Sex disparities in elective valve-sparing root replacement: evidence from a multicentre study.

Objectives
Sex-related disparities are well established in cardiovascular disease, but their impact on outcomes after valve-sparing root replacement (VSRR) is not well defined. In a multicentre international cohort, we evaluated sex-based differences in clinical characteristics, radiographic features and outcomes after elective VSRR.Methods
We retrospectively analysed all patients who underwent VSRR between 2004 and 2024 at three high-volume centres in the United States and Europe. Baseline, operative, and imaging data were compared between sexes. The primary end-point was a composite of all-cause mortality, 30-day cerebrovascular accident, and Zone 0-3 aortic reintervention or aortic valve reintervention. Kaplan-Meier and competing risk analyses were performed, with 4:1 propensity score matching (caliper 0.2) to adjust for baseline imbalances.Results
1'019 patients (191 women, 19%) undergoing VSRR were included in the study. Women were younger (46.7 vs 50.4 years, p = 0.002), more likely to present with heritable thoracic aortic disease (51% vs 17%, p < 0.001), and had smaller aortic diameters but larger indexed dimensions compared with men (all p ≤ 0.001). Aortic valve leaflet repair was performed less frequently in women (17% vs 34%, p < 0.001). After matching, no significant sex differences were observed in early outcomes. At 10 years, freedom from the composite end-point was similar between women and men (82.8% vs 83.9%, p = 0.740), as were survival (95.0% vs 96.4%, p = 0.920) and cumulative incidences of reintervention or dissection. Age thresholds for adverse events were lower in women (>50 years) than in men (>59 years).Conclusions
Only one-fifth of VSRR patients were women, who presented younger with more heritable thoracic aortic disease and smaller absolute aortic diameters. Despite these differences, long-term outcomes were equivalent, suggesting that sex alone does not determine surgical results. Earlier surgical referral guided by indexed aortic measurements may improve recognition and outcomes in women.