Clinical outcomes after biological aortic root replacement: evaluating gender-based differences

Objective: Gender disparities in cardiovascular outcomes remain underexplored in complex valvular procedures such as aortic root replacement (ARR). This study evaluates sex-based differences in early postoperative outcomes and long-term survival following biological ARR using stentless or bio-Bentall techniques. Methods: A retrospective analysis of 291 patients (202 males and 89 females) who underwent biological ARR between 2003 and 2023 was performed. Propensity score matching yielded 79 gender-matched pairs. Preoperative, intraoperative, and postoperative variables were compared. Cox regression identified predictors of long-term mortality. Results: Before matching, females were older and had higher logistic EuroSCORE, more severe NYHA class, and greater renal impairment. Bio-Bentall procedures were more frequent in males. After matching, males had higher rates of permanent pacemaker implantation (10.1% vs. 0%; p = 0.004), while females had significantly higher in-hospital mortality (12.7% vs. 2.5%; p = 0.016). No significant sex differences were observed in atrial fibrillation, low cardiac output syndrome, or tracheostomy. Ten-year survival was comparable (female: 79.2%; male: 74.3%; p = 0.792). Independent predictors of late mortality included peripheral vascular disease (HR 2.652; p = 0.005), previous cardiac surgery (HR 2.684; p = 0.002), and age (HR 1.044/year; p < 0.001). Gender was not associated with late mortality (HR 1.368; p = 0.368). Conclusions: Although long-term survival was similar, women experienced significantly higher early mortality following ARR. These findings underscore the need for further investigation into sex-specific vulnerabilities and perioperative optimization strategies tailored to female patients undergoing biological ARR.