Mikko Uimonen

There is no consensus on a risk threshold for sudden cardiac death (SCD) that could be used in practical design and evaluation of prediction models and decisions regarding implantable cardioverter-defibrillator (ICD) therapy. Baseline assumptions for a simulation framework were derived from previous randomized controlled trials ( n = 18) to identify minimal average SCD risk threshold that would translate to mortality benefit by ICD therapy also considering the effect of competing non-sudden mortality. ICD efficacy to prevent SCDs and other data for simulations were estimated using inverse-variance weighted meta-analysis of included trials. Number needed to treat (NNT) was evaluated over a 5- and 10-year horizons (≤ 20 defined as clinically relevant). Correlation analysis confirmed average annual SCD incidence in trial populations as the key factor associating with ICD therapy effectiveness to reduce mortality (Pearson’s r = 0.653, p < 0.01). In a simulation assuming 5% annual non-sudden mortality (pooled estimate of included RCTs) and a 56% (48–62%) efficacy for ICDs to reduce SCDs or similar events, 3% average annual SCD risk (≈ 12% over 5 years) emerged as the lowest practical threshold even after controlling for excess (overlapping) mortality among those saved successfully from SCD by ICD therapy. In populations with very low incidence of non-sudden mortality (1%), the lowest practical threshold over a longer 10-year time horizon was 1.3% (assuming no overlapping mortality). Even under substantial competing risk, populations with an average 3% (or higher) annual SCD incidence most likely would benefit from ICD therapy. Lower threshold may be considered only in populations with very low non-sudden mortality.

Aim: Postoperative imaging surveillance after thoracic aortic surgery is widely recommended, but its clinical yield, efficiency, and optimal targeting remain poorly defined. We aimed to quantify imaging intensity, determine the procedural yield of surveillance imaging, and assess whether follow-up strategies could be better individualized. Methods: We conducted a retrospective single-centre cohort study of patients undergoing thoracic aortic surgery between 2010 and 2024. Postoperative imaging examinations were reviewed and linked with subsequent treatment decisions. Imaging findings, reinterventions, timing of events, detection context, and follow-up patterns were analysed. Results: The cohort included 380 patients with 1757 postoperative imaging examinations, of which 1074 were classified as surveillance aortic imaging performed ≥30 days after surgery. Overall, 42 examinations led to reintervention in 29 patients (7.6%), including 13 examinations leading to aortic reoperation in 12 patients. Among surveillance aortic examinations, 41 (3.8%) led to reintervention and 16 (1.5%) met treatment thresholds without immediate intervention, yielding a combined directly or potentially actionable finding rate of 5.3%. This corresponded to 26.2 surveillance examinations per reintervention and 82.6 per aortic reoperation. Cumulative incidences of first reintervention were 2.8% at 1 year, 5.9% at 3 years, and 8.3% at 5 years. Most reinterventions were identified during elective surveillance imaging (71.4%). Despite more frequent imaging among emergency patients, reintervention risk and imaging yield were similar to those of non-emergency patients. Conclusions: Postoperative imaging surveillance after thoracic aortic surgery was associated with substantial imaging burden but low immediate procedural yield, with clinically relevant findings concentrated in a minority of patients. These findings support the need to better define patient-specific risk and imaging efficiency but do not establish that less intensive surveillance would be safe without prospective validation.

Background: There is no consensus on a risk threshold for sudden cardiac death (SCD) that could be used in practical design and evaluation of prediction models and decisions regarding implantable cardioverter-defibrillator (ICD) therapy. Methods: Baseline assumptions for a simulation framework were derived from previous randomized controlled trials (n=18) to identify minimal SCD risk threshold that would translate to mortality benefit by ICD therapy also considering the effect of competing non-sudden mortality. ICD efficacy to prevent SCDs and other data for simulations were estimated using inverse-variance weighted meta-analysis of included trials. Number needed to treat (NNT) was evaluated over a five-year horizon (≤21 defined as clinically relevant). Results: Correlation analysis confirmed annual SCD incidence in trial populations as the key factor associating with ICD therapy effectiveness to reduce mortality (Pearson’s r=0.653, p<0.01). In a simulation assuming 5% annual non-sudden mortality (pooled estimate of included RCTs) and a 56% (48-62%) efficacy for ICDs to reduce SCDs or similar events, 3% annual SCD risk (≈12% over five years) emerged as the lowest practical threshold even after controlling for excess (overlapping) mortality among those saved successfully from SCD by ICD therapy. The theoretical minimum threshold for annual SCD risk is 2.0%, 2.5% and 3.5% for populations with the annual incidence of non-sudden deaths 2%, 5% and 10% (assuming no overlapping mortality). Conclusions: Even under substantial competing risk, a 3% annual SCD threshold appears an optimal minimum threshold for identifying patients most likely to benefit from ICD therapy if severe mortality overlap is not observed. Key Questions: What is the minimal risk threshold after which ICD therapy will likely lead to meaningful reduction in overall mortality. This information is needed in practical design of clinical trials and evaluation and development of prediction models Key Finding: Analysis of the data extracted from previous randomized controlled trials revealed that annual SCD risk should be at least 3% in most scenarios (with the annual incidence of non-sudden mortality ≤5%) for ICD therapy to be effective. Take-home Message: Primary prevention SCD and risk models targeted to identify high-risk individual should aim for identifying patients with 3% or higher annual risk for SCD.

To compare preventive medications against graft failures in coronary artery bypass graft surgery (CABG) patients after a 1-year follow-up. Systematic review with Bayesian network meta-analysis and meta-regression analysis. We searched PubMed, Scopus, and Web of Science databases in February 2023 for randomized controlled trials, comparing preventive medications against graft failure in CABG patients. We included studies that reported outcomes at 1 year after surgery. Our primary outcome was graft failure After screening 11,898 studies, a total of 18 randomized trials were included. Acetylsalicylic acid (ASA) [odds ratios (OR) 0.51, 95% credibility interval (CrI) 0.28–0.95, meta-regression OR 0.54, 95% CrI 0.26–1.00], Clopidogrel + ASA (OR 0.27, 95% CrI 0.09–0.76, meta-regression OR 0.28, 95% CrI 0.09–0.85), dipyridamole + ASA (OR 0.50, 95% CrI 0.30–0.83, meta-regression OR 0.49, 95% CrI 0.26–0.90), ticagrelor (OR 0.40, 95% CrI 0.16–1.00, meta-regression OR 0.43, 95% CrI 0.15–1.2), and ticagrelor + ASA (OR 0.26, 95% CrI 0.10–0.62, meta-regression OR 0.28, 95% CrI 0.10–0.68) were superior to placebo in preventing graft failure. Rank probabilities suggested the highest likelihood to be the most efficacious for ticagrelor + ASA [surface under the cumulative ranking (SUCRA) 0.859] and clopidogrel + ASA (SUCRA 0.819). The 95% CrIs of ORs for mortality, bleeding, and major adverse cardio- and cerebrovascular events (MACE) were wide. A trend towards increased bleeding risk and decreased MACE risk was observed when any of the medication regimens were used when compared to placebo. Sensitivity analysis excluding studies with a high risk of bias yielded equivalent results. Of the reviewed medication regimens, dual antiplatelet therapy combining ASA with ticagrelor or clopidogrel was found to result in the lowest rate of graft failures.

We highly appreciate Li et al. [ 1] for their comment on our article ‘Optimal lymph node yield in oesophagectomy for oesophageal cancer: A nationwide population-based study in Finland’ [ 2]. They criticize the lack of details from specific lymph node stations since distribution of metastases varies based on tumour location. They suggest ‘lymphadenectomy targeting relevant lymph node stations … to ensure the removal and examination of potentially metastatic nodes’. Although it is true that distribution of metastases varies, standard lymphadenectomy is needed since skip metastases are very common in oesophageal cancer [ 3]. Furthermore, in Western population, the predominant histology is adenocarcinoma. In our study, 83% of the tumours were distal. In these patients, standard 2-field lymphadenectomy is recommended [ 4]. Li et al. bring up issues in the accuracy of determining the number of lymph nodes by the pathologist. There are multiple reasons why lymph node yield varies. Separation of lymph node stations by the surgeons increases the lymph node yield, which has not been standardly performed during the time frame of our study. Also, there is a high variation in number of lymph nodes examined between individual pathologists, which we have recently shown [ 5]. As said, there are multiple sources of error but lymph node yield is still an important estimate of lymphadenectomy quality suggested also by the guidelines [ 4].

OBJECTIVES: The desirable lymph node count was determined to maximize the survival time expectancy according to the lymph node count among patients who have undergone oesophagectomy for oesophageal cancer. METHODS: The data of national Finnish population-based cohort including all patients who have undergone oesophagectomy due to oesophageal cancer during 2002–2016 were used. Restricted mean survival time (RMST) estimates were determined by lymph node count, and the desirable count was determined using locally estimated scatterplot smoothing regression. RESULTS: A total of 883 patients with the median follow-up time of 3.73 (interquartile range 1.43–7.50) years were included. The lymph node count of 27 (95% confidence interval 25–28) was associated with the highest RMST estimates. Sensitivity analyses indicated that in pN0 patients, the highest RMST estimates was observed at 26 (95% confidence interval 24–28) lymph nodes and in pN+ patients, the RMST estimates peaked at 28 (95% confidence interval 25–33) lymph nodes. CONCLUSIONS: According to the findings of this study, at least 24 examined lymph nodes is the recommended target for the lymph node count after oesophagectomy for oesophageal cancer. The beneficial effect of this count on survival may be achieved regardless of nodal metastases.

Background: We characterized the relation of primary treatment approaches to the need of later surgical interventions and the outcomes of patellar dislocation in patients with patellofemoral osteochondral fracture (OCF). Methods: Overall, 134 patients with OCF were categorized in two groups according to treatment approach: primary surgery (operation within 90 days from injury) and conservative treatment. Data on surgical procedures, OCF characteristics, and patellofemoral anatomy were retrospectively collected. To measure subjective outcomes, 54 patients completed the knee-specific patient-reported outcome measures (PROMs) Kujala score, Tegner activity scale, the knee injury and osteoarthritis outcome score (KOOS) quality of life (QoL) subscale, and visual analog scale pain items. Results: The mean follow-up time was 4.9 years [standard deviation (SD) 2.7 years]. The primary treatment approach was surgery in 73 patients (54%) and conservative in 61 patients (46%) of whim 18 (30%) needed late surgery. Of primary surgery patients, the OCF was reimplanted in 45 patients (62%) and removed in the rest. Of all patients, 31 needed surgery in the later phase after the primary treatment approach (either reoperation or surgery after insufficient outcome of conservative treatment). In conservatively treated patients, OCF was smaller and patellofemoral joint malformation was more severe than in surgery group. Among patients who completed the PROMs, the outcomes appeared generally acceptable in both groups. Conclusions: Although a majority of the primary treatment approaches for OCF after patellar dislocation were definitive, one-fourth of patients required surgery in the later phase. PROMs did not indicate major differences between the study groups.