Female sex is not associated with worse surgical outcomes in infective endocarditis: a prospective study disproving a common assumption.

BACKGROUND

Sex-based disparities in infective endocarditis (IE) have been increasingly recognized, yet their impact on surgical access and outcomes remains controversial. In particular, whether biological sex influences the likelihood of undergoing surgical treatment and the subsequent prognosis of surgical patients remains a subject of debate.

METHODS

This is a single-center, observational, prospective cohort study including 264 consecutive patients diagnosed and treated for IE at a tertiary referral center between January 2023 and December 2025. Among these 264 patients, 194 had an indication for cardiac surgery and 117 finally underwent the operation. Our study included only the group of surgically treated patients. The primary objective was to evaluate the impact of sex on in-hospital mortality following surgery for IE. The secondary objective was to assess the association between sex and mid-term outcomes, defined as a composite endpoint including all-cause mortality, repeat cardiac surgery, hospital readmission for heart failure, or relapse/reinfection of IE within one year from diagnosis. Finally, we investigated whether female sex was associated with reduced surgical access in patients with a formal indication.

RESULTS

A total of 117 patients undergoing cardiac surgery for IE were included: 22 (18.8%) were female. Comorbidities, microbiological etiology and clinical presentation were largely comparable between sexes. The proportion of patients with a formal surgical indication was similar in women and men (67.2% vs. 75.6%, p = 0.175). However, women tended to undergo cardiac surgery less frequently than men (48.9% vs. 63.8%). At univariable analysis female sex emerged as a suggestive factor for reduced access to surgery (OR 0.544, p = 0.076). Overall in-hospital mortality was 12.8% with no significant sex-related differences (9.1% vs. 13.7% in males, p = 0.561). At multivariable analysis, female sex did not emerge as an independent predictor of in-hospital mortality (OR 0.387, p = 0.409) nor mid-term outcomes.

DISCUSSION AND

CONCLUSIONS

This study indicates a potential sex-based disparity in surgical access despite similar clinical indications and survival rates. Our findings challenge the assumption that female sex is associated with worse surgical outcomes, highlighting the need for careful individualized clinical judgment and multidisciplinary discussion to prevent potential treatment disparities.