Our analysis represents a large, single-center series of patients who underwent ascending aortic surgery for AscAA between 2001 and 2021. At the time of surgery, women were older, had significantly larger aneurysmal diameters, higher EuroSCOREs, had more frequent aortic regurgitation, were more often intubated prior to surgery and had higher left ventricular ejection fraction. On the other hand, men were younger and had more frequent bicuspid aortic valves, aortic stenosis, coronary artery disease, and chronic renal insufficiency.

After PSM, only the EuroSCORE, and the indexed aortic diameter were significantly higher in female patients.

Similar to recently published data [8, 14,15,16,17], women are more likely to present later in life, with a significantly larger indexed aortic diameter or absolute aneurysm diameter. This is crucial in highlighting the seriousness of aneurysmal progression in women and their underestimated risk in the current practice. The observed differences in indexed aortic diameter in our cohort support the notion that while females have smaller aortas, the onset of the disease maybe later in life after the menopause, and the nature of the progression maybe more incipient when compared to their male counterparts. This can be further supported by the fact the male patients have more cardiovascular comorbidities and therefore, they might have undergone more regular medical evaluation. These findings emphasize the need for increased awareness and tailored management strategies for women with AscAA.

Historically, female patients had higher cardiovascular risk and later presentation with more advanced disease [18,19,20]. It is unclear, however, whether female patients have comparable outcome profiles to their male counterparts after AscAA repair.

For patients with no elastopathies, the AscAA threshold for surgery has been established at a diameter of 55 mm [9, 10]. In light of recently published data and risk stratification studies, there was an evident trend toward lowering the threshold for AscAA surgery to 50 mm [10]. Nonetheless, few reports advocate for indexing aortic diameter to body surface area or patient’s height, which has been recommended only for patients who are significantly taller or shorter than average [10, 21]. Such differences are not accounted for in current practice and cannot be explored by analysis of patients who actually undergo the surgery.

As their surgery is indicated later in the disease course, published results [14, 15] demonstrated a higher tendency for arch involvement in women. In contrast, we did not observe any difference between both sexes in terms of indicated extended arch replacement. In line with Beller’s and Voigt’s results [14, 15], an isolated supra-coronary aortic replacement was more frequent in women in our cohort, while men tended to undergo more frequent aortic root replacement.

Similar to intraoperative data of other centres [8, 15, 17], men in our cohort had consistently longer operative, cardiopulmonary bypass, and/or aortic cross-clamp times. This difference disappeared after controlling for concomitant procedures, which are indicated more frequently in men across studies such as concomitant CABG as in our male subgroup due to a greater incidence of coronary artery disease or valve replacement [8, 15, 17]. Despite their comparable operation times and less complex surgery, women received more intraoperative blood transfusions with significant difference after PSM. Several studies reported higher transfusion rates, lower preoperative haemoglobin or haematocrit levels prior to cardiovascular surgery and a higher degree of haemodilution on cardiopulmonary bypass in women compared to men [22,23,24,25], which may explain this intraoperative discrepancy in our study. It`s noteworthy that Mehta et al. [24] in a large analysis on 13,739 patients undergoing cardiac surgery, suggest that women have a better tolerance to haemodilution and that specific thresholds for blood transfusions in women may reduce its harmful effects.

Men developed a postoperative delirium and more neurological deficits. This is in line with the findings of Wang et al. [26] showing that male gender is an important predictor for postoperative delirium following cardiac surgery.

In our large cohort, we did not observe differences in mortality rates following surgery or in long-term survival between both sexes. Still, Kampen and colleagues [8] highlighted a significant four-fold higher in-house mortality in women. Such a finding emphasizes the consequence of the delayed indication for surgery in the women subpopulation.

Parallel to our results, in-hospital and short-term mortality following proximal aortic surgery was similar between both sexes in most of the published results [14,15,16, 22]. However, long-term survival was inconsistent in the literature, with some studies showing significantly lower survival in women [8, 14, 15], while others reporting no significant difference between both sexes [16, 22, 27]. Patients in our series had similar survival probability throughout and at 15 years of follow-up. In studies that included only patients with AscAA [8, 14, 15], Kaplan Meier analysis showed significantly lower long-term survival in women when compared to men. In our analysis, women tended to have lower long-term survival, Fig. 1, however, the results did not reach statistical significance.

The previously mentioned data regarding the relationship between sex and survival after proximal aortic surgery point out the higher risk in women, following the same pattern in other cardiovascular surgeries [18,19,20]. Nonetheless, it also encourages a deeper investigation into the specific preoperative characteristics of women, that could impact their preoperative screening, assessment, and surgery planning.