Journal of Clinical Medicine

Background: Off-pump coronary artery bypass grafting (OPCAB) avoids cardiopulmonary bypass (CPB) and may reduce selected perioperative complications, but its technical and hemodynamic demands remain important limitations. Methods: We narratively reviewed the literature indexed in PubMed/MEDLINE and Scopus, supplemented by Google Scholar and reference-list screening, covering January 2000 to August 2026. Priority was given to systematic reviews, meta-analyses, randomized trials, prospective studies, guidelines, and relevant landmark reports. Results: OPCAB may be particularly useful in selected patients at increased risk from CPB or aortic manipulation. Cardiac displacement and coronary stabilization can cause rapid changes in preload, ventricular function, myocardial perfusion, and cardiac output, making invasive monitoring, transesophageal echocardiography, and coordinated hemodynamic management central to anesthetic care. Current evidence does not establish the superiority of volatile anesthesia or total intravenous anesthesia. Comparative studies suggest potential reductions in perioperative stroke, transfusion, renal complications, and hospital stay, although potential stroke benefits depend on the aortic-handling strategy and should not be attributed to avoidance of CPB alone. Concerns remain regarding completeness of revascularization, graft durability, repeat revascularization, and long-term survival. Conclusions: OPCAB should be considered an individualized strategy rather than a universal alternative to on-pump CABG. Optimal outcomes depend on patient selection, surgical expertise, vigilant monitoring, and timely correction of hemodynamic compromise. Potential neurological benefits should be interpreted in relation to the aortic-handling strategy, particularly when an anaortic/no-touch technique is used.

Hypertrophic cardiomyopathy (HCM) is a genetically and phenotypically heterogeneous disease in which management requires integration of clinical assessment, cardiovascular physiology, multimodality imaging, functional evaluation, and arrhythmic risk. This review examines contemporary evaluation, risk stratification, and treatment of sarcomeric HCM across obstructive and non-obstructive phenotypes. In obstructive HCM, conventional negative inotropic therapy and septal reduction therapy remain established treatments, while cardiac myosin inhibitors have introduced a mechanism-based approach that improves left ventricular outflow tract obstruction, symptoms, and exercise capacity. Their role relative to septal reduction therapy should be individualized according to anatomy, hemodynamics, treatment burden, durability, and patient preference. In non-obstructive HCM, treatment remains largely symptom-directed, although recent trials of myosin inhibition have yielded divergent results, emphasizing the importance of appropriate patient selection. Emerging strategies targeting myocardial energetics and earlier disease stages may further expand treatment options. Gene-based therapies, including first-in-human MYBPC3 replacement, offer the possibility of targeting the underlying molecular defect but require careful evaluation of safety, durability, and timing. Overall, HCM remains a paradigmatic disease for physiology-driven, phenotype- and stage-specific care, increasingly complemented by molecularly targeted therapies.

Background: Suboptimal ovarian responders are a clinically important subgroup of patients treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Although their ovarian reserve is usually normal, fewer oocytes than expected are retrieved after controlled ovarian stimulation. Whether the timing of gonadotropin-releasing hormone (GnRH) antagonist initiation affects their reproductive outcomes is unknown. Objective: The objective of this study was to compare reproductive outcomes between fixed and flexible GnRH antagonist protocols in women with suboptimal ovarian response undergoing IVF/ICSI treatment. Methods: This retrospective single-center cohort study included 419 women treated with GnRH antagonist protocol between January 2019 and February 2020. After applying the exclusion criteria, 322 women undergoing IVF/ICSI with a GnRH antagonist protocol were eligible for analysis. Of these, 98 women with normal ovarian reserve and a suboptimal ovarian response (4–9 oocytes retrieved) were included, of whom 89 had a fresh embryo transfer (fixed protocol, n = 41; flexible protocol, n = 48). The primary outcome was live birth rate. Secondary outcomes included ovarian stimulation characteristics, embryo transfer strategy and pregnancy outcomes. Outcomes were analysed per embryo transfer and per oocyte retrieval, and factors associated with live birth were explored with Firth’s penalised logistic regression. Results: Baseline characteristics, including age, AMH, duration of infertility and number of previous IVF attempts, were comparable between groups. Antagonist initiation was later in the flexible group (median day 8 vs. 7), and more embryos were transferred in the fixed group (median 2 vs. 1). The numbers of retrieved and metaphase II oocytes did not differ. Live birth rate per transfer was higher with the fixed protocol (13/41, 31.7% vs. 6/48, 12.5%; p = 0.038), whereas positive β-hCG (43.9% vs. 27.1%; p = 0.12) and clinical pregnancy (41.5% vs. 22.9%; p = 0.071) did not differ significantly; results per oocyte retrieval were similar (live birth 29.5% vs. 11.1%; p = 0.038). In Firth regression, the crude OR for live birth with flexible vs. fixed initiation was 0.32 (95% CI 0.11–0.89); estimates were similar after adjustment for age and previous IVF attempts, whereas the confidence interval crossed 1 once the number of transferred embryos was added to the model (OR 0.36, 95% CI 0.11–1.04). Conclusions: In this small retrospective cohort of women with suboptimal ovarian response, live births were more frequent after fixed than after flexible GnRH antagonist initiation. In view of the small number of events, possible confounding by indication and differences in transfer strategy, this finding is hypothesis-generating and should be tested in a randomised trial.