{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T18:17:20Z","timestamp":1760552240270,"version":"3.41.2"},"reference-count":28,"publisher":"Oxford University Press (OUP)","issue":"6","license":[{"start":{"date-parts":[[2025,5,12]],"date-time":"2025-05-12T00:00:00Z","timestamp":1747008000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,6,3]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>OBJECTIVES<\/jats:title>\n                  <jats:p>To investigate and quantify differences in survival and reinterventions between sexes after aortic root replacement with a stentless bioprosthesis, stratified for preoperative valve lesion.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>METHODS<\/jats:title>\n                  <jats:p>Elective adults undergoing aortic root replacement with the Freestyle bioprosthesis at six North-Atlantic centres were included. Survival analyses were performed using the Kaplan\u2013Meier method or Aalen-Johansen with death as competing risk as relevant. Results were quantified using uni- and multivariable Cox regression tested using a log-rank likelihood ratio test.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>RESULTS<\/jats:title>\n                  <jats:p>In total, 884 patients were analysed for a median follow-up time of 10\u2009years. Females were 4\u2009years older. Survival was significantly worse in females operated for aortic valve insufficiency [60.7% and 72.2% for females and males at 14\u2009years, respectively (P\u2009=\u20090.001)], but not for the other indications, even after correction for age. There were no differences in early outcomes or need for reoperation between the sexes and between the different aortic valve pathologies.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>CONCLUSIONS<\/jats:title>\n                  <jats:p>Sex difference in survival outcomes depends on pathology, and females have, compared to males, more symptoms preoperatively regardless of type of valve lesion and worse outcome after aortic root replacement due to aortic insufficiency. Updated surgical risk scores should account for interaction between sex and pathology, and the surgical community must raise awareness on risk of patient\u2019s or doctors delay to surgery.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ejcts\/ezaf161","type":"journal-article","created":{"date-parts":[[2025,5,12]],"date-time":"2025-05-12T20:35:16Z","timestamp":1747082116000},"source":"Crossref","is-referenced-by-count":1,"title":["Sex difference in aortic root replacement with a stentless bioprosthesis"],"prefix":"10.1093","volume":"67","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0363-7472","authenticated-orcid":false,"given":"Hanna","family":"Dagneg\u00e5rd","sequence":"first","affiliation":[{"name":"Department of Cardiothoracic Surgery, Rigshospitalet , Copenhagen,","place":["Denmark"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6404-0242","authenticated-orcid":false,"given":"Adriaan W","family":"Schneider","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,","place":["The Netherlands"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick T","family":"Timmermans","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,","place":["The Netherlands"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4386-1041","authenticated-orcid":false,"given":"Natalie","family":"Glaser","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Stockholm South General Hospital , Stockholm,","place":["Sweden"]},{"name":"Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm,","place":["Sweden"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Solveig M","family":"Kolseth","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Haukeland University Hospital , Bergen,","place":["Norway"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1005-091X","authenticated-orcid":false,"given":"Farkas","family":"Vanky","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Link\u00f6ping University Hospital , Link\u00f6ping,","place":["Sweden"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomas","family":"Gudbjartsson","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, University Hospital , Reykjavik,","place":["Iceland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rune","family":"Haaverstad","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Haukeland University Hospital , Bergen,","place":["Norway"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alex","family":"Cotovanu","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,","place":["The Netherlands"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2707-0263","authenticated-orcid":false,"given":"Ulrik","family":"Sartipy","sequence":"additional","affiliation":[{"name":"Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm,","place":["Sweden"]},{"name":"Department of Cardiothoracic Surgery, Karolinska University Hospital , Stockholm,","place":["Sweden"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert J M","family":"Klautz","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,","place":["The Netherlands"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morten","family":"Smerup","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Rigshospitalet , Copenhagen,","place":["Denmark"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6722-918X","authenticated-orcid":false,"given":"Jesper","family":"Hjortnaes","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Leiden University Medical Center , Leiden,","place":["The Netherlands"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"North Atlantic Freestyle Collaboration","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jesper","family":"Hjortn\u00e6s","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Klautz","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jerry","family":"Braun","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morten","family":"Smerup","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nikolaj","family":"Ihlemann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"H Gustav H","family":"Thyregod","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jens T","family":"Lund","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ulrik","family":"Sartipy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rune","family":"Haarverstad","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Farkas","family":"Vanky","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomas","family":"Gudbjartsson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jan Brink","family":"Valentin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"S\u00f8ren Paaske","family":"Johnsen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adriaan","family":"Schneider","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick","family":"Timmemanns","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alex","family":"Cotovanu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hanna","family":"Dagneg\u00e5rd","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kirstine","family":"Bekke","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jannie","family":"Lind","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nathalie","family":"Glaser","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Solveig Moss","family":"Kolseth","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"J\u00f8rgen Brekke","family":"Vennemo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Asbj\u00f8rn","family":"Lie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christoffer","family":"Wall\u00e9n","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"H\u00f6r\u00f0ur Ingi","family":"Gunnarsson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2025,5,12]]},"reference":[{"key":"2025060915514484500_ezaf161-B1","doi-asserted-by":"crossref","first-page":"e014733","DOI":"10.1161\/JAHA.119.014733","article-title":"Sex differences in symptom presentation in acute coronary syndromes: a systematic review and meta-analysis","volume":"9","author":"van Oosterhout","year":"2020","journal-title":"J Am Heart Assoc: Cardiovasc Cerebrovasc Dis"},{"key":"2025060915514484500_ezaf161-B2","doi-asserted-by":"crossref","first-page":"1506","DOI":"10.1016\/j.jacc.2021.08.081","article-title":"Sex-related factors in valvular heart disease JACC focus seminar 5\/7","volume":"79","author":"Hahn","year":"2022","journal-title":"J Am Coll Cardiol"},{"key":"2025060915514484500_ezaf161-B3","first-page":"505","article-title":"Sex-based differences in heart failure across the ejection fraction spectrum phenotyping, and prognostic and therapeutic implications","volume":"7","author":"Stolfo","year":"2019","journal-title":"JACC: Hear Fail"},{"key":"2025060915514484500_ezaf161-B4","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1093\/icvts\/ivab191","article-title":"Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis","volume":"33","author":"Robinson","year":"2021","journal-title":"Interact CardioVasc Thorac Surg"},{"key":"2025060915514484500_ezaf161-B5","doi-asserted-by":"crossref","first-page":"e058538","DOI":"10.1136\/bmjopen-2021-058538","article-title":"Sex differences in risks of in-hospital and late outcomes after cardiac surgery: a nationwide population-based cohort study","volume":"12","author":"Chang","year":"2022","journal-title":"BMJ Open"},{"key":"2025060915514484500_ezaf161-B6","doi-asserted-by":"crossref","first-page":"734","DOI":"10.1093\/ejcts\/ezs043","article-title":"EuroSCORE II","volume":"41","author":"Nashef","year":"2012","journal-title":"Eur J Cardio-Thorac Surg"},{"key":"2025060915514484500_ezaf161-B7","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1016\/j.athoracsur.2018.03.003","article-title":"The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 2\u2014statistical methods and results","volume":"105","author":"O\u2019Brien","year":"2018","journal-title":"Ann Thorac Surg"},{"key":"2025060915514484500_ezaf161-B8","first-page":"699","article-title":"Sex-related differences in the extent of myocardial fibrosis in patients with aortic valve stenosis","volume":"13","author":"Tastet","year":"2020","journal-title":"JACC: Cardiovasc Imaging"},{"key":"2025060915514484500_ezaf161-B9","doi-asserted-by":"crossref","first-page":"4100","DOI":"10.3390\/jcm9124100","article-title":"Sex differences in left ventricular remodeling and outcomes in chronic aortic regurgitation","volume":"9","author":"Kammerlander","year":"2020","journal-title":"J Clin Med"},{"key":"2025060915514484500_ezaf161-B10","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1161\/CIRCRESAHA.116.309306","article-title":"Sex-related discordance between aortic valve calcification and hemodynamic severity of aortic stenosis","volume":"120","author":"Simard","year":"2017","journal-title":"Circ Res"},{"key":"2025060915514484500_ezaf161-B11","doi-asserted-by":"crossref","first-page":"1897","DOI":"10.1016\/j.jacc.2020.02.065","article-title":"Transvalvular flow, sex, and survival after valve replacement surgery in patients with severe aortic stenosis","volume":"75","author":"Guzzetti","year":"2020","journal-title":"J Am Coll Cardiol"},{"key":"2025060915514484500_ezaf161-B12","doi-asserted-by":"crossref","first-page":"1186","DOI":"10.1016\/j.athoracsur.2022.05.039","article-title":"Sex-related differences after proximal aortic surgery: outcome analysis of 1773 consecutive patients","volume":"116","author":"Kampen","year":"2023","journal-title":"Ann Thorac Surg"},{"key":"2025060915514484500_ezaf161-B13","doi-asserted-by":"crossref","first-page":"1177","DOI":"10.1161\/CIRCULATIONAHA.118.035805","article-title":"Sex-related differences in patients undergoing thoracic aortic surgery","volume":"139","author":"Chung","year":"2019","journal-title":"Circulation"},{"key":"2025060915514484500_ezaf161-B14","doi-asserted-by":"crossref","first-page":"6327","DOI":"10.3390\/jcm12196327","article-title":"Comparative study of male and female patients undergoing frozen elephant trunk total arch replacement","volume":"12","author":"Benk","year":"2023","journal-title":"J Clin Med"},{"key":"2025060915514484500_ezaf161-B15","doi-asserted-by":"crossref","first-page":"e006370","DOI":"10.1161\/JAHA.117.006370","article-title":"Sex differences in the utilization and outcomes of surgical aortic valve replacement for severe aortic stenosis","volume":"6","author":"Chaker","year":"2017","journal-title":"J Am Hear Assoc: Cardiovasc Cerebrovasc Dis"},{"key":"2025060915514484500_ezaf161-B16","doi-asserted-by":"publisher","first-page":"1712","DOI":"10.1016\/j.jtcvs.2021.07.011","article-title":"Survival after aortic root replacement with a stentless xenograft is determined by patient characteristics","volume":"164","author":"Dagneg\u00e5rd","year":"2022","journal-title":"J Thorac Cardiovasc Surg"},{"key":"2025060915514484500_ezaf161-B17","doi-asserted-by":"crossref","first-page":"1272","DOI":"10.1093\/ejcts\/ezx478","article-title":"Twenty-year experience with stentless biological aortic valve and root replacement: informing patients of risks and benefits","volume":"53","author":"Schneider","year":"2018","journal-title":"Eur J Cardio-Thorac Surg"},{"key":"2025060915514484500_ezaf161-B18","doi-asserted-by":"crossref","first-page":"ezae020","DOI":"10.1093\/ejcts\/ezae020","article-title":"Advanced considerations in survival analysis","volume":"65","author":"Carnero-Alc\u00e1zar","year":"2024","journal-title":"Eur J Cardio-Thorac Surg"},{"key":"2025060915514484500_ezaf161-B19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1093\/icvts\/ivy010","article-title":"Statistical primer: basics of survival analysis for the cardiothoracic surgeon","volume":"27","author":"Thuijs","year":"2018","journal-title":"Interact CardioVasc Thorac Surg"},{"key":"2025060915514484500_ezaf161-B20","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1093\/ejcts\/ezv168","article-title":"Statistical and data reporting guidelines for the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery","volume":"48","author":"Hickey","year":"2015","journal-title":"Eur J Cardiothorac Surg"},{"key":"2025060915514484500_ezaf161-B21","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1016\/0197-2456(96)00075-X","article-title":"A note on quantifying follow-up in studies of failure time","volume":"17","author":"Schemper","year":"1996","journal-title":"Control Clin Trials"},{"key":"2025060915514484500_ezaf161-B22","doi-asserted-by":"crossref","first-page":"452","DOI":"10.1016\/j.pcad.2020.06.004","article-title":"Sex differences in bicuspid aortic valve disease","volume":"63","author":"Kong","year":"2020","journal-title":"Prog Cardiovasc Dis"},{"key":"2025060915514484500_ezaf161-B23","first-page":"e72","article-title":"2020 ACC\/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"143","author":"Otto","year":"2021","journal-title":"Circulation"},{"key":"2025060915514484500_ezaf161-B24","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1093\/eurheartj\/ehab395","article-title":"2021 ESC\/EACTS guidelines for the management of valvular heart disease","volume":"43","author":"Vahanian","year":"2022","journal-title":"Eur Hear J"},{"key":"2025060915514484500_ezaf161-B25","doi-asserted-by":"crossref","first-page":"1010","DOI":"10.1111\/jocs.14523","article-title":"Sex-related difference in outcomes after aortic root replacement","volume":"35","author":"McMullen","year":"2020","journal-title":"J Card Surg"},{"key":"2025060915514484500_ezaf161-B26","first-page":"72","article-title":"Aortic root dimensions among patients with severe aortic stenosis undergoing transcatheter aortic valve replacement","volume":"6","author":"Buellesfeld","year":"2013","journal-title":"JACC: Cardiovasc Interv"},{"key":"2025060915514484500_ezaf161-B27","doi-asserted-by":"crossref","first-page":"e018816","DOI":"10.1161\/JAHA.120.018816","article-title":"Excess mortality and undertreatment of women with severe aortic stenosis","volume":"10","author":"Tribouilloy","year":"2021","journal-title":"J Am Hear Assoc"},{"key":"2025060915514484500_ezaf161-B28","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1053\/j.semtcvs.2022.01.002","article-title":"Male-female differences in ascending aortic aneurysm surgery: 25-year single center results","volume":"35","author":"Voigt","year":"2023","journal-title":"Semin Thorac Cardiovasc Surg"}],"container-title":["European Journal of Cardio-Thoracic Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ejcts\/advance-article-pdf\/doi\/10.1093\/ejcts\/ezaf161\/63158131\/ezaf161.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ejcts\/article-pdf\/67\/6\/ezaf161\/63158131\/ezaf161.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ejcts\/article-pdf\/67\/6\/ezaf161\/63158131\/ezaf161.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,9]],"date-time":"2025-06-09T19:51:55Z","timestamp":1749498715000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ejcts\/article\/doi\/10.1093\/ejcts\/ezaf161\/8129046"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,12]]},"references-count":28,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2025,6,3]]}},"URL":"https:\/\/doi.org\/10.1093\/ejcts\/ezaf161","relation":{},"ISSN":["1873-734X"],"issn-type":[{"type":"electronic","value":"1873-734X"}],"subject":[],"published-other":{"date-parts":[[2025,6]]},"published":{"date-parts":[[2025,5,12]]},"article-number":"ezaf161"}}