Background: Thrombus in transit (TIT) through a patent foramen ovale (PFO) or atrial septal defect (ASD) is a rare but potentially life-threatening condition associated with paradoxical embolism. Despite advances in imaging and interventional techniques, optimal management strategies remain poorly defined. Objectives: To systematically characterize the clinical presentation, diagnostic approaches, management strategies, and outcomes of adult patients with TIT across right-to-left intra-atrial shunts. Design: Systematic review of published cases. Data sources and methods: Following PRISMA guidelines, PubMed, Embase, and Scopus were searched from inception through March 2025 for case reports, case series, and letters describing adult patients with TIT visualized by transthoracic or transesophageal echocardiography. After screening 1736 records, 278 studies reporting 297 patients were included. Two independent reviewers extracted demographic, clinical, imaging, treatment, and outcome data. Descriptive statistics were summarized, and treatment groups were compared using chi-square and Mann–Whitney U tests. Kaplan–Meier survival curves with log-rank testing assessed 120-day survival, and multivariable Cox regression was used to evaluate potential predictors of mortality. Results: A total of 297 patients from 278 studies were included. The mean age was 58.5 ± 15.8 years, and 50.2% were male. Respiratory symptoms predominated (77.7%), followed by cardiac (29.7%) and neurological (23.0%) manifestations. Provoked events accounted for 70.3% of cases, most commonly in the postoperative setting. Thrombi were detected by transthoracic echocardiography in 92.1% of cases and by transesophageal echocardiography in 100%. Management strategies included surgical embolectomy (57.8%), anticoagulation (36.5%), thrombolysis (13.5%), and percutaneous aspiration (2.7%); 61.1% underwent PFO/ASD closure. Overall mortality was 8.3%. Surgical management was associated with the lowest mortality (3.0%) and the highest short-term clinical improvement (90.5%; p < 0.001). Thrombolysis and percutaneous aspiration were associated with higher mortality (16.6% and 25.0%, respectively). Kaplan–Meier analysis demonstrated superior 120-day survival with surgical management compared with other treatment strategies (log-rank p < 0.001). In multivariable Cox models, no independent predictors of mortality were identified. Conclusion: In this largest synthesis of TIT cases to date, surgical management and PFO/ASD closure were associated with favorable short-term outcomes. Surgical intervention demonstrated the lowest observed mortality, while anticoagulation provided acceptable outcomes in selected patients. Thrombolysis and percutaneous aspiration were associated with higher mortality. These findings support the role of definitive management and shunt closure in selected patients, although prospective studies are needed to establish standardized treatment strategies. Trial registration: This study was registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) (Registration number: INPLASY202630021).
Background Robotic-assisted coronary artery bypass grafting (CABG) using bilateral internal mammary arteries (BIMA) provides a minimally invasive option for advanced coronary artery disease (CAD), but evidence on its learning curve and outcomes in the Indian population remains limited. Objectives To evaluate the learning curve associated with robotic CABG using BIMA and to compare perioperative and clinical outcomes between the early and late phases of surgical experience in a real-world setting. Design Retrospective, single-center, observational chart review conducted at a high-volume quaternary cardiac care center in India. Methods This retrospective chart review was performed for 341 patients who underwent robotic-assisted BIMA CABG between 2020 and 2025. The learning curve was assessed using risk-adjusted cumulative summation (CUSUM), while complication trends were examined through sequential probability CUSUM failure analysis. Results The cohort comprised 295 (86.51%) males with a mean age of 59.56 ± 9.93 years and a body mass index (BMI) of 25.98 ± 3.74 kg/m 2 . Mean console time was 101.66 ± 29.99 minutes, ICU stay 2.85 ± 0.98 days, and hospital stay 6.01 ± 2.38 days; conversion to open surgery occurred in 2.93% of cases, with in-hospital mortality of 3.52%. CUSUM analysis identified case 125 as the proficiency inflection point, after which console time significantly decreased (94.95 ± 24.32 vs. 113.38 ± 35.04 minutes; p<0.001), while ventilator duration, ICU and hospital stay, complications, and mortality remained comparable between phases. Readmission and re-exploration rates were low (2.05% each), with no deaths at 6-month follow-up. CUSUM failure analysis confirmed complication rates remained within acceptable thresholds throughout the study. Conclusions Robotic-assisted BIMA CABG demonstrated acceptable outcomes, with operative efficiency improving after approximately 125 cases. These findings support its feasibility in experienced, high-volume centers and warrant further multicentre evaluation.
Background Sex-related differences are well recognized in heart failure with preserved ejection fraction (HFpEF), but real-world data describing clinical outcomes by sex among patients with obesity and HFpEF treated with tirzepatide remain limited. Objectives To compare observed hospitalization, cardiovascular, and gastrointestinal outcomes between male and female patients with obesity and HFpEF treated with tirzepatide. Design Retrospective, propensity score-matched, within-treatment cohort study. Methods A retrospective study was conducted using TriNetX database which included 110 healthcare organizations. Adults with obesity, HFpEF, and taking tirzepatide between June 1, 2022 and January 1, 2025 were identified. Males and females were balanced using 1:1 propensity score matching (n=1,654 per group). Primary outcome assessed included all-cause hospitalization. Secondary outcomes were all-cause mortality, HF exacerbation, major adverse cardiovascular events (MACE), incident atrial fibrillation, nausea/vomiting and diarrhea. Two prespecified falsification endpoints were used. Results During 1-year follow-up, males had a lower hazard of all-cause hospitalization compared with females (HR 0.87, 95% CI 0.77–0.98). No significant differences were observed for all-cause mortality (HR 1.73, 95% CI 0.95–3.18), HF exacerbation (HR 1.14, 95% CI 0.90–1.44), MACE (HR 1.28, 95% CI 0.99–1.65), or incident atrial fibrillation (HR 1.21, 95% CI 0.61–2.43). Males experienced lower rates of nausea and vomiting (HR 0.50, 95% CI 0.37–0.67), while diarrhea was similar (HR 0.84, 95% CI 0.59–1.19). Falsification endpoints showed no significant associations. Conclusion Among tirzepatide-treated patients with obesity and HFpEF, no statistically significant sex-associated differences were detected in major cardiovascular outcomes. Males had a modestly lower observed hazard of hospitalization and fewer coded nausea and vomiting events. Because this was a within-treatment observational comparison without an external comparator, these findings should not be interpreted as evidence of differential tirzepatide effectiveness by sex.
Background Despite the increasing adoption of minimally invasive approaches for valvular heart disease, the learning trajectory for complex thoracoscopic double valve replacement (DVR) remains largely uncharacterized. Objectives To evaluate the learning curve of two-incision thoracoscopic DVR, determine the case threshold for procedural proficiency, and identify independent predictors of major adverse surgical events (MASE). Design Retrospective cohort study. Methods We evaluated 252 consecutive thoracoscopic DVR procedures performed at a single high-volume center between March 2017 and December 2024. Cumulative sum (CUSUM) analysis of cardiopulmonary bypass (CPB) time was utilized to define distinct learning phases. MASE, a composite of mortality, conversion to sternotomy, and reoperation for bleeding, served as the primary clinical outcome. Multivariate logistic regression was performed to identify independent predictors of MASE. Results CUSUM analysis revealed three distinct learning phases: Acquisition (cases 1–67), Acceleration (cases 68–139), and Mastery (cases 140–252). Mean CPB time decreased progressively from 187.5±34.2 to 156.3±27.6 and 138.4±18.9 minutes across the three phases (p<0.001). Concurrently, MASE rates declined significantly from 16.4% in the Acquisition phase to 4.2% in the Acceleration phase, stabilizing at 4.4% during the Mastery phase (p=0.006). A small aortic annulus emerged as the strongest independent predictor of complications (OR 467.483, p<0.001), followed by operations performed during the Acquisition phase (OR 14.564, p=0.007). Conclusion Thoracoscopic DVR demonstrates a three-phase learning curve, with technical proficiency achieved after approximately 139 cases. Early procedural implementation requires risk-adapted case selection, specifically avoiding small aortic annuli during the initial experience. Because standard risk models may significantly underestimate mortality in this context, procedure-specific considerations and learning curve position are essential when evaluating candidates for this advanced minimally invasive approach.
