Background

Type A Aortic Dissection (TAAD) is a cardiac surgical emergency

carrying a highly time-critical mortality of 1-2% per hour after the
initial event. The aetiology of aortic dissection is multifactorial,
consisting of factors which cause structural changes to the aortic
wall, ranging from connective tissue diseases to chronic
hypertension. However, the precipitating factor which causes the
initial rupture of the wall is unknown.
We postulate that a momentary increase in blood pressure results in
the precise moment of aortic rupture and that this is influenced by
external factors, specifically the lunar cycle.

The gravitational forces exerted by the lunar cycle are well

understood for their effects on tides, exhibiting high and low tides on
a daily basis. The lunar cycle lasts for 29.5 days and consists of 4
main phases, each exhibiting differing gravitational pull on the earth.
These are; New Moon, First Quarter (Waning gibbous), Third Quarter
(Waxing gibbous) and Full Moon. During the full and new moon
phases of the lunar cycle the sun and moon align. This results in a
combined solar/lunar gravitational force impacting a greater effect
on tidal variation, leading to higher “spring tides”. The opposite
effect is found when the sun and the moon are situated at 90
degrees, such as during the first and third quarter phases of the lunar
cycle, producing smaller “neap tides” (1).
However there is also evidence to suggest that the lunar cycle has a
significant effect on hormone flux and physiology, including blood
pressure (2,3). As a result, the question arises whether the
physiological influence of the lunar cycle, specifically on blood
pressure, impacts the incidence of aortic dissection, and
furthermore, on the outcome of aortic dissection repair.
A study in 2013, of 210 aortic dissection patients suggested a
significant lunar phase involvement in the outcomes of Type A Aortic
Dissection repair. Shuhaiber et al. observed a significantly decreased
post-operative mortality during the Full Moon phase of the lunar
cycle. Alongside this, they observed a significant increase in
postoperative mortality during winter (4).
Several large studies have demonstrated a relationship between
seasonal variation and incidence of major cardiovascular disease,
including TAAD (5–7). Due to the evidence of seasonal and lunar
variation on cardiovascular risk factors and disease, we firstly
consider the possibility that the lunar cycle may influence a sudden
spike in blood pressure and so determine the precise moment of
rupture in TAAD. Secondly, we consider the physiological changes
occurring through the stages of the lunar cycle may influence TAAD
repair mortality. Thirdly, we consider that seasonal variation may be
significantly related to incidence of TAAD

Aims

The aim of this study is to examine the hypothesis that seasonal

variation and the lunar cycle impact on the incidence and surgically
treated outcomes of TAAD.

Objectives
 To collect retrospective data from a UK Cardiac surgical patient
database
 To correlate basic demographics, outcomes and timing of the
onset of symptoms with the lunar phase and season
 To perform statistical analysis of the results.

Methods

Demographics of patients referred for surgery between July 1996

and September 2017, with TAAD were collected from a single centre
UK cardiac surgical database. Patients were selected where the onset
of symptoms could be identified as a specific date, in order to
identify the initiation of dissection. Equally where this date could not
be specifically identified, patients were excluded. The onset of
symptoms were matched to the relative season and phase of the
lunar cycle. Each season was defined using official seasonal
definitions, as follows;
 Autumn – September 21 – December 20
 Winter – December 21 – March 20
 Spring – March 21 – Jun 20
 Summer – Jun 21 – Sep 20

The phases of the lunar cycle were defined as 3 days either side of
the actual event in order to allow for increasing and decreasing
gravitation pull surrounding the lunar event. For example, a New
moon was classified as 3 days before the actual New Moon event
and 3 days after.

Statistical analysis
Statistical analysis was carried out using SPSSv24. Statistical methods
used include Chi-square tests, t-tests and Bernoulli trials were
applied where appropriate. A significance level of P<0.05 was used to
define statistical significance.
Results

Basic demographics
1. 152 patients were identified from the surgical database. Of
these patients, 103 (67.7%) were male and 49 (32.3%) were
female. The mean age of dissection across all patiennts was 59
years old.

Seasons

Seasonal variation was found to significantly influence the incidence

of TAAD with the majority of dissections occurring during Autumn
and Winter and fewest during summer (p=0.03);
Autumn - 47(29.0%)
Winter – 45(31.5%)
Spring - 36 (23.0%)
Summer – 24 (16.3%)
 SEASONS AND AORTIC DISSECTION
50
45
NUMBER OF DISSECTIONS

40
35
30
25
20
15
10
5
0
WINTER SPRING SUMMER AUTUMN
SEASONS

Figure 1

Lunar Cycle

Incidence of Type A aortic dissection was shown to have a significant

relationship with the lunar cycle. Specifically, the incidence of TAAD
was significantly higher during full moon phase (p=0.04).

New moon – 37(24%)

First quarter – 40(26%)
Full moon – 48 (32%) p=0.04
Third quarter – 27(18%)

LUNAR CYCLE AND AORTIC DIS-

SECTION
45
40
NUMBER OF DISECTIONS

35
30
25
20
15
10
5
0
NM FQ FM TQ
LUNAR PHASE AT ONSET

Figure 2
The lunar cycle analysis was further divided to examine the lunar
effects on the incidence of aortic dissection in males and females
independently. There was found to be a significant difference in the
effects on the sexes, with the full moon having a greater effect on
male incidence than that of females (P=0.03).

Male Female

New Moon 24 13

First Quarter 27 15 Table 1

Full Moon 35 13

Third Quarter 17 11
LUNAR CYCLE, MALE AND FEMALE DIS-
SECTION
NUMBER OF AORTIC DISSECTIONS

40
35
30
25 MALE
20 FEMALE
15
10
5
0
NM FQ FM TQ
LUNAR PHASE

Significant difference in the effect of the Lunar Cycle on Male and

Female patients. P = 0.03

Figure 3
The Lunar Cycle and Post-op Mortality

TAAD post-op mortality was found to have a relationship with the

lunar cycle with a higher number of deaths occurring during the full
moon than in the other stages of the lunar cycle. The mortality
results are as follows;
New Moon – 10 (38%); First quarter -5 (19%); Full Moon – 5 (19%);
Third quarter – 6 (20%).
The lunar cycle was found to have a greater impact on post-op
mortality in men than women.

New Moon First Quarter Full Moon Third Quarter

Male 8 4 5 4
Female 2 1 0 2

Lunar Cycle - Male and female mortality

9
8
7
6
Male
5 Female
4
3
2
1
0
NM FQ FM TQ

Figure 4
Conclusion

The gravitational effects of the lunar cycle, most noticeably

influencing tidal changes, are widely understood and the potential
effects on physiological and pathological processes in both the
cardiovascular system and elsewhere, have been described in
animals (2). From this study we have observed significant effects of
the lunar cycle on both incidence and post-op mortality of TAAD.
Seasonal variation proved to be a significant factor in the incidence
of TAAD, with the highest proportion occurring during Autumn,
closely followed by Winter and the fewest dissections occurring in
summer. It has been previously observed by Takagi (8) that seasonal
variation impacts the incidence of aortic dissection, however with
essentially equal numbers of dissections occurring in Autumn and
Winter respectively. We would suggest that the observed equal risk
between Autumn and Winter may be due to differing definitions of
the seasonal dates. There have been a number of studies which have
linked coronary disease risk factors, such as diet and exercise to
seasonal variation, and others which have suggested a direct
physiological effect of temperature on physiological factors (9).

In this study, the lunar cycle was found to impact the incidence of
aortic dissection. A significantly greater number of dissections
occurred during the full moon phase compared to all other stages of
the cycle. This is in keeping with the study hypothesis; the
gravitational forces exerted by the moon and the sun during the
lunar cycle will have a significant effect on the incidence of Type A
aortic dissection. The postulated method by with this relationship
may occur is that the increased gravitational forces cause a sudden
rise in blood pressure resulting in the precise moment of dissection.
This would therefore suggest that during the stages of the lunar cycle
where the gravitational force is at its greatest (during full and new
moons), the effect on TAAD incidence would be greater. Therefore
the significantly greater number of dissections occurring during the
full moon would support this hypothesis.
Interestingly however, the new moon phase, with its equally
increased gravitational effect, did not replicate the results of the full
moon as expected. The new moon was found to have a far lesser
effect on the incidence of TAAD when compared to both the full
moon phase and also the first quarter phase. This would suggest that
the mechanism by which the full moon is associated with increased
dissection incidence may be less related to gravitational exertion
than expected.
Having observed the significant effect of the lunar cycle on all
dissections within our data set, males and females were assessed
independently. We found that the lunar cycle had no significant
effect on the incidence of TAAD in women, and in fact the number of
dissections was greatest during the first quarter phase, though
dissection rates were relatively similar throughout the lunar cycle.
Therefore, it was in males that the lunar cycle had its significant
effect. The incidence of males was significantly greater during the full
moon than in any other stage of the lunar cycle, this was followed by
first quarter, and then new moon phases. The significantly greater
impact of the lunar cycle in males over females (with relatively
similar female incidence throughout the cycle) was also observed by
Roman et al. when looking at the relationship of the lunar cycle with
the incidence of hospital admissions relating to gastrointestinal
bleeding (10). The mechanism by which males and females are
affected differently may be the focus of further research.
Further to incidence, the effect of the lunar cycle on post-op
mortality was found to be significant. Mortality rates were highest
when patient presented during the new moon phase, followed by
the third quarter moon, first quarter and finally full moon, with
mortality found to be two times higher during the new moon phase
than during the full moon phase. Interestingly, as with incidence, the
lunar cycle had a significantly greater impact on post-op mortality in
males. These results correlate to those of Shuhaiber et al (2013) who
also found differences in post-op mortality during different phases of
the lunar cycle, finding fewer deaths during the full moon phase.
Recent descriptions of a significant increased mortality after Cardiac
surgery performed in the morning, compared with the afternoon (11)
and faster healing of wounds acquired in the day rather than night
(12) are evidence for a fluctuating affect of the (internal) diurnal
rhythm on the function of the heart. In this study we present
evidence of the affects of external cyclical events on the body,
specifically the cardiovascular system.