Long-term results of heart transplantation in females.

Background: Sex-related differences in heart failure (HF) management are well documented, yet data remain scarce regarding how sex influences both short- and long-term outcomes after heart transplantation (HT). Understanding this interaction is crucial to optimize post-transplant care and survival. Methods: We conducted a retrospective analysis of HT recipients at a tertiary center between 1998 and 2022 (n = 464). Patients were stratified by sex (male, 353; female, 111). The primary endpoint was all-cause mortality during follow-up. We compared demographic and clinical characteristics, perioperative outcomes, and long-term survival between groups. Results: Female recipients accounted for 24% of the cohort. They were significantly Younger and had fewer cardiovascular risk factors compared to males. Ischemic cardiomyopathy was the leading cause of HF among men, while women more frequently had non-ischemic etiologies, including chemotherapy-induced and hypertrophic cardiomyopathy. Immediate post-transplant outcomes, including primary graft dysfunction, were similar between sexes, although women had a shorter hospital stay. Over a median follow-up of 13 years, female recipients had significantly better long-term survival (61.4% vs. 45.9%, p = 0.004). After multivariable Cox regression analysis, female sex remained independently associated with better survival (hazard ratio (HR), 0.60 (0.38-0.95); p = 0.030). Although rejection rates and cardiac allograft vasculopathy (CAV) were comparable, causes of death differed: Men had more solid organ malignancies, while women had more hematologic cancers and cardiovascular deaths. Conclusions: Women present a different clinical trajectory than men, with better survival and distinct risks of complications during follow-up. These findings highlight the need to integrate sex-specific perspectives into transplant evaluation and long-term care strategies. Graphical abstract: Central legend presents the differences in survival comparing male and female transplant recipients. Female cohort shows a significantly better survival. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-025-02099-z.