Sex-based differences in long-term outcomes of patients with ascending aortic dilation

Abstract Background Ascending aortopathy (AA) is mostly asymptomatic and often incidentally diagnosed with a guideline recommendation of surgical aortic graft replacement once it becomes aneurysmal. Differences in long-term outcomes in such patients, based on sex, are uncertain. Objective We sought to evaluate clinical characteristics and differences in long-term outcomes of patients with AA, based on sex. Methods We included 14,244 patients with an unrepaired AA (≥4 cm), diagnosed on echocardiography between 1/2010 and 12/2023 at our large tertiary referral center. We excluded patients presenting with an acute aortic dissection/rupture as an initial presentation (n=1179). Clinical (including aortic surgery/dissection/rupture during follow-up) and maximal ascending aortic measurements on echocardiography data was collected. Primary outcome was all-cause mortality. Results Characteristics of patients, separated on basis of sex, are shown in Figure 1A. Women were slightly older but had significantly lower proportion of baseline comorbidities (Figure). At 0.86±2.2 years from initial evaluation, 3721 (26.1%) patients underwent surgical AA replacement (843 28.2% women vs. 2878 25.6% men, p=0.002) with 33 (0.9%) in-hospital mortality. At 6.2±4.3 years of follow-up, there were 1690 (11.9%) deaths, higher in women (426 14.2% women vs. 1264 11.2% men, log-rank statistic 14.5, p0.001, Figure 1B). Similarly, a higher proportion of women presented with aortic dissections during follow-up (Figure 1A). On multivariable Cox survival analysis (Hazard ratio or HR 95% confidence interval or CI), female sex (1.14 1.07-1.21), in addition to age (2.01 1.90-2.14), atrial fibrillation (1.12 1.01-1.24) chronic pulmonary disease (1.92 1.79-2.18), chronic kidney disease (1.60 1.44-1.76), maximal AA diameter (HR 1.20 1.11-1.30) and lower left ventricular ejection fraction (1.03 1.02-1.04), was associated with worse long-term survival, while AA replacement surgery (0.81 0.70-0.93) was associated with improved survival (all p0.01). Conclusions Despite lower co-morbidities, similar AA size at presentation, a lower proportion of aneurysms (≥5 cm) and a higher proportion undergoing aortic replacement surgery, longer-term survival and freedom from aortic dissection in women were significantly worse compared to men, independent of other co-morbidities. This might be related to under-recognition of a higher AA diameter (or area) relative to height. There is a need to re-evaluate AA size thresholds for surgical timing, based on sex and height.1A:Clinical characteristics based on sex 1B:Kaplan-Meier curve, based on sex