Sex-specific Patterns of Valvulo-Aortopathy in Bicuspid Aortic Valve According to the International Consensus...

To characterise sex-specific patterns of bicuspid aortic valve (BAV) valvulo-aortopathy using consensus phenotyping and to assess how aortic normalisation strategies influence sex-related differences in aortic dimensions.

We analysed 808 adults with BAV (mean age 49.9 ± 17.5 years; 588 men) from the RE-BAV registry. Valve morphology, aortopathy phenotypes, and clinical valvulo-aortopathy categories were classified according to consensus definitions. Typical and uncomplicated forms were additionally analysed together as a non-complex category. Proximal aortic dimensions were defined as the aortic root and ascending aorta.Valve morphology distribution did not differ by sex. Although the prevalence of aortic dilatation was similar, phenotype distribution differed: women more frequently exhibited the extended phenotype (34.7% vs 23.3%, p = 0.001), whereas the root phenotype was more common in men (15.1% vs 7.8%, p = 0.006). Moderate-to-severe aortic regurgitation was more prevalent in men (50.3% vs 29.1%, p < 0.001). Sex differences in proximal aortic dimensions varied by normalisation strategy. For the ascending aorta, indexing to body surface area yielded larger values in women (21.1 ± 4.0 vs 20.0 ± 4.0 mm/m2, p = 0.001), whereas diameter/height showed no sex-related difference at this level. Conversely, the cross-sectional area-to-height ratio remained higher in men across proximal segments, most prominently at the sinuses of Valsalva (6.9 ± 2.0 vs 5.6 ± 1.6 cm2/m, p < 0.001). Age was independently associated with larger proximal aortic dimensions across all strategies.

Sex-related differences in BAV involved aortopathy phenotype, aortic regurgitation burden, and proximal aortic dimensions. Interpretation of proximal aortic dimensions depended on the normalisation strategy used, indicating that indexing methods should not be treated as interchangeable.