ASIAN CARDIOVASCULAR & THORACIC ANNALS最新文献

Ischemia with nonobstructive coronary arteries (INOCA) is a clinically significant yet underrecognized condition characterized by anginal symptoms and evidence of myocardial ischemia in the absence of obstructive coronary artery disease. Once considered benign, INOCA is now associated with adverse outcomes such as myocardial infarction and heart failure.¹ This narrative review synthesizes current understanding of the multifactorial pathophysiology underlying INOCA, including coronary microvascular dysfunction (CMD), epicardial coronary vasospasm, endothelial dysfunction, hormonal influences, and autonomic nervous system imbalance. Diagnostic challenges are explored, highlighting the utility of both invasive and noninvasive modalities (e.g. coronary flow reserve, index of microcirculatory resistance, acetylcholine provocation testing, cardiac PET, MRI, and single-photon emission computed tomography). Evidence-based management strategies are discussed with emphasis on mechanism-targeted pharmacologic therapy, alignment of treatments with specific pathophysiological processes, emerging interventions (such as Rho-kinase inhibitors), and lifestyle modifications. By identifying knowledge gaps, this review provides a narrative overview of current diagnostic approaches and management options for INOCA, while underscoring areas of ongoing research and clinical uncertainty.

The Y-incision aortic annular enlargement technique offers a reliable solution for the aortic valve replacement in patients with small aortic annuli. By enlarging the annulus and root using a Y-incision and rectangular patch, this technique enables implantation of significantly larger prostheses to effectively avoid prosthesis-patient mismatch without affecting mitral geometry. Based on our experience using minimally invasive access, tailored patch design, modified closure of aortotomy, and integration with ascending aortic replacement when needed, the technique is reproducible and adaptable. Early outcomes are promising, though long-term follow-up and multicenter comparison are required to evaluate its benefits and potential risks.

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis and is now an established alternative to surgical aortic valve replacement (SAVR) for all surgical risk categories. However, the extension of TAVI to younger, low-risk patients has raised important questions regarding the long-term outcomes, valve durability, and lifetime management strategies for these patients. This narrative review summarizes the current evidence from pivotal randomized trials and contemporary registries comparing TAVI and SAVR in young, low-risk patients, integrating the latest 2025 ESC/EACTS guidelines. While short-term outcomes and early recovery favor TAVI, SAVR remains associated with proven durability, lower rates of conduction disturbances, and a potential advantage in long-term outcomes as follow-up data extend beyond five years. Anatomical challenges such as bicuspid valves, coronary access, and patient-prosthesis mismatch further complicate the use of TAVI in this population. A "SAVR-first" lifetime management approach appears to provide greater procedural flexibility and a lower reintervention risk. Ultimately, the choice between TAVI and SAVR in young patients should be individualized through a multidisciplinary Heart Team process, balancing early procedural benefits with long-term durability and reintervention considerations. This review highlights the need for dedicated long-term data and patient-tailored strategies in the evolving management of aortic stenosis in young low-risk individuals.

Obstructive hypertrophic cardiomyopathy (oHCM) presents a significant clinical challenge, with left ventricular outflow tract obstruction being a primary driver of symptoms and adverse outcomes. Surgical septal myectomy (SM) performed under cardiopulmonary bypass and cardioplegic arrest has stood as the gold standard therapy, offering durable and complete relief of obstruction. However, its widespread adoption has been severely hampered by the limited surgical field, lack of real-time intraoperative assessment, and steep learning curve. In an effort to streamline SM, we have developed an innovative transapical beating-heart SM (TA-BSM) procedure. In this article, we outline the design of the beating-heart myectomy device that enables off-pump, real-time assessment of resection via a small left thoracotomy. We synthesize the evidence from the initial feasibility study in swine, the first-in-human trial, and large-scale clinical applications, indicating its compelling safety and efficacy profile. Furthermore, we analyze the learning curve of the TA-BSM procedure and present a structured framework for training future surgeons. Finally, we discuss the profound implications of this technique for global dissemination of oHCM care, potentially making this life-changing surgery accessible to thousands of underserved patients worldwide. In summary, TA-BSM represents not merely an incremental improvement but a true paradigm shift, moving oHCM surgery from a static, blind procedure to a dynamic, precise intervention.

Single Port Video-Assisted Thoracic Surgery (VATS) is now the standard of care for many pulmonary operations. The adoption of Single Port VATS for mediastinal surgery has been considerably slower. Nonetheless, intercostal, subxiphoid, and robot-assisted single-port surgery approaches for mediastinal conditions have been explored in recent years. This narrative review looks at the variety of techniques described and offers an appraisal of the clinical evidence surrounding them.

The conventional primary-secondary classification of spontaneous pneumothorax fails to capture the complexity encountered during thoracoscopic surgery, where CT imaging often misses subtle apical scarring, early emphysematous changes, or fibrotic, noncompliant lung tissue. To provide a more operative-relevant clinical framework, we hereby propose the PLEX Classification, based on Pattern of lung abnormality, Location of leak and lung reserve, Extent of disease, and eXpected surgical complexity and surgical outcome. This system categorizes pneumothorax into four different variants: Type I (apical vulnerability pneumothorax), Type II (multibullous pneumothorax), Type III (emphysematous pneumothorax), and Type IV (fibrotic lung pneumothorax). Applied to 710 surgeries, PLEX demonstrated a clear gradient of increasing surgical difficulty and complications from Type I to Type IV. PLEX offers a pragmatic, surgically actionable system for planning, communication, as well as outcome prediction.

BackgroundRobotic-assisted mitral valve surgery (RAMVS) has emerged as an alternative to conventional minimally invasive mitral valve surgery (MIMVS). However, previous studies have been limited by small sample sizes, heterogeneous techniques and reliance on unmatched or indirectly compared cohorts, resulting in inconclusive evidence. This meta-analysis focuses exclusively on propensity-matched studies to provide a more robust comparison of RAMVS and MIMVS.MethodsA comprehensive literature search was performed to identify propensity-matched studies comparing RAMVS and MIMVS. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using RevMan 8.13.0. Subgroup analyses, including mitral valve repair only, non-isolated mitral valve surgery and MIMVS via right minithoracotomy, were conducted to explore heterogeneity.ResultsEight studies comprising 3352 patients were included, with 1578 (47.1%) undergoing RAMVS. The RAMVS was associated with a shorter hospital stay (MD -1.8 days; 95% CI -3.0 to -0.5; p = 0.006) but significantly longer cardiopulmonary bypass time (MD 21.8 min; 95% CI 0.8-42.9; p = 0.04), and higher odds of conversion to sternotomy (OR 2.9; 95% CI 1.6-5.4; p = 0.0007) and re-exploration for bleeding (OR 1.86; 95% CI 1.1-3.2; p = 0.02). Intensive care unit stay, operative time and postoperative complications were comparable. All subgroup analyses consistently showed higher conversion rates with RAMVS.ConclusionThe RAMVS offers potential recovery benefits but at the cost of greater intraoperative complexity. Careful patient selection and technical expertise are essential to maximise outcomes.

IntroductionSurgical revascularization through coronary artery bypass is a widely accepted approach for treating diseases affecting multiple coronary vessels. While the standard approach uses a single arterial graft combined with vein grafts, using numerous arterial grafts may improve long-term outcomes. Although supported by observational data and guideline recommendations, the broader adoption of multiple arterial grafting has been limited due to a lack of definitive randomized trial evidence and uncertainties in specific patient subgroups.MethodsA systematic review and meta-analysis were conducted to compare long-term survival in patients receiving multiple versus single arterial grafts during coronary artery bypass surgery. Twenty-seven studies (including one randomized trial) involving more than one million patients were included. The primary outcome was long-term all-cause mortality. Hazard ratios with 95% confidence intervals were pooled using a random-effects model. Subgroup analyses were performed based on age, sex, diabetes status, graft conduit type, extent of arterial revascularization, and left ventricular function. Meta-regression examined the impact of patient characteristics.ResultsMultiple arterial grafting was associated with a significant reduction in long-term mortality compared to single arterial grafting. The pooled hazard ratio indicated an approximate 20% relative reduction in mortality. This survival benefit was consistent across all evaluated subgroups. Meta-regression did not identify any patient characteristic that significantly altered the benefit of multiple arterial grafting. No significant publication bias was detected.ConclusionMultiple arterial grafting is associated with improved long-term survival in coronary artery bypass surgery. These findings support the broader implementation of this strategy in suitable patients while emphasizing the need for individualized surgical decision-making.

Acute type A aortic dissection is a life-threatening condition that requires urgent surgical intervention. This article presents our institutional approach, offering a systematic, step-by-step guide to surgical management. Key aspects include preoperative preparation, intraoperative monitoring, arterial cannulation strategies, management of malperfusion, cardiopulmonary bypass, myocardial and cerebral protection, and reconstruction of the aortic root, arch, coronary artery, and left subclavian artery. The use of the frozen elephant trunk technique with hybrid devices is described in detail. Operative photographs, echocardiography, and computed tomography angiography are incorporated to support technical understanding and clinical practice.

IntroductionThe optimal extent of aortic arch intervention for acute type A aortic dissection (ATAAD) remains uncertain. Total arch replacement with a frozen elephant trunk (TAR + FET) prolongs circulatory-arrest time, whereas hybrid arch repair (HAR)-supra-aortic debranching in combination with antegrade endovascular stent grafting-reduces ischemic time but may increase the risk of late reintervention.ObjectiveThis study aims to compare mid-term survival and freedom from reintervention after HAR versus TAR in ATAAD.MethodsPubMed, Embase, and Scopus were searched from their inception to May 2025. Kaplan-Meier Curves were digitized, and individual-participant data were reconstructed with a validated algorithm. Pooled hazard ratios (HR) were derived from a one-stage flexible parametric model; robustness was assessed with two-stage random-effects meta-analysis, leave-one-out tests.ResultsFive propensity-matched studies (n = 697; 338 HAR, 359 TAR) met inclusion criteria. Hybrid arch repair shortened cardiopulmonary bypass and avoided circulatory arrest time. Five-year survival was 86.5% for HAR versus 76.2% for TAR (log-rank p < 0.001). Hybrid arch repair provided a significant early-to-mid-term survival advantage over TAR in ATAAD (HR 0.46 (95% CI 0.31-0.69; p < 0.001)), corresponding to about 6 months of survival benefit at 5 years. Hybrid arch repair was associated with greater likelihood of early reintervention (HR 4.07, 95% CI 0.55-30.34).ConclusionHybrid arch repair offers a significant early-to-mid-term survival advantage over TAR in ATAAD. In patients requiring aortic arch replacement, HAR may be favored over TAR/FET, while extensive TAR/FET procedures are reserved for anatomically unsuitable cases.