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Male-female Differences In The Natural History Of Ascending Thoracic Aortic Aneurysms: The DisSEXion Study
Maximiliaan L. Notenboom, BSc1, Arjen Gökalp, MD1, Kevin M. Veen, PhD1, Roland van Kimmenade, MD, PhD2, Guillaume Geuzebroek, MD, PhD2, Michel Verkroost, MD, PhD2, Jolien W. Roos-Hesselink, MD, PhD1, Ad J.J.C. Bogers, MD, PhD1, Johanna J.M. Takkenberg, MD, PhD1.
1Erasmus University Medical Center, Rotterdam, Netherlands, 2Radboud University Medical Center, Nijmegen, Netherlands.

OBJECTIVE:
To investigate the natural history of ascending thoracic aortic aneurysms (ATAAs) before surgical intervention with particular emphasis on male-female differences.
METHODS:
Adult ATAA patients who received diagnostic imaging and/or follow-up imaging between 2007-2020 were included in this retrospective cohort study. Aortic growth was calculated with CT-, MRI- and echocardiographic data by multivariable linear models, according to the instrumental variable approach, taking age and sex into account through interaction terms. Other outcomes of interest were differences in initial presentation, surgical intervention and mortality.
RESULTS:
A total of 939 patients were included (31.8% female). Median age was 62.4 [IQR 52.6-69.7] years for female patients and 59.0 [50.6-65.9] years for male patients (p<0.001). Male patients more often had a previous myocardial infarction (p<0.001) or previous dissection or aneurysm in a major artery other than the ascending aorta (p=0.009) before diagnosis. The 1- and 10-year survival rates for female patients were 98.9%±0.6% and 83.5%±3.1%, respectively. The 1- and 10-year survival rates for male patients were 98.8%±0.4% and 88.4%±1.8%, respectively (log-rank p=0.046). Aortic growth was comparable between female (0.42mm/y[0.24-0.60]) and male patients (0.40mm/y[0.28-0.52]) at the level of the sinus of Valsalva (p=0.709). However, at the level of the tubular ascending aorta, female patients demonstrate faster growth than male patients (0.66mm/y[0.49-0.83] versus 0.49mm/y[0.36-0.62], p=0.003). Cumulative incidence of surgical intervention was higher in female patients at 30d (6% versus 2.8%, p=0.018) and 10y (60.2% versus 48.6%, p=0.011) after diagnosis.
CONCLUSIONS:
ATAA expansion is faster in female patients at the level of the tubular ascending aorta, but not at the aortic root. Female patients undergo surgery more often and more quickly after diagnosis. Clinical practice would benefit from insights regarding male-female differences in presentation, treatment and outcomes of ATAAs and subsequent implementation of insights into guidelines.


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