Clinical differences between men and women undergoing surgery for acute Type A aortic dissection

Clinical differences between men and women undergoing surgery for acute Type A aortic dissection Abstract OBJECTIVES The differences in clinical features, surgical outcome and long-term prognosis between men and women who undergo surgery for Type A aortic dissection are not well known. METHODS From January 2004 to December 2016, 303 patients, consisting of 147 women and 156 men, underwent surgery for acute Type A aortic dissection at our institution. We compared clinical outcomes between the 2 cohorts. RESULTS Women were older than men (72.6 vs 63.0; P < 0.001). Operative mortality was similar between the groups (8.2% vs 8.9%; P = 0.80). The duration of intensive care unit stay (54 vs 64 h median; P = 0.03) and mechanical ventilator support (34 vs 43 h; P = 0.02) was significantly shorter in women. Multivariate logistic regression analysis revealed that preoperative cardiopulmonary resuscitation, cardiac tamponade, chronic obstructive pulmonary disease, haemodialysis and longer cardiopulmonary bypass time were independent risk factors for early death. Among the hospital survivors, the actuarial survival rate was 59.0% in women and 65.7% in men at 10 years (P = 0.81). During the follow-up period, there were 9 female and 27 male patients who underwent reoperation related to the aortic dissection. The rate of 10-year actuarial freedom from reoperation was 80.7% in women and 53.1% in men (log-rank P = 0.018). CONCLUSIONS No differences were observed in both early and long-term mortality between women and men. Male patients had a significantly higher rate of reoperation. CLINICAL REGISTRATION NUMBER UMIN000029179. Acute Type A aortic dissection, Gender, Aortic surgery INTRODUCTION Female gender is widely recognized as a risk factor for short- and long-term mortality after cardiac surgery, and this is particularly well documented after coronary artery bypass surgery [1–5]. Several reasons have been suggested, including older age, smaller body size and more comorbidities such as anaemia and diabetes. Women on average have longer life spans than men and present with atherosclerotic disease at a more advanced age [6–8]. Acute Type A aortic dissection is a catastrophic and devastating condition in both men and women, which carries a mortality rate of up to 50% in the absence of surgical intervention [9, 10]. There is very little information in the literature describing gender-related differences in patient background and surgical outcome in acute Type A aortic dissection. The aim of this study was to identify gender-related features by comparing the clinical background and surgical outcome of male and female patients who underwent emergent surgery for acute Type A aortic dissection. PATIENTS AND METHODS From January 2004 to December 2016, 303 patients, consisting of 147 women and 156 men, underwent surgery for acute Type A aortic dissection at our institution. We compared patient background and surgical outcome between the 2 cohorts. The primary end-point was operative mortality, and the secondary end-points were late mortality and late reoperation. Patients undergo outpatient follow-up through computed tomography about every 6–12 months after hospital discharge. The Institutional Review Board of the Shiga University of Medical Science approved the study, and all patients granted permission for the use of their medical records for research purposes. Operative technique The operation was performed through median sternotomy in all patients. We used 3 main arterial cannulation sites: the femoral artery, the axillary artery and the ascending aorta (central cannulation). Circulatory arrest was achieved at a tympanic temperature of 25–27°C, after which the ascending aorta was opened. If an intimal tear was found in the ascending aorta or proximal transverse aorta, replacement of the ascending aorta or hemiarch replacement was performed using an open distal anastomosis technique under circulatory arrest only. When the arrest time was likely to exceed 35 min because of the complexity of the distal anastomotic site, we additionally employed retrograde cerebral perfusion or antegrade selective perfusion. In cases in which an intimal tear was found in the transverse aorta, total arch replacement was performed to exclude the intimal tear. When no intimal tear could be identified in the ascending or transverse aorta, only the ascending aorta was replaced. When total arch replacement was required, we adjunctively used a selective cerebral perfusion technique. Distal anastomosis was performed with 4-0 monofilament continuous sutures that were reinforced with Teflon felt strips. After completion of the distal repair, antegrade systemic circulation was restarted through the side branch of the prosthesis, and rewarming was begun. Proximal anastomosis was performed about 1 cm above the sinotubular junction with Teflon felt strip reinforcement. After completion of the proximal anastomosis and de-airing of each heart chamber, the prosthesis was declamped and coronary circulation started. Statistical analysis Data are presented as the mean ± standard deviation, or the median and interquartile range. Normality was tested using the Shapiro–Wilk test. Categorical variables were analysed using the χ2 or the Fisher’s exact test and continuous variables using a t-test or the Mann–Whitney U-test, as appropriate. Univariate and multivariate logistic regression analyses were performed for the analysis of significant predictors of hospital mortality. The clinical variables listed in Tables 1 and 2 were used for univariate analysis. The multivariate analyses were performed with a stepwise forward regression model into which each variable with a probability value of <0.2 in the univariate analysis was entered. Univariate and multivariate Cox proportional hazard regression was performed for the analysis of late mortality and late reoperation. Variables with a probability value of <0.2 in the univariate analysis were entered into the multivariate analyses. The Homer–Lemeshow goodness-of-fit test was used to evaluate the calibration of the model and demonstrated its predictive ability (P > 0.05 for all models). Table 1: Preoperative patient characteristics Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 a Proximal entry: the primary entry tear located in the proximal aorta (ascending or arch). b Distal entry: the primary entry located in the distal to descending aorta. BMI: body mass index; BSA: body surface area; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; PVD: peripheral vascular disease; SD: standard deviation. Table 1: Preoperative patient characteristics Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 a Proximal entry: the primary entry tear located in the proximal aorta (ascending or arch). b Distal entry: the primary entry located in the distal to descending aorta. BMI: body mass index; BSA: body surface area; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; PVD: peripheral vascular disease; SD: standard deviation. Table 2: Operative data Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Table 2: Operative data Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Actuarial survival and reoperation-free survival curves were estimated using the Kaplan–Meier method comparing differences between groups with log-rank test. Calculated P-values of <0.05 were considered significant. Data were analysed using SPSS 22.0 (SPSS Inc., Chicago, IL, USA) for Windows (Microsoft Corp, Redmond, WA, USA). Data definitions Preoperative chronic kidney disease was defined as a level of serum creatinine >1.5 mg/dl. As a dissection-related complication, cardiac tamponade was defined as haemodynamic instability with cardiac effusion, and aortic valve regurgitation as a more than moderate degree observed in preoperative echocardiography. Shock was defined as a blood pressure lower than 80 mmHg, coronary ischaemia as ST change in the electrocardiogram, and cerebral ischaemia as permanent or transient loss of consciousness or paralysis. Postoperative stroke was defined as a neurological deficit that was confirmed postoperatively by means of computed tomography. If patients had preoperative stroke, postoperative stroke was defined as worsening of the neurological deficit in new imaging findings. Temporary neurological dysfunction was defined as a postoperative neurological deficit with a negative brain computed tomography scan and complete resolution at discharge. Operative mortality was defined as death within 30 days after surgery. Postoperative renal failure was defined as a new temporary requirement for haemodialysis. RESULTS Preoperative data Baseline patient characteristics are listed in Table 1. Female patients were significantly older (72.6 vs 63.0; P < 0.001) and smaller (body mass index 22.2 vs 24.3, body surface area 1.46 vs 1.91 m2; P < 0.001) than male patients. Male patients had more prevalence of smoking history than female patients (9.5% vs 71%; P < 0.001). Regarding dissection-related data, DeBakey Type II was more common in female patients than male patients (19% vs 10%; P = 0.043), while the proportion of patients with primary entry distal to the descending aorta was larger in men than women (27% vs 17%; P = 0.037). No other differences were observed in patient preoperative characteristics or dissection-related status. Operative and postoperative data The operative data are presented in Table 2 and postoperative data in Table 3. The primary entry was located in the ascending or transverse aorta in 83% of women and 73.1% of men. The primary entry was distal to the descending aorta in 17% of women and 26.9% of men, which was a significant difference (P = 0.03). Operative mortality was similar between the 2 groups (8.2% vs 8.9%; P = 0.8). The duration of intensive care unit stay and mechanical ventilator support was significantly shorter in women (54 vs 64 h median; P = 0.03 and 34 vs 43 h; P = 0.02, respectively). The number of days from surgery to discharge was also shorter in women (21.5 vs 24.1 days mean; P = 0.04). Table 3: Postoperative data All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 ICU: intensive care unit; TND: temporary neurological dysfunction; SD: standard deviation. Table 3: Postoperative data All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 ICU: intensive care unit; TND: temporary neurological dysfunction; SD: standard deviation. Multivariate analysis for operative mortality Multivariate logistic regression analysis revealed that preoperative cardiopulmonary resuscitation (P = 0.012), cardiac tamponade (P = 0.001), chronic obstructive pulmonary disease (P = 0.005), haemodialysis (P = 0.035) and longer cardiopulmonary bypass time (P < 0.001) were independent risk factors for early death (Table 4). Table 4: Multivariate logistic regression analyses for hospital death Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 CPB: cardiopulmonary bypass. Table 4: Multivariate logistic regression analyses for hospital death Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 CPB: cardiopulmonary bypass. Late reoperation The indications for dissection-related reoperation were dilatation of the thoracic aorta of ≥55 mm, dilatation of the abdominal aorta of ≥50 mm, rupture or impending rupture of the aorta, rapid dilatation of the aorta of >5 mm per half year, artificial prosthesis infection and progressive aortic valve regurgitation of more than moderate degree. During the follow-up period, there were 9 female and 27 male patients who underwent reoperation that was related to the aortic dissection. Male patients had a significantly higher rate of reoperation than female patients (27/140 = 19.3% vs 9/134 = 6.7%; P = 0.003). The details of reoperation are listed in Table 5. The rate of 10-year actuarial freedom from reoperation was 80.7% in women and 53.1% in men, which is a significant difference (log-rank P = 0.018) (Fig. 1). The results of the multivariate Cox proportional hazard regression analysis for independent predictors of long-term reoperation are listed in Table 6. Female gender was an independent suppressing factor for long-term reoperation. Table 5: Details of late reoperation Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Table 5: Details of late reoperation Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Table 6: Multivariate Cox proportional hazard regression analyses of late reoperation and long-term death Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Table 6: Multivariate Cox proportional hazard regression analyses of late reoperation and long-term death Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Figure 1: View largeDownload slide The rate of 6-year actuarial freedom from all-cause death. Log-rank analysis revealed no difference between the 2 groups. Figure 1: View largeDownload slide The rate of 6-year actuarial freedom from all-cause death. Log-rank analysis revealed no difference between the 2 groups. Long-term mortality Mean follow-up duration was 6.8 ± 4.8 years (maximum 12.9 years) in the population as a whole. The follow-up rate was 96.0% (291 of 303) and showed no difference between the groups. Among the hospital survivors (except for hospital death; 134 women and 140 men), there were 10 (7.5%) deaths in female patients and 13 (9.3%) deaths in male patients during the follow-up period. The actuarial survival rate was 59.0% in female patients and 65.7% in male patients at 10 years. Log-rank analysis revealed no difference between the 2 groups (P = 0.81) (Fig. 2). The results of the multivariate Cox proportional hazard regression analysis for independent predictors of long-term death from all causes are listed in Table 6. Figure 2: View largeDownload slide The rate of 6-year actuarial freedom from reoperation: men versus women. Log-rank analysis showed a significant difference (P = 0.018). Figure 2: View largeDownload slide The rate of 6-year actuarial freedom from reoperation: men versus women. Log-rank analysis showed a significant difference (P = 0.018). COMMENT The surgical mortality associated with Type A aortic dissection remains high for both men and women, with rates ranging from 8% to 26% [11–14]. This high mortality rate is due not only to the difficulty from the surgical aspect but also to various dissection-related complications such as organ malperfusion, respiratory failure, brain damage and inflammatory response [15, 16]. Generally, female gender is a significant risk factor for surgical mortality after cardiovascular surgery such as coronary artery bypass grafting, mitral valve operation and aortic valve replacement [17–19]. There is very little information in the literature describing gender-related differences in emergent surgery for acute Type A aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) is the one and only large registry, in which 18 large centres participate to reveal the whole clinical picture of acute aortic dissection [9]. In 2004, a subanalysis of IRAD evaluating gender-related differences [20] found that female patients were older and had a longer duration from onset to diagnosis than male patients. Moreover, women had more preoperative complications including rupture, tamponade and impaired consciousness, and women with acute Type A dissection were less likely to undergo surgery than men. Haemodynamic instability in ongoing acute Type A aortic dissection worsens progressively and may eventually result in cardiac arrest. The patient must therefore be transferred to the operating theatre for cardiopulmonary support as soon as possible. At our institution, we have adopted a system of direct transfer to the operating theatre so that all patients with acute Type A dissection are rushed to the operating theatre immediately after arrival at the hospital. In most previous reports, the ratio of men to women undergoing emergent surgery for acute Type A dissection was approximately 2:1 [21–23]. In our series, the ratio was close to 1:1. The reason is not clear but may relate to the characteristics of the Japanese population. In Japan, the mean life expectancy is highest in the world for women at over 87 years, but 7 years shorter for men at 80 years. Another particular difference at Japanese high-volume centres in the IRAD study was that no fewer than 28.5% of women who had acute Type A aortic dissection were not admitted to medical treatment against only 13% of men, which raises the issue of selection bias. At our institution, after in-hospital diagnosis of acute Type A dissection was made, almost all patients were immediately transferred to the operating theatre, except for cases of unsuccessful resuscitation. In the IRAD study, the surgical mortality rate for acute Type A dissection was 31.9% in women and 21.9% in men, which is a significant difference (P = 0.013). Older age at onset, delayed transfer to hospital and more complications including tamponade, shock, heart failure and coma are cited as potential reasons for higher surgical mortality. Although, as stated above, female gender generally has a negative impact on surgical outcome in cardiovascular disease, women had similar early and long-term mortality to men in this series and the rate of late reoperation was significantly lower among women. Moreover, the durations of intensive care unit stay, ventilator support and postoperative hospital stay were shorter in women, suggesting that women have a tendency to faster recovery than men. The expected reason for this difference is that the population with smoking history was higher in men (71%) than in women (10%). It is well known that respiratory failure after surgery for acute Type A aortic dissection is serious and occasionally fatal [24–26]. Smoking may add fuel to pulmonary damage after surgery for acute Type A dissection and thus prolong ventilator support time in male smokers. Interestingly, as Fukui et al. [24] presented similar data, the proportion of patients with primary entry distal to the descending aorta was larger in men than women in this series (27% vs 17%; P = 0.037), while the proportion of DeBakey Type II was larger in women (19% vs 10%). The primary entry cannot be resected when located distal to the descending aorta. A larger number of male patients with residual primary entry would render the surgical outcome worse than for women and might result in a reduced difference in mortality. In previous reports, actuarial freedom from reoperation was approximately 60–88% at 10 years [21–24, 27]. Several risk factors for late reoperation have been reported, including residual primary entry, DeBakey Type I, younger age, Marfan syndrome, a patent false lumen and lack of a β-blocker [21–24]. In this study, we found that the female gender was a preventative factor for late reoperation (hazard ratio 0.4). Fukui et al. [24] also reported a lower rate of late reintervention in female patients. We suggest several possible explanations of this point. The older age of female patients may be related to the lower rate of reintervention because older age is a frequent reason for deciding against late reoperation. Residual primary entry, which is a well-known cause of late reoperation, was seen commonly in men in this study, which may be related to the prevalence of late reoperation in male patients. In terms of patient background, male patients had a slightly higher prevalence of comorbidities such as smoking (71.3% vs 9.5%), diabetes mellitus (11.5% vs 7.5%), chronic obstructive pulmonary disease (8.3% vs 4.8%) and Marfan syndrome (6.4% vs 2.7%), which may also be related to the reoperation rate. It is noteworthy that the patients who required late reoperation due to prosthesis infection were all smoking men with Marfan syndrome. Another potential factor is that we decided whether to perform reoperation according to the size of the dilated aorta using the same criterion for both men and women. As the size of the aorta is generally smaller in women than men, it may take a longer time for the aortic size to achieve the criterion for reoperation in women than in men. It may thus not be entirely fair to use the same criterion for both men and women. Although long-term survival after repair of acute Type A dissection has been reported to range from 45% to 88% at 5 years and 30% to 60% at 10 years [21, 26, 28–30], little is known about the gender difference in long-term survival. The only relevant past report, by Fukui et al. [24], showed that the actuarial survival rate at 5 years was 80.1% in female patients and 89.3% in male patients (P = 0.06). In this study, the actuarial survival rate was 59.0% in female patients and 65.7% in male patients at 10 years, with no significant difference (P = 0.81), and multivariate Cox proportional hazard regression analysis revealed that female gender was not a risk factor for late mortality. Limitations The limitations of this study include its retrospective nature and the lack of a randomized treatment assignment. Additionally, the number of subjects is small, and there is lack of information on medication during follow-up. Small changes in the technical procedure over time, such as a higher temperature strategy, no use of cerebral perfusion and the use of a new haemostatic glue, may influence the outcome. However, the study does have strong points: despite the more than 12-year duration of the study, all procedures were consecutively performed by 2 high-volume surgeons with a consistent shared policy at a single institution. Our policy is to accept all patients at any time and never to refuse an emergency operation. Hence, this study is real-world based and reliable without patient selection bias. CONCLUSION In summary, this study found some notable differences between women and men following surgery for acute Type A aortic dissection. Contrary to most previous reports, we found no differences in surgical mortality, surgical complications or long-term mortality between women and men. 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Aortic enlargement and late reoperation after repair of acute type A aortic dissection . Ann Thorac Surg 2007 ; 84 : 479 – 86 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Clinical differences between men and women undergoing surgery for acute Type A aortic dissection

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
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1569-9285
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10.1093/icvts/ivy005
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Abstract

Abstract OBJECTIVES The differences in clinical features, surgical outcome and long-term prognosis between men and women who undergo surgery for Type A aortic dissection are not well known. METHODS From January 2004 to December 2016, 303 patients, consisting of 147 women and 156 men, underwent surgery for acute Type A aortic dissection at our institution. We compared clinical outcomes between the 2 cohorts. RESULTS Women were older than men (72.6 vs 63.0; P < 0.001). Operative mortality was similar between the groups (8.2% vs 8.9%; P = 0.80). The duration of intensive care unit stay (54 vs 64 h median; P = 0.03) and mechanical ventilator support (34 vs 43 h; P = 0.02) was significantly shorter in women. Multivariate logistic regression analysis revealed that preoperative cardiopulmonary resuscitation, cardiac tamponade, chronic obstructive pulmonary disease, haemodialysis and longer cardiopulmonary bypass time were independent risk factors for early death. Among the hospital survivors, the actuarial survival rate was 59.0% in women and 65.7% in men at 10 years (P = 0.81). During the follow-up period, there were 9 female and 27 male patients who underwent reoperation related to the aortic dissection. The rate of 10-year actuarial freedom from reoperation was 80.7% in women and 53.1% in men (log-rank P = 0.018). CONCLUSIONS No differences were observed in both early and long-term mortality between women and men. Male patients had a significantly higher rate of reoperation. CLINICAL REGISTRATION NUMBER UMIN000029179. Acute Type A aortic dissection, Gender, Aortic surgery INTRODUCTION Female gender is widely recognized as a risk factor for short- and long-term mortality after cardiac surgery, and this is particularly well documented after coronary artery bypass surgery [1–5]. Several reasons have been suggested, including older age, smaller body size and more comorbidities such as anaemia and diabetes. Women on average have longer life spans than men and present with atherosclerotic disease at a more advanced age [6–8]. Acute Type A aortic dissection is a catastrophic and devastating condition in both men and women, which carries a mortality rate of up to 50% in the absence of surgical intervention [9, 10]. There is very little information in the literature describing gender-related differences in patient background and surgical outcome in acute Type A aortic dissection. The aim of this study was to identify gender-related features by comparing the clinical background and surgical outcome of male and female patients who underwent emergent surgery for acute Type A aortic dissection. PATIENTS AND METHODS From January 2004 to December 2016, 303 patients, consisting of 147 women and 156 men, underwent surgery for acute Type A aortic dissection at our institution. We compared patient background and surgical outcome between the 2 cohorts. The primary end-point was operative mortality, and the secondary end-points were late mortality and late reoperation. Patients undergo outpatient follow-up through computed tomography about every 6–12 months after hospital discharge. The Institutional Review Board of the Shiga University of Medical Science approved the study, and all patients granted permission for the use of their medical records for research purposes. Operative technique The operation was performed through median sternotomy in all patients. We used 3 main arterial cannulation sites: the femoral artery, the axillary artery and the ascending aorta (central cannulation). Circulatory arrest was achieved at a tympanic temperature of 25–27°C, after which the ascending aorta was opened. If an intimal tear was found in the ascending aorta or proximal transverse aorta, replacement of the ascending aorta or hemiarch replacement was performed using an open distal anastomosis technique under circulatory arrest only. When the arrest time was likely to exceed 35 min because of the complexity of the distal anastomotic site, we additionally employed retrograde cerebral perfusion or antegrade selective perfusion. In cases in which an intimal tear was found in the transverse aorta, total arch replacement was performed to exclude the intimal tear. When no intimal tear could be identified in the ascending or transverse aorta, only the ascending aorta was replaced. When total arch replacement was required, we adjunctively used a selective cerebral perfusion technique. Distal anastomosis was performed with 4-0 monofilament continuous sutures that were reinforced with Teflon felt strips. After completion of the distal repair, antegrade systemic circulation was restarted through the side branch of the prosthesis, and rewarming was begun. Proximal anastomosis was performed about 1 cm above the sinotubular junction with Teflon felt strip reinforcement. After completion of the proximal anastomosis and de-airing of each heart chamber, the prosthesis was declamped and coronary circulation started. Statistical analysis Data are presented as the mean ± standard deviation, or the median and interquartile range. Normality was tested using the Shapiro–Wilk test. Categorical variables were analysed using the χ2 or the Fisher’s exact test and continuous variables using a t-test or the Mann–Whitney U-test, as appropriate. Univariate and multivariate logistic regression analyses were performed for the analysis of significant predictors of hospital mortality. The clinical variables listed in Tables 1 and 2 were used for univariate analysis. The multivariate analyses were performed with a stepwise forward regression model into which each variable with a probability value of <0.2 in the univariate analysis was entered. Univariate and multivariate Cox proportional hazard regression was performed for the analysis of late mortality and late reoperation. Variables with a probability value of <0.2 in the univariate analysis were entered into the multivariate analyses. The Homer–Lemeshow goodness-of-fit test was used to evaluate the calibration of the model and demonstrated its predictive ability (P > 0.05 for all models). Table 1: Preoperative patient characteristics Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 a Proximal entry: the primary entry tear located in the proximal aorta (ascending or arch). b Distal entry: the primary entry located in the distal to descending aorta. BMI: body mass index; BSA: body surface area; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; PVD: peripheral vascular disease; SD: standard deviation. Table 1: Preoperative patient characteristics Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 Characteristics All (n = 303) Women (n = 147) Men (n = 156) P-value Age (years), mean ± SD 67.6 ± 12.6 72.6 ± 10.3 63.0 ± 12.9 <0.001  >80 years, n (%) 54 (18) 40 (27) 14 (9) <0.001 BMI, mean ± SD 23.3 ± 3.5 22.2± 3.2 24.3± 4.4 <0.001 BSA (m2), mean ± SD 1.69 ± 1.0 1.46 ± 0.9 1.91 ± 1.2 <0.001 Smoking history, n (%) 126 (42) 14 (10) 112 (71) <0.001 Hypertension, n (%) 245 (81) 119 (81) 126 (81) 0.97 Dyslipidaemia, n (%) 70 (23) 35 (24) 35 (22) 0.78 Diabetes mellitus, n (%) 29 (10) 11 (7) 18 (12) 0.23 COPD, n (%) 20 (7) 7 (5) 13 (8) 0.21 CKD (serum creatinine >1.5), n (%) 22 (7) 13 (9) 9 (6) 0.30 PVD, n (%) 13 (4) 6 (4) 7 (4) 0.86 Marfan syndrome, n (%) 14 (5) 4 (3) 10 (6) 0.21 Dissection-related status  DeBakey Type I, n (%)   Proximal entrya 193 (64) 94 (64) 99 (63) 0.93   Distal entryb 67 (22) 25 (17) 42 (27) 0.037  DeBakey Type II, n (%) 43 (14) 28 (19) 15 (10) 0.043  Shock, n (%) 106 (35) 51 (35) 55 (35) 0.91  Tamponade, n (%) 88 (29) 41 (28) 47 (30) 0.67  Aortic valve regurgitation, n (%) 33 (11) 16 (11) 17 (11) 0.99  Cardiopulmonary resuscitation, n (%) 22 (7) 11 (8) 11 (7) 0.88  Cerebral ischaemia, n (%) 41 (14) 23 (16) 18 (12) 0.29  Organ malperfusion, n (%) 74 (24) 34 (23) 40 (26) 0.61   Limbs, n (%) 35 (11) 14 (10) 21 (13) 0.28   Carotid artery, n (%) 16 (5) 8 (5) 8 (5) 0.90   Coronary artery, n (%) 38 (13) 18 (12) 20 (13) 0.88   Abdominal viscera, n (%) 14 (5) 6 (4) 8 (5) 0.65 a Proximal entry: the primary entry tear located in the proximal aorta (ascending or arch). b Distal entry: the primary entry located in the distal to descending aorta. BMI: body mass index; BSA: body surface area; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; PVD: peripheral vascular disease; SD: standard deviation. Table 2: Operative data Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Table 2: Operative data Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Procedures All (n = 303) Women (n = 147) Men (156) P-value Ascending/hemiarch replacement, n (%) 285 (94) 141 (96) 144 (92) 0.27 Total arch replacement, n (%) 18 (6) 6 (4) 12 (8) 0.31 Concomitant operation, n (%)  Aortic root replacement 7 (2) 2 (1) 5 (3) 0.21  Coronary bypass 26 (9) 9 (6) 17 (11) 0.20  Aortic valve repair or replacement 20 (7) 10 (7) 10 (6) 0.93  Lower limb bypass 8 (3) 2 (1) 6 (3) 0.32 Method of cerebral protection: additional to circulatory arrest n (%)  Retrograde perfusion 22 (7) 11 (8) 11 (7) 0.88  Selective antegrade perfusion 25 (8) 9 (6) 16 (10) 0.19  Circulatory arrest only 256 (85) 127 (86) 129 (83) 0.37 Duration of procedure (min), median (interquartile range)  Operation time 205 (171–248) 199 (172–239) 210 (173–1256) 0.17  Cardiopulmonary bypass time 111 (94–137) 110 (92–135) 113 (97–140) 0.58  Coronary ischaemia time 52 (43–68) 52 (42–68) 52 (44–68) 0.35  Circulatory arrest time 26 (21–36) 26 (21–38) 24 (21–33) 0.49 Status of dissection  Location of primary entry, n (%)   Ascending/arch aorta 236 (78) 122 (83) 114 (73) 0.037   Distal to descending aorta 67 (22) 25 (17) 42 (27) 0.037  Residual primary entry 78 (26) 30 (20) 48 (31) 0.039 Actuarial survival and reoperation-free survival curves were estimated using the Kaplan–Meier method comparing differences between groups with log-rank test. Calculated P-values of <0.05 were considered significant. Data were analysed using SPSS 22.0 (SPSS Inc., Chicago, IL, USA) for Windows (Microsoft Corp, Redmond, WA, USA). Data definitions Preoperative chronic kidney disease was defined as a level of serum creatinine >1.5 mg/dl. As a dissection-related complication, cardiac tamponade was defined as haemodynamic instability with cardiac effusion, and aortic valve regurgitation as a more than moderate degree observed in preoperative echocardiography. Shock was defined as a blood pressure lower than 80 mmHg, coronary ischaemia as ST change in the electrocardiogram, and cerebral ischaemia as permanent or transient loss of consciousness or paralysis. Postoperative stroke was defined as a neurological deficit that was confirmed postoperatively by means of computed tomography. If patients had preoperative stroke, postoperative stroke was defined as worsening of the neurological deficit in new imaging findings. Temporary neurological dysfunction was defined as a postoperative neurological deficit with a negative brain computed tomography scan and complete resolution at discharge. Operative mortality was defined as death within 30 days after surgery. Postoperative renal failure was defined as a new temporary requirement for haemodialysis. RESULTS Preoperative data Baseline patient characteristics are listed in Table 1. Female patients were significantly older (72.6 vs 63.0; P < 0.001) and smaller (body mass index 22.2 vs 24.3, body surface area 1.46 vs 1.91 m2; P < 0.001) than male patients. Male patients had more prevalence of smoking history than female patients (9.5% vs 71%; P < 0.001). Regarding dissection-related data, DeBakey Type II was more common in female patients than male patients (19% vs 10%; P = 0.043), while the proportion of patients with primary entry distal to the descending aorta was larger in men than women (27% vs 17%; P = 0.037). No other differences were observed in patient preoperative characteristics or dissection-related status. Operative and postoperative data The operative data are presented in Table 2 and postoperative data in Table 3. The primary entry was located in the ascending or transverse aorta in 83% of women and 73.1% of men. The primary entry was distal to the descending aorta in 17% of women and 26.9% of men, which was a significant difference (P = 0.03). Operative mortality was similar between the 2 groups (8.2% vs 8.9%; P = 0.8). The duration of intensive care unit stay and mechanical ventilator support was significantly shorter in women (54 vs 64 h median; P = 0.03 and 34 vs 43 h; P = 0.02, respectively). The number of days from surgery to discharge was also shorter in women (21.5 vs 24.1 days mean; P = 0.04). Table 3: Postoperative data All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 ICU: intensive care unit; TND: temporary neurological dysfunction; SD: standard deviation. Table 3: Postoperative data All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 All (n = 303) Women (n = 147) Men (n = 156) P-value Stroke, n (%) 38 (13) 18 (12) 20 (13) 0.88 TND, n (%) 15 (5) 9 (6) 6 (4) 0.36 Reoperation for bleeding, n (%) 18 (6) 8 (5) 10 (6) 0.72 Renal failure requiring temporary dialysis, n (%) 35 (12) 14 (10) 21 (14) 0.28 Mediastinitis 4 (1) 1 (1) 3 (2) 0.65 Pneumonia 40 (13) 18 (12) 22 (14) 0.63 Prolonged ventilation (>48 h) 112 (37) 48 (33) 64 (41) 0.13 Ventilator support time (h), median (interquartile range) 40 (18–67) 34 (16–60) 43 (19–74) 0.02 Myocardial infarction 3 (1) 1 (1) 2 (1) 0.99 Intestinal complication 11 (4) 5 (3) 6 (4) 0.99 Multiple organ failure 11 (4) 4 (3) 7 (5) 0.99 Sepsis 6 (2) 3 (2) 3 (2) 0.99 ICU stay (h), median (interquartile range) 56 (34–102) 54 (29–79) 64 (36–103) 0.03 Days to discharge, mean ± SD 22.7 ± 26.0 21.5 ± 21.3 24.1 ± 30.7 0.04 Mortality (hospital), n (%) 29 (10) 13 (9) 16 (10) 0.68 Mortality (30 days), n (%) 26 (9) 12 (8) 14 (9) 0.80 ICU: intensive care unit; TND: temporary neurological dysfunction; SD: standard deviation. Multivariate analysis for operative mortality Multivariate logistic regression analysis revealed that preoperative cardiopulmonary resuscitation (P = 0.012), cardiac tamponade (P = 0.001), chronic obstructive pulmonary disease (P = 0.005), haemodialysis (P = 0.035) and longer cardiopulmonary bypass time (P < 0.001) were independent risk factors for early death (Table 4). Table 4: Multivariate logistic regression analyses for hospital death Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 CPB: cardiopulmonary bypass. Table 4: Multivariate logistic regression analyses for hospital death Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 Variables Odds ratio 95% confidence interval P-value For whole patients  Cardiopulmonary resuscitation 4.3 1.4–13.5 0.012  Tamponade 6.5 2.2–19 0.001  Chronic obstructive pulmonary disease 7.1 1.8–28 0.005  Haemodialysis 6.1 1.1–33 0.035  CPB time (per min) 1.01 1.00–1.02 <0.001 For women  Tamponade 10.1 2.4–21 0.001  CPB time (per min) 1.01 1.01–1.02 0.002 For men  Cardiopulmonary resuscitation 7.4 1.1–5.5 0.05  Tamponade 3.3 2.7–29 0.002  Chronic obstructive pulmonary disease 8.1 2.3–25 0.001  Haemodialysis 4.5 2.9–33 0.006  CPB time (per min) 1.01 1.01–1.02 <0.001 CPB: cardiopulmonary bypass. Late reoperation The indications for dissection-related reoperation were dilatation of the thoracic aorta of ≥55 mm, dilatation of the abdominal aorta of ≥50 mm, rupture or impending rupture of the aorta, rapid dilatation of the aorta of >5 mm per half year, artificial prosthesis infection and progressive aortic valve regurgitation of more than moderate degree. During the follow-up period, there were 9 female and 27 male patients who underwent reoperation that was related to the aortic dissection. Male patients had a significantly higher rate of reoperation than female patients (27/140 = 19.3% vs 9/134 = 6.7%; P = 0.003). The details of reoperation are listed in Table 5. The rate of 10-year actuarial freedom from reoperation was 80.7% in women and 53.1% in men, which is a significant difference (log-rank P = 0.018) (Fig. 1). The results of the multivariate Cox proportional hazard regression analysis for independent predictors of long-term reoperation are listed in Table 6. Female gender was an independent suppressing factor for long-term reoperation. Table 5: Details of late reoperation Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Table 5: Details of late reoperation Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Hospital survivors (n = 274) Women (n = 134) Men (n = 140) P-value Late reoperation, n (%) 36 (13) 9 (7) 27 (19) 0.003  Total arch replacement, n (%) 12 (4) 3 (2) 9 (6) 0.14  Aortic valve replacement, n (%) 7 (3) 2 (1) 5 (4) 0.45  Descending aortic replacement, n (%) 13 (5) 2 (1) 11 (8) 0.02  Root replacement, n (%) 6 (2) 1 (1) 5 (4) 0.22  Abdominal aortic replacement, n (%) 2 (1) 2 (1) 0 (0) 0.24  Artificial prosthesis infection, n (%) 4 (1) 0 (0) 4 (3) 0.12 Table 6: Multivariate Cox proportional hazard regression analyses of late reoperation and long-term death Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Table 6: Multivariate Cox proportional hazard regression analyses of late reoperation and long-term death Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Variables Hazard ratio 95% confidence interval P-value Late reoperation  For whole patients   Age 1.03 1.01–1.06 0.008   Tamponade 3.9 1.1–14 0.02   Female gender 0.4 0.2–0.9 0.02   Malperfusion (at least 1 organ) 2.0 1.0–4.0 0.04  For women   Tamponade 4.5 1.11–18 0.02  For men   Age 1.04 1.01–1.07 0.005   Residual primary entry 2.1 1.1–4.1 0.03   Malperfusion (at least 1 organ) 2.6 1.2–5.9 0.02 Long-term death  For whole patients   Cerebrovascular disease (preoperatively) 3.2 1.05–9.8 0.04   Chronic obstructive pulmonary disease 4.6 1.64–12.8 0.004   Longer operation time (per min) 1.01 1.00–1.01 0.003  For women   Tamponade 4.5 1.11–18 0.001   Chronic obstructive pulmonary disease 10 2.9–40 <0.001   Longer operation time (per min) 1.01 1.01–1.02 <0.001  For men   Age 1.06 1.01–1.1 0.02   Cerebrovascular disease (preoperatively) 4.4 1.6–12 0.01 Figure 1: View largeDownload slide The rate of 6-year actuarial freedom from all-cause death. Log-rank analysis revealed no difference between the 2 groups. Figure 1: View largeDownload slide The rate of 6-year actuarial freedom from all-cause death. Log-rank analysis revealed no difference between the 2 groups. Long-term mortality Mean follow-up duration was 6.8 ± 4.8 years (maximum 12.9 years) in the population as a whole. The follow-up rate was 96.0% (291 of 303) and showed no difference between the groups. Among the hospital survivors (except for hospital death; 134 women and 140 men), there were 10 (7.5%) deaths in female patients and 13 (9.3%) deaths in male patients during the follow-up period. The actuarial survival rate was 59.0% in female patients and 65.7% in male patients at 10 years. Log-rank analysis revealed no difference between the 2 groups (P = 0.81) (Fig. 2). The results of the multivariate Cox proportional hazard regression analysis for independent predictors of long-term death from all causes are listed in Table 6. Figure 2: View largeDownload slide The rate of 6-year actuarial freedom from reoperation: men versus women. Log-rank analysis showed a significant difference (P = 0.018). Figure 2: View largeDownload slide The rate of 6-year actuarial freedom from reoperation: men versus women. Log-rank analysis showed a significant difference (P = 0.018). COMMENT The surgical mortality associated with Type A aortic dissection remains high for both men and women, with rates ranging from 8% to 26% [11–14]. This high mortality rate is due not only to the difficulty from the surgical aspect but also to various dissection-related complications such as organ malperfusion, respiratory failure, brain damage and inflammatory response [15, 16]. Generally, female gender is a significant risk factor for surgical mortality after cardiovascular surgery such as coronary artery bypass grafting, mitral valve operation and aortic valve replacement [17–19]. There is very little information in the literature describing gender-related differences in emergent surgery for acute Type A aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) is the one and only large registry, in which 18 large centres participate to reveal the whole clinical picture of acute aortic dissection [9]. In 2004, a subanalysis of IRAD evaluating gender-related differences [20] found that female patients were older and had a longer duration from onset to diagnosis than male patients. Moreover, women had more preoperative complications including rupture, tamponade and impaired consciousness, and women with acute Type A dissection were less likely to undergo surgery than men. Haemodynamic instability in ongoing acute Type A aortic dissection worsens progressively and may eventually result in cardiac arrest. The patient must therefore be transferred to the operating theatre for cardiopulmonary support as soon as possible. At our institution, we have adopted a system of direct transfer to the operating theatre so that all patients with acute Type A dissection are rushed to the operating theatre immediately after arrival at the hospital. In most previous reports, the ratio of men to women undergoing emergent surgery for acute Type A dissection was approximately 2:1 [21–23]. In our series, the ratio was close to 1:1. The reason is not clear but may relate to the characteristics of the Japanese population. In Japan, the mean life expectancy is highest in the world for women at over 87 years, but 7 years shorter for men at 80 years. Another particular difference at Japanese high-volume centres in the IRAD study was that no fewer than 28.5% of women who had acute Type A aortic dissection were not admitted to medical treatment against only 13% of men, which raises the issue of selection bias. At our institution, after in-hospital diagnosis of acute Type A dissection was made, almost all patients were immediately transferred to the operating theatre, except for cases of unsuccessful resuscitation. In the IRAD study, the surgical mortality rate for acute Type A dissection was 31.9% in women and 21.9% in men, which is a significant difference (P = 0.013). Older age at onset, delayed transfer to hospital and more complications including tamponade, shock, heart failure and coma are cited as potential reasons for higher surgical mortality. Although, as stated above, female gender generally has a negative impact on surgical outcome in cardiovascular disease, women had similar early and long-term mortality to men in this series and the rate of late reoperation was significantly lower among women. Moreover, the durations of intensive care unit stay, ventilator support and postoperative hospital stay were shorter in women, suggesting that women have a tendency to faster recovery than men. The expected reason for this difference is that the population with smoking history was higher in men (71%) than in women (10%). It is well known that respiratory failure after surgery for acute Type A aortic dissection is serious and occasionally fatal [24–26]. Smoking may add fuel to pulmonary damage after surgery for acute Type A dissection and thus prolong ventilator support time in male smokers. Interestingly, as Fukui et al. [24] presented similar data, the proportion of patients with primary entry distal to the descending aorta was larger in men than women in this series (27% vs 17%; P = 0.037), while the proportion of DeBakey Type II was larger in women (19% vs 10%). The primary entry cannot be resected when located distal to the descending aorta. A larger number of male patients with residual primary entry would render the surgical outcome worse than for women and might result in a reduced difference in mortality. In previous reports, actuarial freedom from reoperation was approximately 60–88% at 10 years [21–24, 27]. Several risk factors for late reoperation have been reported, including residual primary entry, DeBakey Type I, younger age, Marfan syndrome, a patent false lumen and lack of a β-blocker [21–24]. In this study, we found that the female gender was a preventative factor for late reoperation (hazard ratio 0.4). Fukui et al. [24] also reported a lower rate of late reintervention in female patients. We suggest several possible explanations of this point. The older age of female patients may be related to the lower rate of reintervention because older age is a frequent reason for deciding against late reoperation. Residual primary entry, which is a well-known cause of late reoperation, was seen commonly in men in this study, which may be related to the prevalence of late reoperation in male patients. In terms of patient background, male patients had a slightly higher prevalence of comorbidities such as smoking (71.3% vs 9.5%), diabetes mellitus (11.5% vs 7.5%), chronic obstructive pulmonary disease (8.3% vs 4.8%) and Marfan syndrome (6.4% vs 2.7%), which may also be related to the reoperation rate. It is noteworthy that the patients who required late reoperation due to prosthesis infection were all smoking men with Marfan syndrome. Another potential factor is that we decided whether to perform reoperation according to the size of the dilated aorta using the same criterion for both men and women. As the size of the aorta is generally smaller in women than men, it may take a longer time for the aortic size to achieve the criterion for reoperation in women than in men. It may thus not be entirely fair to use the same criterion for both men and women. Although long-term survival after repair of acute Type A dissection has been reported to range from 45% to 88% at 5 years and 30% to 60% at 10 years [21, 26, 28–30], little is known about the gender difference in long-term survival. The only relevant past report, by Fukui et al. [24], showed that the actuarial survival rate at 5 years was 80.1% in female patients and 89.3% in male patients (P = 0.06). In this study, the actuarial survival rate was 59.0% in female patients and 65.7% in male patients at 10 years, with no significant difference (P = 0.81), and multivariate Cox proportional hazard regression analysis revealed that female gender was not a risk factor for late mortality. Limitations The limitations of this study include its retrospective nature and the lack of a randomized treatment assignment. Additionally, the number of subjects is small, and there is lack of information on medication during follow-up. Small changes in the technical procedure over time, such as a higher temperature strategy, no use of cerebral perfusion and the use of a new haemostatic glue, may influence the outcome. However, the study does have strong points: despite the more than 12-year duration of the study, all procedures were consecutively performed by 2 high-volume surgeons with a consistent shared policy at a single institution. Our policy is to accept all patients at any time and never to refuse an emergency operation. Hence, this study is real-world based and reliable without patient selection bias. CONCLUSION In summary, this study found some notable differences between women and men following surgery for acute Type A aortic dissection. Contrary to most previous reports, we found no differences in surgical mortality, surgical complications or long-term mortality between women and men. 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Aortic enlargement and late reoperation after repair of acute type A aortic dissection . Ann Thorac Surg 2007 ; 84 : 479 – 86 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Feb 6, 2018

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