Sex‐Based Differences in Long‐Term Outcomes of Patients With Ascending Aortic Dilation

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Background Thoracic ascending aortopathy (AA) is often asymptomatic and incidentally diagnosed, with surgical replacement recommended once it becomes aneurysmal. We report sex‐based characteristics and long‐term outcomes of patients with AA. Methods This study analyzed 14 244 patients (21.1% women) with unrepaired AA (≥4 cm) diagnosed via echocardiography from 2010 to 2023, excluding those with acute aortic dissection/rupture at presentation (n=1179). Baseline data, including height‐indexed measurements (ascending aortic area height index and cross‐sectional area to height ratio), were collected. AA surgery and rates of aortic dissection/rupture during follow‐up were recorded. Cox proportional hazards and Kaplan–Meier survival analysis were performed for all‐cause mortality. Results Women were older (63.6 versus 62.3 years) and had fewer comorbidities, including hypertension, diabetes, coronary artery disease, and dyslipidemia (all P <0.001). However, women had higher height‐indexed aortic measurements (ascending aortic area height index: 2.81 versus 2.59 cm/m; cross‐sectional area to height ratio: 10.3 versus 9.5 cm 2 /m, both P <0.001) and fewer aneurysms ≥5 cm (20.6% versus 22.8%, P =0.04). At 0.86 years, 26.1% underwent surgery, with higher rates in women (28.2% versus 25.6%, P =0.002) and low in‐hospital mortality (0.9%). Over 6.2 years, women had worse survival (14.2% versus 11.2%, log‐rank P <0.001), with female sex independently associated with higher mortality (hazard ratio [HR], 1.14; P <0.001). Aortic surgery improved survival (HR, 0.81; P <0.001). Among unoperated patients (n=10 523), 62.9% of deaths and 72.4% of dissections/ruptures occurred in women with aortic diameters <5 cm. Conclusions Despite fewer comorbidities and higher surgical rates, women with AA had worse long‐term survival. Sex‐specific thresholds for AA surgery may warrant consideration.

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