Sex-Related Differences After Proximal Aortic Surgery: Outcome Analysis of 1773 Consecutive Patients

Guidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta.

A total of 1773 patients underwent nonemergency surgical procedures on the aortic valve (AV) and proximal aorta at our institution between 2000 and 2018. Of these, 772 patients (21.8% women) received a Bentall procedure, 349 (20.3% women) had AV-sparing root replacement, and 652 (31.1% women) underwent AV and supracommissural ascending aorta replacement. Primary outcomes were in-hospital mortality and midterm survival.

When assessing sex-related differences within the entire group of patients that received an operation on the proximal aorta, women were found to be older, had a lower body mass index, and were smokers less often. Despite shorter procedural times, median ventilation times and intensive care unit length of stay were longer in women. In-house mortality was also higher in women (3.6% vs 0.9%, P < .001). Multivariable logistic regression revealed age (odds ratio [OR], 1.8; 95% CI, 1.4-2.3 per 5 years added; P < .001), female sex (OR, 2.6; 95% CI, 1.2-5.8; P = .02), and urgent surgery (OR, 3.1; 95% CI, 1.2-7.3; P = .01) as independent risk factors for in-house death. Midterm survival was lower for women in the entire cohort (P = .02) and particularly within the Bentall subgroup (P = .004).

Female sex is an independent risk factor for operative mortality in patients undergoing proximal aortic surgery but is currently not addressed in guidelines. More research should focus on etiology and prevention of these worse outcomes in female patients.