Sex difference in aortic root replacement with a stentless bioprosthesis

OBJECTIVES: To investigate and quantify differences in survival and reinterventions between sexes after aortic root replacement with a stentless bioprosthesis, stratified for preoperative valve lesion. METHODS: Elective adults undergoing aortic root replacement with the Freestyle bioprosthesis at six North-Atlantic centres were included. Survival analyses were performed using the Kaplan-Meier method or Aalen-Johansen with death as competing risk as relevant. Results were quantified using uni- and multivariable Cox regression tested using a log-rank likelihood ratio test. RESULTS: In total, 884 patients were analysed for a median follow-up time of 10 years. Females were 4 years older. Survival was significantly worse in females operated for aortic valve insufficiency [60.7% and 72.2% for females and males at 14 years, respectively (P = 0.001)], but not for the other indications, even after correction for age. There were no differences in early outcomes or need for reoperation between the sexes and between the different aortic valve pathologies. CONCLUSIONS: Sex difference in survival outcomes depends on pathology, and females have, compared to males, more symptoms preoperatively regardless of type of valve lesion and worse outcome after aortic root replacement due to aortic insufficiency. Updated surgical risk scores should account for interaction between sex and pathology, and the surgical community must raise awareness on risk of patient's or doctors delay to surgery.