A new analysis demonstrates how pathology and sex differences influence survival outcomes in patients undergoing aortic root replacement (ARR), with women having more symptoms pre-procedure and worse outcomes post-procedure compared to men. Hanna Dagnegård, MD, PhD, from Rigshospitalet, Copenhagen, and colleagues, discussed the corresponding data in a manuscript published online in the European Journal of Cardio-Thoracic Surgery. Women and men typically have different symptoms of cardiovascular diseases, which influences decision-making, pathophysiology and treatment options. Being of the female sex has been identified as an independent risk factor for mortality in cardiac surgery. No studies had investigated the relationship between female sex and its associations with the outcomes and procedure of ARR thus far. The investigators in this retrospective, observational study examined the differences between women in men post-ARR with a stentless bioprothesis. The Freestyle bioprothesis (Medtronic) was used in patients across 6 centers in Scandinavia and Western Europe. A total of 884 patients (female n=285, mean age=68 years; men n=599, mean age=64 years) were examined over a median follow-up time of 10 years. In patients who were operated for aortic valve insufficiency, women had significantly lower survival rates (60.7%) compared with men (72.2%, p=0.001) at 14 years, but not for any other indications. Women had more severe pre-operative symptoms in patients who presented with aortic valve insufficiency (AI) or patients who initially had aortic valve stenosis (AS) (p<0.001). No differences were observed between sexes and between different aortic valve pathologies in early outcomes or the need for repeat surgery. Overall, females had more symptoms before surgery regardless of the type of valve lesion and worse outcomes after ARR due to aortic insufficiency, the investigators concluded. In a recent letter to the editor, Khaled Ebrahim Al Ebrahim, MD, Professor of Cardiac Surgery at King Abdulaziz University, Jeddah, Saudi Arabia, elaborated on the importance of noting the substantial differences between sexes in cardiac surgery and interventional cardiology procedures. “To mitigate these disparities, several measures should be adopted: incorporation of sex-specific variables into surgical risk models; tailoring surgical and interventional techniques, including the use of smaller access devices and optimized anesthetic protocols; and implementing targeted perioperative support, particularly for ventilation management and early mobilization,” Dr. Al Ebrahim wrote. Sources: Dagnegård H, Schneider AW, Timmermans PT, et al. Sex difference in aortic root replacement with a stentless bioprothesis. Eur J Cardiothorac Surg. 2025 May 12. https://doi.org/10.1093/ejcts/ezaf161 Al Ebrahim KE. Expanding the evidence: Persistent sex-based disparities across cardiac surgical and interventional procedures. Eur J Cardiothorac Surg. 2025 July (Article in press). Image Credit: Evgenia – stock.adobe.com