Marco Tomasino, Núria Fernández-Hidalgo, Nahéma Issa, Julien Ternacle, Dmytro Kosovan, Oana Joean, Lorenzo Bertolino, Antonio Fiore, Massimo A Padalino, Pierre Emmanuel Noly, Elisa García Vázquez, Antonio Salsano, Maria Khan, Audrey Le Bot, Carmen Hidalgo-Tenorio, Karel Van Praet, Henrique Moreira, Kristiāns Meidrops, Carmen Olmos, Salvatore Nicolardi, Francesc Escrihuela-Vidal, Daniele Zoni, Josune Goikoetxea Agirre, Elisabet Berastegui, Sara Grillo, Karlos Reviejo Jaka, Manuel Poyato Borrego, Antonia Calvo-Cano, Cristiane Lamas, Gustavo A Méndez, Nedyalko Nedyalkov, Pau Rello, Eduard Ródenas-Alesina, Ignacio Ferreira-González, ESCMID Study Group for Bloodstream Infections, Endocarditis, and Sepsis (ESGBIES), BESOS investigators group
In this large contemporary multinational cohort of patients undergoing surgery for left-sided IE, female sex was independently associated with higher 30-day mortality. The persistence of this association after PSM and multivariable adjustment suggests that the excess risk in women is not fully explained by differences in baseline characteristics, disease presentation, or preoperative severity, highlighting the need to better understand sex-related disparities in surgical IE outcomes.
OBJECTIVES: We aimed to describe sex differences in clinical characteristics and 30-day mortality in a large contemporary cohort of patients undergoing surgery for left-sided IE.
METHODS: The international BESOS (Barcelona Endocarditis Surgery Outcome Score) registry included consecutive patients undergoing surgery for active left-sided IE across 55 centers in 19 countries in 2025. Clinical characteristics and outcomes were prospectively collected. The primary outcome was 30-day mortality. Propensity score 1:1 nearest-neighbor matching (PSM) was performed to generate balanced male and female cohorts. Cox proportional hazards models were used to assess the association between sex and mortality, with adjustment for age, comorbidities and frailty, IE characteristics, and preoperative severity.
RESULTS: Among 1,085 patients undergoing surgery for left-sided IE (median age 65 years, interquartile range 53-73), 239 (22%) were women. Men and women had a similar burden of cardiovascular risk factors and comorbidities, although women exhibited greater frailty (Clinical Frailty Scale ≥7: 22/236 [9%] vs 36/826 [4%]; p=0.01). Women more frequently presented with isolated mitral valve involvement (116/238 [49%] vs 238/845 [29%]) and staphylococcal etiology (86/239 [36%] vs 218/846 [26%]; p=0.03). PSM identified 225 balanced male-female pairs. 30-day mortality was significantly higher in women than in men in both the overall cohort (49/230 [21%] vs 87/822 [11%]; p<0.01) and the matched cohort (45/217 [21%] vs 28/222 [13%]; p=0.02). Female sex remained associated with increased 30-day mortality after adjustment (HR 1.58, 95% CI 1.02-2.45; p=0.04).
CONCLUSIONS: In this large contemporary multinational cohort of patients undergoing surgery for left-sided IE, female sex was independently associated with higher 30-day mortality. The persistence of this association after PSM and multivariable adjustment suggests that the excess risk in women is not fully explained by differences in baseline characteristics, disease presentation, or preoperative severity, highlighting the need to better understand sex-related disparities in surgical IE outcomes.