Unequal Benefits: Sex-Specific Outcomes After Minimally Invasive Ascending Aortic Surgery

All articles of this category (opens in new window) Background: Minimally invasive techniques have become increasingly important in the surgery of the aortic valve, root, and ascending aorta and have been proven to be beneficial, especially concerning postoperative time-of-stay and transfusion requirements. However, evidence regarding predictors of postoperative outcomes, particularly concerning sex-specific differences, remains scarce. Methods: We conducted a retrospective single-center analysis with prospective follow-up of 387 patients undergoing minimally invasive supracoronary ascending aorta replacement, Wheat, David, or Bentall procedures via upper hemisternotomy. A multivariate linear model was applied to identify predictors of prolonged intensive care unit (ICU) stay. To assess the influence of sex on perioperative complications, outcomes, and survival, a propensity score-matched analysis including 120 women and 120 men was performed. Short-term outcome and in-hospital complication rates were compared, as well as long-term survival, which was evaluated via our outpatient clinic and analyzed using the Kaplan–Meier analysis. Results: Female sex and older age were identified as independent predictors of longer postoperative ICU stay. After propensity score matching, female patients showed a significantly higher perioperative stroke rate compared to men (8.3% vs. 1.7%, p = 0.018). Although the operation times were significantly shorter in women (median 225 minutes [IQR: 190–268] vs. 262 minutes [IQR: 221–309], p < 0.001), female patients required more intra- and postoperative erythrocyte transfusions (median 4 [IQR: 2–5] vs. 2 [IQR: 0–4], p < 0.001). No significant sex-related differences were observed in short- or long-term survival. Conclusion: Sex significantly influences outcomes after minimally invasive ascending aortic surgery. Parameters previously associated with the benefits of minimally invasive approaches, such as shorter ICU stay and reduced transfusion requirements, appear less favorable in women, showing worse short-term outcomes with significantly higher stroke rates compared to men. This evidence calls for sex-specific decision-making when considering minimally invasive techniques. Further investigations are needed to determine the factors responsible for the higher rate of postoperative complications in women. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany