Andreas Böning

Background: Development of organ dysfunction or death is still common in patients undergoing cardiac surgery. Yet, current risk stratification tools fail to adequately incorporate both preoperative vulnerability and immediate postoperative physiological derangements. This study aims to develop a predictive model integrating these critical timepoints to identify high‐risk patients for presence of organ dysfunction or death 48 hours after surgery. Methods: This is a post hoc analysis of an international, multicenter, randomized, controlled trial in patients undergoing cardiac surgery (n=1394). Prespecified patient characteristics (age, Clinical Frailty Scale, at nutrition risk, combined procedures, urgent surgery, moderate–severe chronic kidney disease, left ventricular ejection fraction, European System for Cardiac Operative Risk Evaluation II, cardiopulmonary bypass duration, sex, Charlson Comorbidity Index, and Sequential Organ Failure Assessment score) were included in logistic regression models employing bootstrap validation. Results: A total of 434 (31.1%) patients had organ dysfunction or died 48 hours after surgery. The preoperative model identified Clinical Frailty Scale, nutrition risk, urgent surgery and European System for Cardiac Operative Risk Evaluation II as significant predictors of organ dysfunction or death 48 hours after surgery (optimism‐corrected area under the receiver operating characteristic curve, 0.644 [95% CI, 0.610–0.678]). Incorporation of postoperative variables (Sequential Organ Failure Assessment score at intensive care unit admission, and cardiopulmonary bypass duration) improved predictive performance (area under the receiver operating characteristic curve, 0.773 [95% CI, 0.745–0.801]). Conclusions: Incorporation of variables collected the day of surgery substantially improved the ability to predict organ dysfunction or death 48 hours after surgery compared with using presurgical variables only. This pragmatic, clinically actionable model may enable targeted resource allocation and personalized interventions and may provide a stratification tool for future research. Registration: URL: clinicaltrials.gov ; Unique Identifier: NCT02002247.

In Germany, it is often said that not apples and oranges, but apples and pears are incomparable. The phrase is deceptively simple, yet it captures a recurrent challenge in contemporary thoracic and cardiovascular surgery: The tendency to compare entities that appear similar on the surface but differ fundamentally in their characteristics. This challenge is increasingly evident in how evidence is generated, interpreted, and translated into clinical decision-making. Surgical techniques, devices, and treatment strategies are frequently juxtaposed as if they were interchangeable commodities. However, as with apples and pears, similarity does not equate to equivalence. Differences in anatomy, pathology, patient selection, surgeon expertise, institutional infrastructure, and perioperative management profoundly influence outcomes. Ignoring these distinctions risks drawing conclusions that are, at best, incomplete and, at worst, misleading. Registry-based analyses compete with prospective-randomized studies. In registries, large datasets provide statistical power and real-world insight, yet they are inherently shaped by selection bias and unmeasured confounding. When registry outcomes are contrasted with those from randomized controlled trials—or when registries from different health care systems are compared—the temptation to declare superiority can be strong. As Gaudino and Borger[1] emphasize, “only randomized trials should be used” when assessing true comparative efficacy, and Doenst et al[2] have highlighted the inherent limitations of comparing randomized versus registry evidence. From the perspective of the Editor-in-Chief, the responsibility for editors, reviewers, and readers alike is clear. Comparisons must be framed transparently, with explicit acknowledgment of their limitations. Should methodological rigor be matched by conceptual clarity: What exactly is being compared, and why? Are the underlying assumptions justified, or are we forcing equivalence where none exists? In this issue, two original investigations exemplify this challenge: “Is total arterial grafting superior to multiarterial grafting in coronary bypass?” by Leviner et al,[3] and “Postoperative results of patients undergoing minimally invasive tricuspid valve procedure” by Klocksin et al.[4] Both manuscripts address clinically relevant questions and analyze retrospectively sampled data to compare surgical strategies that, while related, are not identical in indication, execution, or patient selection. As the Editor-in-Chief, I wish to be transparent that each of these papers received a reject recommendation from one of the reviewers, reflecting legitimate concerns regarding comparability, residual confounding, and the risk of overinterpretation. Nevertheless, I elected to retain both manuscripts for publication—explicitly in conjunction with this editorial—to emphasize an important didactic point. These studies should not be read as definitive answers to questions of superiority. Rather, they should be interpreted as hypothesis-generating contributions that illustrate both the value and the inherent limitations of retrospective comparisons. I, therefore, encourage readers to approach the presented analyses with appropriate skepticism. Differences observed between groups may reflect selection effects, institutional preferences, or unmeasured variables rather than true causal effects of the surgical technique itself. Awareness of these constraints does not diminish the scientific merit of such work; instead, it places the findings in their proper context and guards against unwarranted generalization. Recognizing when we are comparing apples with pears—and resisting the urge to declare one categorically superior to the other—is a mark of scientific maturity. By embracing complexity and respecting difference, we can ensure that comparisons illuminate rather than obscure, and that evidence serves its intended purpose: Improving outcomes for our patients and advancing the discipline. Article published online: 12 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

OBJECTIVES: For the treatment of aortic valve stenoses, both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are available. We compared the frequently used Euroscore with the AKL-Cath- and the AKL-Chir Score, describing the mortality risk of the two different treatment methods. METHODS: Based on a retrospective cohort study using mandatory quality assurance data, we analysed the frequency and the outcomes (primary end-point: in-hospital mortality) of all patients treated in Germany between 2015 and 2020. The observed results were compared to the predicted risk using the Euroscore, the AKL-Cath Score and the AKL-Chir Score. RESULTS: Our data show a reduction in the number of isolated SAVR procedures from 9,790 in 2015 to 6,106 in 2020, corresponding to a 37.6% decrease. Over the same period, the number of TAVI procedures increased from 15,653 to 21,501, an increase of 37.3%. Regarding in-hospital mortality following TAVI, there was a decline from 4% (2015) to 2.5% (2020), while in-hospital mortality following SAVR remained nearly constant at 3%. Over the study period, there is an overestimation of TAVI risk while simultaneously underestimating SAVR risk by EuroSCORE II. In contrast, the mortality risk of patients is well estimated using the AKL-Kath Score in the TAVI group and the AKL-Chir Score in the SAVR group. The AKL-Chir Score in TAVI patients overestimates their mortality, while the AKL-Kath Score underestimates the mortality of SAVR patients. CONCLUSIONS: AKL Chir score and AKL Cath score estimate the mortality risk of SAVR and TAVI patients more precisely than the Euroscore II.

BACKGROUND: Minimalist treatment strategies for transcatheter aortic valve implantation have been widely adopted because of continued procedural evolution, but large randomized trials are lacking. The DOUBLE-CHOICE trial (Randomized Study Comparing Both Latest Generation Self-Expanding Valves and a Minimalist Approach Versus Standard of Care in Transcatheter Aortic Valve Implantation) evaluated the safety and efficacy of a minimalist approach (MA) compared with the standard of care (SoC) for transfemoral transcatheter aortic valve implantation. METHODS: In this investigator-initiated, 2×2 factorial, open-label, randomized, multicenter, noninferiority trial, patients with symptomatic aortic stenosis were included at 10 German sites. Patients were randomly assigned to the MA, including isolated local anesthesia, versus the SoC using conscious sedation. The primary end point was a composite of all-cause mortality, vascular and bleeding complications, infection requiring antibiotic therapy, and neurological events at 30 days. The noninferiority of the MA compared with the SoC was tested in the intention-to-treat population with an absolute noninferiority margin of −6% at an α level of 0.05. RESULTS: Between July 11, 2022, and January 14, 2025, 752 patients were randomly assigned to the MA (n=377) and SoC (n=375). The median age was 83 (interquartile range, 79–86) years, 439 (58.5%) patients were women, and the median Society of Thoracic Surgeons risk score was 4.6% (interquartile range, 2.9–8.0). The primary end point occurred in 80 (22.9%) of 350 patients in the MA group and in 91 (25.8%) of 353 patients in the SoC group (rate difference, 2.9%; lower boundary of the 1-sided 95% CI, −2.4%; P for noninferiority=0.003; 2-sided 95% CI, −3.4 to 9.3; P for difference=0.37). Patient-reported anxiety and stress levels during the procedure were higher in the MA group. CONCLUSIONS: The MA including isolated local anesthesia was noninferior to the SoC with conscious sedation, highlighting the safety and efficacy of the MA for transcatheter aortic valve implantation. The burden of intraprocedural pain and discomfort is potentially higher in the MA group. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05036018.

Background: The implantation of a Swan-Ganz catheter for invasive hemodynamic monitoring is an established measure after cardiac surgery. A rare but serious complication is the formation of a knot in the heart, which can be diagnostically challenging. We report on a patient who developed left heart failure postoperatively after quadruple bypass surgery combined with aortic valve replacement and in whom a knot formed inadvertently during monitoring using a Swan-Ganz catheter. Case presentation: An 82-year-old female underwent combined quadruple coronary artery bypass grafting and aortic valve replacement for severe coronary and valvular heart disease. Postoperatively, she experienced acute left ventricular dysfunction, necessitating mechanical circulatory support with an Impella device. A Swan-Ganz catheter was placed through the internal jugular vein for accurate hemodynamic monitoring. After placement, unexpected catheter immobility raised suspicion of an intracardiac knot. Initial transthoracic echocardiography did not clearly visualize the lesion; however, subsequent chest radiography and jugular vein ultrasound confirmed catheter-associated intracardiac knot formation. Considering the heightened risk for cardiac injury and thromboembolic events, interdisciplinary consensus recommended bedside surgical extraction. The catheter and associated knot were successfully removed via transcutaneous vascular incision without complications. Inspection revealed knot formation proximal to the catheter thermistor, while the balloon remained intact and functional. Conclusion: Intracardiac knot formation associated with Swan-Ganz catheter placement is rare but presents significant risks. Timely interdisciplinary assessment, multimodal imaging, and surgical extraction under controlled conditions effectively mitigate potential complications, enabling safe catheter removal and favorable patient outcomes.

Objectives: The “German Registry for Acute Aortic Dissection Type A” (GERAADA) long-term follow-up firstly investigates the neurologic outcomes over a 16-year timeframe and secondly determines whether acute Stanford type A aortic dissection (ATAAD) patients are at risk for secondary neurologic complications. Methods: Thirty-three centres provided follow-up data of 2686 individuals. Of those, 814 provided long-term data regarding their neurological status and incidence of stroke. Multivariable regression analysis was used to identify risk factors of both postoperative and secondary neurologic deficits. Subgroup analyses of patients operated in hypothermic circulatory arrest with or without selective antegrade cerebral perfusion was performed to assess further influencing factors. Results: Four hundred and fifteen (15%) out of the 2686 patients experienced postoperatively a new-onset neurologic deficit while being hospitalized. Age, renal malperfusion, dissected supra-aortic vessels, extracorporeal circulation time, and re-exploration were independent risk factors (all P < .05) for worse neurological outcomes while hemiarch replacement seemed to have a protective effect (OR = 0.68; P = .008). Neither cerebral protection strategy nor temperature management showed significant differences between the groups regarding neurological outcome. Out of the 814 follow-up patients, 188 (23%) experienced secondary neurologic deficits after initial treatment for ATAAD within a median follow-up of 10.2 years. Long-term risk factors were a persistent cerebral malperfusion and late reoperation. No association between perioperative neurologic damage and operative techniques on long-term neurologic outcomes could be found. Conclusions: Surgery for ATAAD is associated with frequent early neurologic complications that can be predicted by perioperative factors. Open treatment of the aortic arch shows a positive effect on neurological outcome. Further, every fourth follow-upped patients suffered from secondary neurological damage highlighting the importance of a close surveillance.

Objectives: Data from the German Aortic Valve Registry (GARY) were analysed to determine whether there are differences between patients with and without chronic lung disease (CLD) undergoing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) and whether TAVI or SAVR is more beneficial in patients with preexisting CLD. Methods: Follow-up data from GARY registry patients treated from 2014 to 2015 and from 2018 to 2019 were incorporated in the analysis. Demographic results for each of the 2 treatment modalities were evaluated, and patients with and without CLD were compared. In a second step, variables that would have influenced the treatment decision in CLD patients in direction of either SAVR or TAVI were accounted for in the adjusted analysis. This led to a subgroup of 1385 patients with CLD that was subjected to propensity score weighted analysis to compare outcomes of TAVI and SAVR. Results: After exclusion, 11 457 SAVR patients and 2378 TAVI patients were analysed. CLD patients were sicker than patients without CLD, although the observed 30-day mortality was lower than expected by 3 risk scores. Accordingly, long-term survival in CLD patients was lower in both treatment groups than in patients without CLD. Thirty-day mortality was similar in the 2 treatment groups (SAVR 2.3%, TAVI 3.8%, P = .964) in spite of a possible selection bias in favour of SAVR. During a 5-year follow-up, survival after TAVI (44.6%) was significantly lower than after SAVR (56.7%), P = .029. Conclusions: Patients with CLD undergoing SAVR or TAVI are generally at higher risk for complications or death after the procedure than patients without CLD. After 5 years, patient-reported outcomes were similar in TAVI and in SAVR patients.

As I step into my new role as editor of this esteemed scientific journal, the Thoracic and Cardiovascular Surgeon, I am reminded of a simple yet profound lesson that has guided me throughout my career in science: progress is never a solitary endeavor. In fact, it is the result of collaboration, the exchange of ideas, and the collective effort of a community. Just as the legendary Beatles song suggests, “With a little help from my friends”, the scientific journey we embark upon is rarely one we undertake alone. Science, at its core, is a cooperative process. Each discovery, every breakthrough, and every question that pushes the boundaries of human knowledge emerges not in isolation but in the context of the ideas, critiques, and perspectives shared by others. The world of research is interwoven with partnerships—whether between researchers from different disciplines, reviewers and editorial board members, or even collaborations between editors from Japan and Germany that span continents. But just as collaboration is vital, it is equally important to foster a community that embraces support and constructive feedback. Peer review, for instance, is not just a gatekeeping mechanism but a vital part of refining ideas and elevating research. It is a reminder that science is not a pursuit for ego, but a shared mission for truth. This is a space where our “friends”—the fellow researchers, the reviewers, and the critics—help us sharpen our work to its finest form. As a new editor, I view my role not just as an editor of papers, but as a cultivator of this supportive environment. I hope to create a space where researchers feel empowered to collaborate, to challenge each other, and to share not only their successes but their failures as well. Failures, after all, are just as important in the scientific process as successes. It is in the moments of uncertainty and struggle that true growth occurs, and in these moments, the guidance of peers and colleagues can often be the key to finding the way forward. This journal, like the German Society of Thoracic and Cardiovascular Surgery, the German Society of Pediatric Cardiology, and the associated Swiss, Luxembourg, and Austrian Societies it serves, thrives because of the collaboration between editors, reviewers, authors, and readers. Our ability to provide constructive criticism, support novel ideas, and embrace innovation is what will propel us into the future. So, as we look toward the future of this journal, I invite you to join the editors in this collective effort. Whether you are a seasoned researcher or just starting your journey, your voice, your ideas, and your collaboration matter. Just as the Beatles (or later Joe Cocker in his legendary version) sing: “Oh, I get by with a little help from my friends Mmm, I get high with a little help from my friends Ooh, I'm gonna try with a little help from my friends.” Article published online: 01 August 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany