Khaled Ebrahim Al Ebrahim

Gender disparities persist across cardiac and thoracic surgical care, influencing access, procedural selection, perioperative risk, and long-term outcomes. Despite major advances in operative technique and perioperative pathways, women continue to experience delayed diagnosis, lower procedural referral rates, and distinct complication profiles after high-risk procedures, including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR), and transcatheter edge-to-edge repair (TEER). These patient-level disparities parallel persistent inequities within the cardiothoracic surgery workforce, raising the possibility that structural workforce imbalances may influence clinical outcomes. This study aimed to synthesize contemporary evidence (2020–2025) characterizing sex- and gender-based disparities across cardiac and thoracic surgery, identify interconnected root causes, and outline strategies and research priorities for reducing inequities. A narrative review (2020–2025) combined structured database searches of trials and registries with synthesis of mechanistic and health-system literature to interpret heterogeneous evidence. Women undergoing cardiothoracic procedures often present at older age with greater frailty, smaller anatomical dimensions, and more atypical symptoms, increasing procedural complexity and perioperative risk. CABG and SAVR show higher early morbidity in women, while PCI disparities have narrowed but persist due to delayed recognition; TAVR demonstrates higher early complications yet better mid- and long-term survival. In thoracic surgery, women generally have lower perioperative mortality, but experience delayed diagnosis, lower screening rates, and reduced use of minimally invasive approaches. These outcome differences occur alongside persistent workforce inequities, including the underrepresentation of women in surgical practice, leadership, and academia. Gender disparities in cardiac and thoracic surgery are multifactorial and closely intertwined with systemic workforce inequities. Solutions require sex-aware risk assessment, equitable referral pathways, inclusive device development, mandated sex-stratified reporting, and targeted workforce reforms. Addressing both patient-level and structural contributors is essential to achieve durable gender equity in cardiothoracic surgical care.

Background: Major post-operative complications remain a principal determinant of morbidity, mortality, and intensive care utilization after cardiac surgery despite advances in operative techniques and perioperative care. Early recognition, protocolized management, and multidisciplinary critical care are essential to improving outcomes. Emerging digital technologies, particularly artificial intelligence (AI), are beginning to reshape monitoring, risk prediction, and clinical decision-making within the cardiac intensive care unit (ICU). Objective: The objective of the study is to review contemporary advances in the prevention, early detection, and management of major post-operative cardiac surgery complications and to highlight the emerging role of AI-supported decision systems and their implications for resident training. Methods: A targeted narrative review of recent clinical trials, meta-analyses, and international guidelines published between 2020 and 2025 was conducted. The review focused on major post-operative complications including atrial fibrillation, acute kidney injury (AKI), bleeding and transfusion-related syndromes, respiratory failure, neurologic complications, infection, and low cardiac output syndrome (LCOS). Evidence was synthesized to emphasize ICU-applicable management strategies and the growing integration of AI-assisted monitoring and predictive analytics. Results: Post-operative atrial fibrillation remains the most common rhythm disturbance, with prevention centered on perioperative beta-blockade, electrolyte optimization, and selective amiodarone prophylaxis. AKI affects up to one-third of patients; KDIGO-based care bundles, biomarker-guided detection, and hemodynamic optimization improve early recognition and outcomes. Contemporary patient blood management strategies, including viscoelastic-guided transfusion and antifibrinolytic therapy, reduce bleeding and re-exploration. Respiratory complications are mitigated through lung-protective ventilation, fast-track extubation protocols, and early mobilization. Neurologic complications and infections require systematic screening, prevention bundles, and prompt multidisciplinary intervention. LCOS remains a critical post-operative challenge requiring early hemodynamic optimization and timely escalation to mechanical circulatory support. Increasingly, AI-driven predictive models are being explored to support early complication detection, risk stratification, and real-time clinical decision support in the cardiac ICU. Conclusion: Post-operative complications continue to shape outcomes after cardiac surgery. Contemporary management relies on standardized care bundles, early detection strategies, and coordinated multidisciplinary ICU care. The integration of AI-enabled monitoring and predictive analytics may further enhance early recognition of deterioration, optimize resource utilization, and provide a valuable educational framework for training the next generation of cardiac surgery residents.

10.1055/a-2765-7072 I read with interest the recently published article describing mitral valve surgery combined with multivessel coronary artery bypass grafting (CABG) through a single left anterior minithoracotomy (total coronary revascularization via left anterior thoracotomy [TCRAT] approach).[1] While the authors should be commended for technical innovation, I believe that both the interpretation of the results and the broader implications of this technique warrant serious concern. The central limitation of the report is the conflation of technical feasibility with procedural safety and clinical acceptability. Performing an extremely complex combined operation in a very small, highly selected cohort does not justify extrapolation to routine practice. The reported cardiopulmonary bypass and aortic cross-clamp times are prolonged, underscoring the significant physiological burden imposed by restricted exposure and constrained operative angles—factors that are particularly relevant in combined valve and multivessel coronary surgery. More importantly, the article does not adequately address the quality or durability of coronary revascularization. Complete revascularization with meticulous distal coronary anastomoses remains the cornerstone of successful CABG and long-term freedom from ischemic events.[2] [3] [4] Limited exposure inherent to the TCRAT approach inevitably compromises target visualization, anastomotic precision, and bailout options. Early survival and short-term outcomes cannot be used as surrogates for graft durability or completeness of revascularization. Similarly, mitral valve surgery demands optimal exposure to ensure precision, reproducibility, and durability of repair or replacement. Any approach that restricts visualization or limits corrective options risks compromising the very principles that define high-quality valve surgery. In contrast, conventional CABG through median sternotomy remains a well-established, reproducible, and extensively validated strategy. It provides unparalleled exposure of all coronary territories, facilitates optimal conduit selection, and allows meticulous, tension-free distal anastomoses. When combined with standard mitral valve surgery, median sternotomy offers a proven platform for achieving complete revascularization, durable valve correction, and maximal procedural safety. These advantages are consistently supported by randomized trials and large meta-analyses. Innovation in cardiac surgery should address a clear unmet clinical need or demonstrate superior—or at least non-inferior—long-term outcomes. In the absence of such evidence, the promotion of highly complex minimally invasive approaches for combined mitral valve and multivessel coronary disease risks prioritizes technical novelty over durability, reproducibility, and patient safety. We believe that the conclusions of the present article extend beyond what the presented data can support. Until compelling evidence demonstrates equivalent long-term safety and durability, conventional CABG via median sternotomy combined with standard mitral valve surgery should remain the reference approach for this challenging patient population. K.A. contributed to conceptualization, supervision, writing–original draft, writing–review and editing. Received: 16 January 2026 Accepted: 09 February 2026 Article published online: 24 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Khaled Ebrahim Al Ebrahim, F.R.C.S.C.. J Chest Surg -0001;0:. https://doi.org/10.5090/jcs.25.170

10.1055/a-2493-1495 I read with interest the article by Taghiyev et al. examining short-term renal outcomes after combined treatment for aortic stenosis and coronary artery disease (CAD).[1] While the authors provide useful early data on creatinine trajectories, the study's narrow renal focus, limited sample size, and 7-day follow-up restrict its clinical impact. Major decisions between transcatheter aortic valve replacement (TAVR) + percutaneous coronary intervention (PCI) and surgical aortic valve replacement (SAVR) + coronary artery bypass grafting (CABG) hinge on a broader matrix of determinants—including frailty, anatomical complexity, operative risk, durability expectations, and all-cause morbidity and mortality—not on transient renal fluctuations alone. Recent literature comparing TAVR + PCI versus SAVR + CABG in patients with atherosclerosis and CAD offers a more nuanced picture. A large multicenter registry published in 2025 reported that, in intermediate-risk patients, early (30-day) mortality was similar between the two strategies; over 3 years the unmatched analysis even showed higher mortality in the TAVR + PCI group (37.1 vs. 25.5%, p = 0.02), although after propensity matching the difference lost significance.[2] Notably, early surgical complications—including stroke, acute kidney injury, bleeding, transfusion requirement, and delirium—were more common in the SAVR + CABG group, whereas TAVR + PCI had higher rates of pacemaker implantation and vascular complications.[2] Moreover, a recent meta-analysis including over 100,000 patients found that TAVR + PCI was associated with lower rates of 30-day acute kidney injury, but higher long-term all-cause mortality and increased need for repeat coronary revascularization compared with SAVR + CABG.[3] Thus, while TAVR + PCI may offer some short-term advantages (reduced acute kidney injury, shorter hospitalization, fewer early bleeding, or surgical complications), these benefits must be weighed against potentially worse long-term survival, higher rate of repeat coronary interventions, and nontrivial vascular/conduction complications.[4] [5] [6] Given these data and the many variables at play—comorbidities, coronary disease complexity, anatomical considerations, procedural risk, and long-term durability—I remain unconvinced that early renal stability alone is a sufficiently robust basis to favor one strategy over another. Until larger prospective studies with long-term follow-up address survival, major adverse cardiac and cerebrovascular event, reinterventions, and quality-of-life outcomes, claims of superiority of one strategy on the basis of short-term renal data remain premature. K.A. contributed to conceptualization, data curation, methodology, visualization, writing—original draft, writing—review and editing. Received: 30 December 2025 Accepted: 26 January 2026 Article published online: 11 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany