Sex Differences in Outcomes After Elective and Acute Aortic Surgery—A Single-Centre Experience over the Last Two Decades

<b>Background/Objectives:</b> Recent studies show conflicting results regarding sex-related differences in outcomes following aortic surgery. This study primarily evaluated 20-year mortality rates, along with 30-day and one- and five-year rates, and postoperative complications in female and male patients who underwent elective and acute ascending aortic surgery at a tertiary care centre. <b>Methods:</b> This retrospective observational study analysed data from 676 adult patients who underwent ascending aortic surgery in Amsterdam UMC, between January 2001 and December 2020. Descriptive statistics, Fisher's Exact test, Kaplan-Meier survival analysis, and logistic regression were used to assess differences in mortality rates. <b>Results:</b> Patient characteristics for elective and acute procedures were different. Females were generally older (elective: 69 vs. 62 years, <i>p</i> < 0.001, acute: 70 vs. 62 years, <i>p</i> = 0.002), with smaller body surface area (elective/acute: 1.8 vs. 2.1 m², <i>p</i> < 0.001), lower preoperative haemoglobin (elective: 8.3 vs. 8.9 mmol/L, <i>p</i> < 0.001, acute: 7.8 vs. 8.4 mmol/L, <i>p</i> < 0.001) and estimated glomerular filtration rate (elective: 64 vs. 91 mL/min, <i>p</i> < 0.001; acute: 67 vs. 83 mL/min, <i>p</i> = 0.004). Females undergoing elective procedures had a lower body mass index (25.0 vs. 26.6 kg/m², <i>p</i> = 0.006), better left ventricle function (<i>p</i> = 0.048) and higher incidence of chronic obstructive pulmonary disease (15 vs. 8%, <i>p</i> = 0.032). In elective procedures, the 20-year mortality rate (49% vs. 30%, <i>p</i> < 0.001) was significantly higher in females, especially those under 60 years (OR of 3.158 [1.2-8.6], <i>p</i> = 0.024). Mortality rates up to one year were comparable. Five-year mortality rate (26% vs. 16%, <i>p</i> = 0.027) was higher. Females had longer ventilation times (32% vs. 15%, <i>p</i> < 0.001) and intensive care unit stays (2 vs. 1 days, <i>p</i> = 0.005). For acute procedures, morbidity and mortality rates were comparable between sexes. <b>Conclusions:</b> Females under 60, undergoing elective ascending aortic surgery showed higher long-term all-cause mortality rates. Implementing sex-specific management strategies and extended follow-up could be essential for improving outcomes in this group.