Sex Specific Outcome Differences in Congenital Aortic Valve Surgery: A 7-Year High-Volume Center Experience

All articles of this category (opens in new window) Background: Several studies suggest sex differences in surgical aortic valve replacement (SAVR). For bicuspid aortic valves (BAV), differences in prevalence, valvular dysfunction, and aortopathy have been documented. This study analyzed potential sex differences in patients with BAV undergoing aortic valve surgery (AVS). Methods: A prospective clinical database of 482 patients who received elective A vs. from January 2016 to August 2023 was screened for bicuspid ( n = 437, 90.5%) or unicuspid ( n = 45, 9.3%) aortic valves, with or without concomitant aneurysms. Results: Of 482 patients, 348 (72.1%) were male (M) and 134 (27.8%) female (F). Groups differed significantly in age (M:53 ± 15 vs. F:56 ± 12 years, p = .006), body surface area (M:2.06 ± 0.20 vs. F:1.82 ± 0.24 m 2 , p < .001), creatinine (M:1.10 ± 0.47 vs. F:0.87 ± 0.82 mg/dL, p = .008), and LVEF (M:55 ± 10% vs. F:58 ± 8%, p = .003). Incidence ratio of AI vs. AS (AI:158 (45.4%)/AS:156 (44.8%) in M vs. AI:31 (23.1%)/AS:92 (68.7%) in F, p < .001) and primary surgical indication differed between sexes ( p < .001). Men were more likely to present with isolated AI (26.3% vs. 6.0%), women with isolated AS (44.8% vs. 31.0%). Other combinations were less common and showed no major sex differences. Biological SAVR was performed most frequently (62.6%M vs. 74.6%F). AV repair was carried out in 28.2%M vs. 11.9%F. Ross procedure was performed in 4% of male and 7.5% of female patients. Mechanical SAVR was least common (3.2%M vs. 3.0%F, p = .006). Bentall procedure was performed in 6.9% M vs. 1.5% F, David operation in 3.4% M vs. 3.0% F, and a Yacoub procedure in 2.6% M vs. 2.2% F ( p = .253). Concomitant replacement of the ascending aorta was performed in 21.0% of males and 30.6% of females ( p = .026). ICU stay (M:2 ± 2 vs. F:3 ± 2 days, p = .015) and discharge LVEF (M:51 ± 11% vs. F:56 ± 8%, p < .001) were significantly lower in M compared to F. Kaplan–Meier survival at 3 (96% vs. 98%), 5 (95% vs. 97%), and 7 years (93% vs. 97%) was comparable ( p = .196). Reoperations were more frequent in men (9.5% vs. 3.0%, p = .018), mainly due to recurrence of AI after aortic valve repair (64%). At 5 years, freedom from reoperation was 79% in men vs. 92% in women. Conclusion: In BAV patients undergoing AVS, females were older, had lower LVEF, and longer ICU stay. Early and mid-term outcomes were comparable between sexes, with low mortality and excellent survival, while reoperation was more frequent in males due to a higher rate of valve repair. Careful patient selection and long-term follow-up are essential in this subgroup. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany