Invited commentary to: Type A aortic dissection is more aggressive in women

Gasser et al. [1] report on their single-centre experience on gender-related differences in patients presenting with an acute type A dissection. Although their results are in line with other recently published studies that showed that women presenting with an acute type A dissection are older compared to men, Gasser et al. found significant differences in neurologic complications and perioperative mortality between female and male patients that could not be shown in other studies [2, 3]. A close look at the data presented by authors shows that the time from symptoms to surgery is extremely short with a median time of 7.3 h in women and 6.5 h in men. Even though the time from symptom onset to surgery in the authors’ study is extremely short, 7.9% of female patients but only 2.2% of male patients did not survive until the initiation of cardiopulmonary bypass. This makes clear that many cases of type A dissection in female patients might be missed if the time from onset of symptoms to diagnosis is long and could be 1 explanation for the difference in morbidity and mortality that was found in the authors’ study compared to other publications. The fact that female patients were older and also presented with a significantly higher rate of preoperative CPR, cerebral malperfusion, neurologic dysfunction and preoperative intubation underlines that they presented in a more critical disease state than male patients. Interestingly enough there is no significant difference in the median GERAADA score between female and male patients which is unexpected as one would expect a higher GERAADA score as all of the above-mentioned preoperative parameters have been identified as independent predictors for mortality in the GERAADA score [4]. Another interesting finding in the study is the second peak of mortality in female patients 5–7 years after surgical repair and the statistically significant impaired long-term survival in female patients. Although other studies could not show a statistically significant long-term survival, Fukui et al. [5] report on a 5-year survival that was 80.1% for women vs 89.3% for men (P = 0.067) and Conway et al. [6] report on a 10-year survival of 58% for women vs 73% for men (P = 0.284). In both studies, the difference in long-term survival did not reach statistical significance but points into the same direction as the findings of Gasser et al. As the competing risk analysis including postoperative neurologic injury and death revealed no differences between female and male patients, the authors speculate that less extensive aortic repair might have contributed to the higher long-term mortality but also report that aortic death was seen in only 12% of patients without gender-specific differences, which makes this explanation rather unlikely. In conclusion, the study from Gasser et al. provides an important insight into gender differences in patients presenting with an acute type A dissection as it clearly shows that female patients are at a higher risk for mortality in the initial period after the onset of symptoms and also present in a more severe disease state; therefore, early diagnosis and referral for treatment are key to improve survival in female patients but even the extremely short time ranged between the onset of symptoms and surgery as in the authors’ study could not prevent a higher perioperative mortality and morbidity compared to male patients. Another concerning finding is the second peak in mortality after 5–7 years after surgical repair in female patients and the impaired long-term survival that should trigger further research to improve the long-term survival of female patients after type A dissection.