Indian Journal of Thoracic and Cardiovascular Surgery最新文献

Rheumatic heart disease (RHD) remains a significant public health concern in India, disproportionately affecting women in the child-bearing age. Delayed diagnosis, limited awareness, and inadequate access to specialized cardiac care, contribute to advance disease presentation and poor outcome. Despite the availability of early detection tools and effective antibiotic prophylaxis, many Indian women are diagnosed at the late stages, necessitating complex surgical interventions such as balloon valvuloplasty, valve repair, or valve replacement. Surgical management presents unique challenges particularly regarding the choice between the mechanical and bioprosthetic valves, as the former requires lifelong anticoagulation therapy which poses risk during pregnancy. Socioeconomic impacts of RHD on women include not only financial constraints and loss of productivity but also significant disparities in healthcare access which further hinder timely and effective treatment. This narrative review will provide the comprehensive overview of the current state of research in a specific field and would explore the multifaceted surgical implications of RHD in Indian woman, and would also address demographic consideration, including the age of onset; clinical, reproductive, and hormonal factors; and socio-economic dimensions which influence disease progression and surgical outcomes. It also emphasizes the importance of early screening programs, tailored surgical strategies, and a multidisciplinary approach to care including preconception counselling and postoperative follow-up to improve outcomes. Addressing these gaps is essential to reduce the morbidity and mortality, and enhancing the overall quality of life for woman affected with RHD in India.

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-025-02068-6.

Cardiothoracic surgery is one of the most gender-imbalanced specialties, with women representing less than 10% of the workforce worldwide. Despite a notable increase in recruitment and certification into the specialty in recent years, the disproportion is still notable and there is no expectation for that gap to be reduced in the next decades. Women in cardiothoracic surgery experience unique challenges such as inherited bias, discrimination, sexual misconduct, and extreme imbalance in work-life balance, especially around pregnancy and childcare. These challenges are not only important during recruitment into the specialty and training but continue throughout the whole surgical career. Despite recent efforts from surgical societies worldwide to augment women in cardiothoracic visibility and support, a lot of work is needed to facilitate the path for future generations.

Cardiovascular disease remains the leading global cause of death, with coronary artery bypass grafting (CABG) serving as the gold standard for managing complex coronary artery disease. Despite advancements in surgical techniques and perioperative care, women undergoing CABG continue to face poorer outcomes compared to men, including higher operative and long-term mortality, greater rates of graft failure, and an increased incidence of postoperative complications such as stroke and sternal wound infections. Women also exhibit higher readmission rates, worse recovery trajectories, and lower quality of life after surgery. The underlying factors contributing to these disparities are multifactorial. Women typically present with advanced age, a higher burden of cardiovascular risk factors, and smaller coronary artery and graft diameters, all of which pose technical challenges and may reduce graft patency. Additionally, socioeconomic barriers, delayed diagnoses due to atypical symptom presentation, and lower utilization of evidence-based secondary prevention strategies widen the outcome gap. Efforts to address these disparities must include greater representation of women in clinical trials, as well as designing trials dedicated to women, as emphasized by the Randomized Comparison of the Clinical Outcome of Single vs Multiple Arterial Grafts: Women (ROMA: Women) and Revascularization Choices Among Under-Represented Groups Evaluation (RECHARGE) trials. Future strategies should prioritize personalized cardiac care, optimize surgical approaches tailored to sex-specific anatomy, and strengthen secondary prevention adherence in women.

Background: While gender-based disparities in coronary artery bypass grafting (CABG) outcomes are well established, there is limited evidence on the influence of gender on the selection and outcomes of bilateral internal mammary artery (BIMA) grafts, particularly in Indian populations. Aim of the study was to evaluate whether gender influences the use of BIMA in CABG, and to assess short-term outcomes including postoperative complications and re-hospitalization rates across genders.

Methods: A prospective observational study included 280 patients undergoing elective off-pump CABG at a tertiary cardiac center. Patients were grouped by gender and type of graft received. Comparative analysis was conducted between males and females receiving BIMA, and between females receiving BIMA versus those receiving single internal mammary artery (SIMA) with vein grafts. Key perioperative variables, including inotropic support, infection, and hospital stay, were evaluated over a two-month follow-up.

Results: Among 39 female patients, 51.28% received BIMA grafts compared to 31.54% of 241 male patients (p = 0.016). Female BIMA recipients had higher rates of diabetes (70% vs. 42.11%, p = 0.026), hypothyroidism (30% vs. 2.63%, p < 0.001), and osteoporosis (25% vs. 1.32%, p < 0.001). Re-hospitalization within two months was more common in females (15% vs. 1.32%, p = 0.006). No significant difference in mortality or echocardiographic improvement was observed.

Conclusion: In this study, females were significantly more likely to receive BIMA grafts than males. Despite a higher burden of comorbidities, short-term outcomes were comparable across genders.

Graphical abstract:

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-025-02094-4.

Purpose: Infective endocarditis (IE) remains a severe and complex disease with persistently high morbidity and mortality despite advances in diagnosis and treatment. Sex-related differences in cardiovascular disease are well established, yet their influence on the surgical management and outcomes of IE remains poorly understood. This review aims to synthesize current evidence on how sex impacts the clinical presentation, surgical decision-making, and postoperative outcomes in patients with IE.

Methods: A structured literature search was conducted. Twenty-five original studies and two recent systematic reviews (one with meta-analysis) were included.

Results: IE is generally more prevalent in men, who more frequently undergo surgical intervention, particularly for aortic valve involvement. In contrast, women tend to be older at diagnosis and have a higher burden of comorbidities such as diabetes and chronic kidney disease. Despite having similar surgical indications, women are less frequently referred for surgery and experience higher perioperative mortality. Several studies reported higher short-term mortality in female patients, while others found no significant differences between sexes. Long-term outcomes were more variable, being comparable between sexes in some studies.

Conclusion: These findings highlight the need for greater awareness of sex-related differences in IE and the importance of incorporating sex-specific factors into clinical decision-making and future research. Addressing these disparities may contribute to more equitable treatment strategies and improved outcomes for both sexes.

Purpose: Postoperative bleeding is a critical concern in coronary artery bypass grafting (CABG), influencing patient outcomes and healthcare resources. This study evaluates sex-related differences in postoperative bleeding, transfusion requirements, and associated complications in CABG patients.

Methods: A narrative review was conducted using studies assessing postoperative bleeding in male and female CABG patients. The literature was analyzed to identify variations in bleeding volume, transfusion needs, coagulation parameters, and clinical outcomes.

Results: Postoperative bleeding in CABG results from a complex interplay of surgical, hematologic, and physiological factors. Risk factors include advanced age, preoperative antithrombotic use, anemia, hypertension, diabetes, and prolonged cardiopulmonary bypass (CPB) time. Women exhibit a higher prevalence of diffuse coagulopathy, anemia, and transfusion requirements, whereas men more frequently require surgical re-exploration for localized bleeding. Sex-based differences in endothelial function and pharmacologic management further impact outcomes. Optimizing perioperative strategies, including patient blood management, antifibrinolytic therapy, and individualized anticoagulation, is crucial to improving prognosis.

Conclusion: Sex disparities in postoperative bleeding reflect physiological, anatomical, metabolic, and therapeutic differences. While women may have a lower risk of intraoperative bleeding, they are more vulnerable to hemorrhagic complications, anemia, and transfusion dependence, reinforcing the need for individualized perioperative management. Tailored strategies, including early risk stratification, optimized hemodilution, and personalized anticoagulation, are essential to reducing complications and improving outcomes. These findings highlight the importance of revising clinical guidelines to enhance the surgical care of women undergoing CABG.

Diversity in cardiothoracic surgery will not occur passively. It requires a concerted effort. Historically, cardiothoracic surgery has been one of the least diverse specialties in medicine. The first woman was certified by the American Board of Thoracic Surgery in the early 1960s, nearly one-half century after the specialty was established, but progress from there continued slow. It took another 20 years before the number of women cardiothoracic surgeons exceeded one dozen. More recent efforts by leaders in the specialty have focused on making the specialty more attractive to women with a view towards making cardiothoracic training seem normal, regardless of the trainee's gender. Diversifying any specialty begins with recruitment, mentorship, support, and finally sponsorship to cultivate future leaders with merit-based promotion. These principles are not only applicable for gender diversity but also for racial and ethnic diversity. The American Association for Thoracic Surgery Medical Student Diversity Scholarship exemplifies a concerted effort to encourage diversity in cardiothoracic surgery. Early reports from this program are encouraging and demonstrate the potential outcome of a group committed to taking action and making a long-term positive change.

Purpose: Sex differences in long-term outcomes of patients with repaired tetralogy of Fallot (TOF) are increasingly recognised. However, the sex-specific timing of re-intervention is still unclear.

Methods: A systematic review and meta-analysis was performed across six electronic databases from inception to February 2025. Inclusion criteria were studies that reported outcomes of sex differences in right ventricular (RV) volume, function, and right ventricular outflow tract obstruction (RVOTO) in patients after repaired TOF. Studies were identified and data were extracted by two independent reviewers. Data were extracted and pooled using random effects models and Review Manager 5.4 software.

Results: The findings of three studies with 767 patients who underwent cardiac magnetic resonance (CMR) and one study of 148 patients who underwent echocardiography were included. The mean QRS interval reported in three studies was 148.9 ± 27.9 ms in males and 134.7 ± 24.6 ms in females; this was significant in all three studies [1-3]. Males had higher indexed right ventricular end-diastolic volume (RVEDVi) and indexed right ventricular end-systolic volume (RVESVi). In contrast, they had lower mean right ventricular ejection fraction (RVEF). Males had higher mean indexed left ventricular end-diastolic volume (LVEDVi) and mean indexed left ventricular end-systolic volume (LVESVi). Similarly, males had lower mean left ventricular ejection fraction (LVEF). Echocardiography findings showed that LVEF and strain were lower in males. Cardiopulmonary exercise test (CPET) findings reported in one study showed that males had a higher peak oxygen uptake and lower ventilation per unit of carbon dioxide production (VE/VCO₂) slope than females.

Conclusion: In view of significant long-term outcome differences in RV function and volume between males and females, we recommend a sex-specific threshold rather than a unisex threshold when it comes to consideration of the timing of re-intervention. More multi-centred studies are required to understand this better.Central message We have shown that there are long-term outcome differences between males and females. Therefore, we recommend sex-specific thresholds when it comes to consideration of timing for re-intervention. [Table: see text].