Sex-Related Differences in Prosthesis-Patient Mismatch Following Aortic Valve Replacement with Perceval Sutureless Valve

(1) Background: Prosthesis–patient mismatch (PPM) after aortic valve replacement (AVR) impairs left ventricular (LV) recovery and is more common in women due to smaller aortic dimensions. Although the Perceval sutureless valve provides larger effective orifice areas, sex-specific PPM outcomes remain unclear. This study evaluated sex-related differences in PPM incidence, severity, and early impact after Perceval AVR. (2) Methods: We retrospectively analyzed 139 patients (68 males, 71 females) who underwent Perceval AVR between 2016 and 2020. PPM was defined per Valve Academic Research Consortium-3 (VARC-3) criteria using indexed effective orifice area (EOAi) and stratified by body-mass-index (BMI) (<30 vs. ≥30 kg/m2). Echocardiography assessed hemodynamic performance. (3) Results: PPM was markedly more frequent in women than men (74.6% vs. 22.1%, p < 0.001). Among non-obese patients, 47.9% of females versus 16.2% of males developed PPM (p < 0.001). Women received smaller valves and consistently exhibited lower EOAi despite similar gradients. Postoperatively, females had reduced EOAi (0.8 vs. 0.9 cm2/m2, p < 0.001) but higher LV ejection fraction (55.8% vs. 49.5%, p = 0.004). Early clinical outcomes were comparable between sexes. (4) Conclusions: Despite favorable hemodynamics of sutureless AVR, anatomical sex differences result in persistently higher PPM rates in women, predominantly of moderate severity. Tailored strategies—including aortic root enlargement and sex-specific EOAi thresholds—may improve prosthesis selection and outcomes in female patients.