Sex disparities in elective valve-sparing root replacement: evidence from a multicentre study.

Objectives Sex-related disparities are well established in cardiovascular disease, but their impact on outcomes after valve-sparing root replacement (VSRR) is not well defined. In a multicentre international cohort, we evaluated sex-based differences in clinical characteristics, radiographic features and outcomes after elective VSRR.Methods We retrospectively analysed all patients who underwent VSRR between 2004 and 2024 at three high-volume centres in the United States and Europe. Baseline, operative, and imaging data were compared between sexes. The primary end-point was a composite of all-cause mortality, 30-day cerebrovascular accident, and Zone 0-3 aortic reintervention or aortic valve reintervention. Kaplan-Meier and competing risk analyses were performed, with 4:1 propensity score matching (caliper 0.2) to adjust for baseline imbalances.Results 1'019 patients (191 women, 19%) undergoing VSRR were included in the study. Women were younger (46.7 vs 50.4 years, p = 0.002), more likely to present with heritable thoracic aortic disease (51% vs 17%, p 50 years) than in men (>59 years).Conclusions Only one-fifth of VSRR patients were women, who presented younger with more heritable thoracic aortic disease and smaller absolute aortic diameters. Despite these differences, long-term outcomes were equivalent, suggesting that sex alone does not determine surgical results. Earlier surgical referral guided by indexed aortic measurements may improve recognition and outcomes in women.