Are Women at Higher Risk for Isolated Surgical Aortic Valve Replacement? An Analysis of 170,000+ Patients

T. Ogami¹, D. Serna-Gallegos², C. E.. Diaz-Castrillon³, I. Hasan⁴, J. Phillippi², I. Sultan^2
1University of Pittsburgh Medical Center, Erie, Pennsylvania ²University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania ³University of Pittsburgh Medical Center, Hummelstown, Pennsylvania ⁴Cedars Sinai Medical Center, Los Angeles, California

Purpose: Female gender is a well-known risk factor for morbidity and mortality in cardiac surgery. This study aimed to assess the characteristics and contemporary outcomes of surgical aortic valve replacement (SAVR) in women compared to men.

Methods: All patients who underwent isolated SAVR from 2014 through 2022 were identified using the Society of Thoracic Surgery national database. Patient characteristics were compared between women and men. Propensity score matching was used to adjust the differences in characteristics between them. The selected variables for propensity score calculation included age, annular enlargement, renal function, body surface area, ejection fraction, infective endocarditis, the Society of Thoracic Surgeons Predicted Risk of Mortality, a history of myocardial infarction, urgent or emergent status, and indication for aortic valve stenosis. The primary interest of outcomes was operative mortality. The yearly trend in valve choice was evaluated.

Results: A total of 178,014 patients undergoing isolated SAVR were identified, including 64,684 36.3%) women and 113,330 (63.7%) men. Women were older (66.1 years vs. 63.6 years in men, SMD = 0.21) and had smaller body surface area (1.84 m2 vs. 2.09 m2 in men, SMD = 1.15). A history of infective endocarditis was more common in men (10.5% vs. 5.4% in women, SMD = 0.19). Women were more likely to undergo annular enlargement (8.4% vs. 2.9% in men, SMD = 0.24). Despite the baseline differences between the two cohorts, unadjusted risk of operative mortality was similar (2.4% in women vs. 1.7% in men, SMD = 0.05). Propensity score matching yielded 35,241 pairs in each sex. After the matching, operative mortality was comparable between sexes (2.1% in women vs. 1.8% in men, SMD = 0.02). Likewise, the rest of the complications were similarly observed between the groups (Figure). Among women, the use of mechanical valve was 10.9% (n = 564) in 2014 versus 18.8% (n = 1078) in 2022 (P = .01).

Conclusion: Women undergoing isolated SAVR demonstrated similar morbidity and mortality compared to men despite having smaller body surface area and higher frequency of annular enlargement. Given the improved outcomes with contemporary practice in SAVR, sex may no longer be a risk factor for worse outcomes in isolated SAVR.

Identify the source of the funding for this research project: None