic dissection repair. Insidious postoperative complication with poor short- and long-term prognosis

Acute type A aortic dissection (ATAAD) is a life-threatening aortic disease. Many systems and organs are affected by malperfusion which presents preoperatively and postoperatively. Postoperative acute renal failure after ATAAD constitutes a severe and insidious complication. Acute renal damage is observed in many patients with ATAAD preoperatively and it burdens the renal function postoperatively. Renal replacement therapy represents an additional risk factor for short-, mid-, and long-term outcomes after ATAAD repair. Brown et al.'s present study highlight the clinical significance of this complication. Also, they remind us of the importance of optimizing perioperative renal protective strategies in patients undergoing ATAAD repair.

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.