Sex-Based Differences in Long-Term Outcomes of Patients With Ascending Aortic Dilation

Thoracic ascending aortopathy (AA) is often asymptomatic and incidentally diagnosed, with surgical replacement recommended once it becomes aneurysmal. We report sex-based characteristics and long-term outcomes of patients with AA.

This study analyzed 14 244 patients (21.1% women) with unrepaired AA (≥4 cm) diagnosed via echocardiography from 2010 to 2023, excluding those with acute aortic dissection/rupture at presentation (n=1179). Baseline data, including height-indexed measurements (ascending aortic area height index and cross-sectional area to height ratio), were collected. AA surgery and rates of aortic dissection/rupture during follow-up were recorded. Cox proportional hazards and Kaplan-Meier survival analysis were performed for all-cause mortality.

Women were older (63.6 versus 62.3 years) and had fewer comorbidities, including hypertension, diabetes, coronary artery disease, and dyslipidemia (all P<0.001). However, women had higher height-indexed aortic measurements (ascending aortic area height index: 2.81 versus 2.59 cm/m; cross-sectional area to height ratio: 10.3 versus 9.5 cm²/m, both P<0.001) and fewer aneurysms ≥5 cm (20.6% versus 22.8%, P=0.04). At 0.86 years, 26.1% underwent surgery, with higher rates in women (28.2% versus 25.6%, P=0.002) and low in-hospital mortality (0.9%). Over 6.2 years, women had worse survival (14.2% versus 11.2%, log-rank P<0.001), with female sex independently associated with higher mortality (hazard ratio [HR], 1.14; P<0.001). Aortic surgery improved survival (HR, 0.81; P<0.001). Among unoperated patients (n=10 523), 62.9% of deaths and 72.4% of dissections/ruptures occurred in women with aortic diameters <5 cm.

Despite fewer comorbidities and higher surgical rates, women with AA had worse long-term survival. Sex-specific thresholds for AA surgery may warrant consideration.