Journal and News Scan

This article provides a detailed overview of using composite outcomes in clinical trials, particularly in cardiovascular and thoracic surgery. The main takeaways include the advantages of composite endpoints in increasing statistical power by combining multiple relevant outcomes, which can reduce sample size and improve trial feasibility. However, the authors also highlight key issues such as the potential for bias, the halo effect, and the importance of carefully selecting and interpreting composite outcomes. They emphasize the necessity of analyzing individual components within a composite to avoid misleading conclusions about treatment efficacy. The article also discusses the win ratio approach, a method that prioritizes clinically important outcomes when evaluating composite endpoints. Understanding the nuances of this statistical method is crucial for interpreting trial results and optimizing patient care. 

Myocardial infarction due to coronary artery disease (CAD) is the leading cause of death worldwide. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are the primary treatment modalities of choice for patients with CAD. Surgical myocardial revascularization remains the gold standard for patients with more complex CAD. For decades, surgical myocardial revascularization, using the in situ left internal mammary artery (LIMA) bypass for the anterior wall of the heart and single aortocoronary venous bypasses for the lateral and posterior areas of the heart, have been the standard cardiac surgical procedure. The dynamics of increasingly older and sicker patients, along with the efforts of cardiac surgeons to perfect the surgical treatment of CAD, have led to a variety of different surgical revascularization concepts. The primary goal is to complete revascularization of all coronary arteries compromised by significant stenoses. In many cardiac surgery centers, there is a trend toward extended arterial revascularization, especially in younger patients, because arterial coronary bypasses are considered to have better long-term openness rates than venous bypasses. In situ bypass with the LIMA to the left anterior descending (LAD) artery, combined with an additional arterial bypass with proximal anastomosis to the LIMA to the affected branches of the circumflex system and the right coronary artery, have been established by many surgeons. 

The proximal anastomosis of the right internal mammary artery (RIMA) as a free graft of the radial artery (RA) with the LIMA is performed in a T- or Y-shape (fig. 1), respectively, to be able to supply all cardiac regions with the limited available arterial graft material in terms of length. However, complete arterial revascularization cannot be achieved in every patient and should not be forced under any circumstances. 

Aortic stenosis affects more than 9 million people worldwide and is commonly treated with surgical aortic valve replacement (SAVR), which is known for producing excellent long-term outcomes. Recent advancements in transcatheter aortic valve replacement (TAVR) have shown noninferior or improved outcomes compared to SAVR across various risk levels. Despite TAVR's growth, innovations in surgical valves, such as sutureless aortic valves (SURD), are maintaining SAVR's relevance. The Perceval S valve, a sutureless option, has shown promising early and midterm results. It reduces cardiopulmonary bypass and aortic cross-clamp times, which are linked to lower morbidity and mortality. This review highlights the design, deployment, and clinical outcomes of the Perceval S valve. While it offers benefits similar to TAVR, it presents unique advantages for certain patients, including those requiring minimally invasive SAVR (such as robotic, mini thoracotomy, or mini sternotomy approach), those with small aortic annuli, patients undergoing concomitant procedures aimed at shortening cardiopulmonary bypass times, and redo scenarios. However, it presents unique risks as well, including an increased risk of postoperative need for permanent pacemaker implantation. Future research is needed to refine techniques and further evaluate long-term outcomes. 

This study examines trends and long-term survival outcomes for heart transplants involving donation after circulatory death (DCD) versus donation after brain death (DBD). Using data from December 2019 to September 2023, the study identified 792 DCD transplants out of 11,625 total heart transplants, with 249 classified as normothermic regional perfusion (DCD-NRP) and 543 classified as direct procurement and perfusion (DCD-DPP). The proportion of DCD transplants increased from 2 percent in December 2019 to 11 percent in early 2023. Survival rates at 1 and 3 years posttransplant were similar between DBD and both DCD-NRP and DCD-DPP groups. Rates of postoperative complications, including stroke, dialysis, acute graft rejection, and primary graft dysfunction, were also comparable. The study found that survival rates were consistent across different recipient risk levels and transplant center volumes. These results suggest that DCD hearts offer comparable long-term survival to DBD hearts and support the expanding use of DCD donors to increase the available organ pool.