Indian Journal of Thoracic and Cardiovascular Surgery最新文献

Background: Hypertrophic cardiomyopathy (HCM) is a dynamic disease with a spectrum of clinical presentations ranging from incidental diagnosis to sudden cardiac death. Symptomatic patients are initially managed medically, and newer drugs are currently under investigation. Invasive therapy is needed for patients with intractable symptoms despite maximal medical therapy, and surgical myectomy is the gold standard treatment with better long-term survival.

Results: Over three decades, more than 4000 patients underwent surgical myectomy at the Cleveland Clinic. We conducted a detailed analysis of patients who underwent surgery for HCM between 2005 and 2015. Within this study period, 1549 patients underwent surgical myectomy. Their mean pre-operative peak left ventricular outflow tract (LVOT) gradient was 63 ± 4.6 mmHg, and it reduced to 15 ± 8.9 mmHg after surgery. Mean aortic cross-clamp time was 28 ± 10 min for isolated septal myectomy, and the mean mass of muscle resected was 8.1 ± 3.7 g. Complications include new incidences of pacemaker insertion in 4.2% of the patients, iatrogenic ventricular septal defects in two patients, and the overall operative mortality was 0.38%. Mean hospital stay was 6 days, and the majority of the patients are in New York Heart Association (NYHA) class I in their post-operative follow-up.

Conclusion: Septal myectomy is a curative therapy for most patients of HCM who are symptomatic despite maximal medical management. Clear understanding of individual septal anatomy and mechanisms of LVOT obstruction are key to successful surgical outcomes. Septal myectomy can be done safely with excellent long-term results.

Hypertrophic cardiomyopathy (HCM) is a common, often genetic, cardiomyopathy that is characterized by substantial heterogeneity. Cardiovascular magnetic resonance (CMR), with its high spatial resolution and tomographic imaging capability, has emerged as an imaging modality particularly well suited to characterize the diverse phenotypic expression in this disease. CMR allows for accurate diagnosis of HCM and differentiating HCM from other causes of left ventricular (LV) hypertrophy. CMR plays a critical role in risk stratification and prevention of sudden death in HCM, identifying important risk markers including massive LV hypertrophy, LV apical aneurysms, end-stage HCM, and extensive late gadolinium enhancement, with one or more of these risk markers is associated with a higher risk of sudden death and deserving consideration for primary prevention implanted cardioverter defibrillators. CMR also aids in management of LV outflow obstruction by defining outflow tract anatomy and guiding pre-procedural surgical planning for surgical septal myectomy. The 20-year experience of CMR in HCM has helped transform HCM into a contemporary treatable disease associated with low mortality rates for the vast majority of patients.

There is increasing attention to the contemporary management of hypertrophic cardiomyopathy (HCM), particularly the consequences of obstruction to left ventricular (LV) outflow recognized as largely responsible for heart failure-related limiting symptoms. In this regard, 60-year-old trans aortic surgical myectomy (among the oldest of the open heart operations) has stood the test of time, surviving several major challenges over this extended period, including excessive early mortality, introduction of alcohol septal ablation, dual-chamber pacing, and most recently cardiac myosin/inhibitors. However, myectomy remains a highly effective strategy due to permanent and complete relief of subaortic obstruction and normalization of LV pressure with low operative mortality (≤ 0.5%/year) at experienced centers. As a result, > 90% of operated patients achieve significant relief of disabling heart failure-related symptoms, including restoration of normal daily activity. Myectomy therefore provides young patients with decades of unrestricted lifestyle during which the advantages of surgery can be realized, as well as a long-term survival benefit (including possibly reduced sudden death risk) comparable to an age- and sex-matched general population, offering patients the reasonable expectation for normal if not extended life expectancy with good quality of life.

Development of mitral and tricuspid devices has exploded, although the number of procedures is still limited. Women are under-represented in clinical trials, and in many trials, outcomes are not specified for sex. In mitral and tricuspid trials, the sex distribution is more even than in transcatheter aortic valve implantation (TAVI) trials. In these trials, in general, females are older, have more bleeding complications, and have less kidney injury than men. Procedural results are good. Long-term observation is still not available because of short observation time. In tricuspid procedures, other factors than device success play a role, like right heart failure, pulmonary hypertension, and atrial fibrillation. We should, for the future, focus more on differences in outcome between men and women to better customize treatment options.

Graphical abstract: Transcatheter mitral and tricuspid interventions, outcomes in women. Generated by AI.

Primary mediastinal germ cell tumors represent approximately 10% of all mediastinal tumors and occur predominantly in men; their presentation in women is exceptionally rare. We describe three female patients illustrating the clinical, radiologic, and pathological spectra. Two patients with large anterior mediastinal mature teratomas underwent complete surgical resection and remain disease-free after long-term follow-up, confirming the curative potential of surgery. The third patient presented with a mixed nonseminomatous germ cell tumor composed of yolk sac tumor, mature teratoma, and immature teratoma. After multiple resections and platinum-based chemotherapy regimens, she developed recurrent intrathoracic and central nervous system metastases and died of progressive disease seven and a half years after diagnosis. These cases underscore the curability of completely resected mature teratomas and highlight that nonseminomatous mediastinal germ cell tumors require complex multidisciplinary management but can achieve prolonged survival in selected patients, although outcomes remain historically poor, with 5-year survival rates of 30-50%. Systematic reporting of female primary mediastinal germ cell tumors is critical to refine prognosis and guide management.

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.

This manuscript highlights the persistent underrepresentation of women in the field of cardiothoracic surgery, despite increasing participation of females in medical training worldwide. It traces the historical milestones of pioneering women, illustrating the long-standing barriers faced by women in surgery. Globally, women still constitute a small fraction of practicing cardiothoracic surgeons in leadership, academic, and research roles. The literature demonstrates ongoing gender disparities in remuneration, mentorship, and career advancement, compounded by gender bias, stereotypes, and workplace toxicity. Despite these challenges, recent trends show increasing female involvement in scientific meetings, publications, and mentorship programmes, as well as suggesting that female surgeons often achieve superior surgical outcomes. The paper also emphasises critical global health needs, especially in low-resource settings where access to cardiothoracic care remains severely limited, and advocates for greater international collaboration, training, and remote education initiatives. The complex interplay of work-life balance challenges faced by women, highlighting the sacrifices necessary for a career in this demanding specialty, is discussed. Recognising the societal and healthcare benefits of diversifying the surgical workforce, the author calls for concerted efforts to address gender biases, promote mentorship, and expand opportunities for female cardiothoracic surgeons to better serve global populations, particularly in underserved regions worldwide.

Mitral valve disease (MVD) remains a prevalent cardiac condition and a leading cause of morbidity and mortality globally. Sex-based disparities have been observed in the MVD in terms of clinical presentation, surgical management, and postoperative outcomes. Thereby, women often face delayed referral, more complex valvular pathology, and worse postoperative prognosis. Minimally invasive mitral valve surgery (MIMVS) has gained widespread acceptance as an alternative to traditional median sternotomy in the surgical management of MVD, offering advantages such as reduced surgical trauma, quicker recovery, and improved cosmetic results. Despite the promising results of minimally invasive surgical techniques, compared to conventional sternotomy, studies investigating the correlation between different surgical approaches and female sex are lacking. In this narrative review, we summarize the current evidence regarding sex-related differences in the management and treatment of MVD, with particular attention to MIMVS using the Port-Access system. We emphasize the importance of incorporating sex-specific considerations into both surgical planning and broader clinical decision-making.

Cardiothoracic surgery in India started with the beginnings of thoracic and closed heart surgery in the 1940s. Surgery in children has been a part of the story since inception and has reached the current exalted status of pediatric cardiothoracic surgery. The journey was arduous amidst formidable challenges that were overcome with immense courage and perseverance of the pioneers. The women have been a part of the journey entering the challenging field of cardiothoracic surgery and rose to high positions. There is not much published work in India from the early years making the history largely oral, anecdotes told and retold by the legends themselves, stray papers, and the occasional preserved hospital records. The review explores the journey of the pioneering years from 1961 onwards when the first open heart surgery was performed. The time frame has been split into three parts demarcated by specific interventions, not all necessarily related to surgery. Some challenges from the past have been overcome; few have taken a new shape even as others loom large in the horizon.