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This study underscores the efficacy of a structured interhospital transfer program in managing patients requiring various levels of cardiac surgical intervention. Key findings reveal distinct patterns in patient characteristics, urgency classifications, and clinical outcomes, similar findings were found in a study from Sanaiha et al. [7]. Emergent patients displayed significantly higher rates of myocardial infarction, preoperative shock, and mechanical ventilation, which correlated with an elevated in-hospital mortality rate of 6.9%, findings consistent with these were reported by Metkus [8]. These results were not surprising, as those criteria are, per se, predictors of in-hospital mortality in the STS Score and the EuroSCORE II [9, 10]. In contrast, urgent and elective patients had lower mortality rates and reduced preoperative risk profiles. At Düsseldorf University Hospital, we operated on an average of 1,650 patients per year. The overall in-hospital mortality rate was 5.2%. Stratified by urgency, the mortality rate was 2.0% for elective cases, 5.2% for urgent cases, and 16% for emergency cases. The markedly high mortality rate among emergency patients can be attributed, among other factors, to the high proportion of in-house resuscitations from other departments within the university hospital, as well as to the frequent admissions following out-of-hospital cardiac arrests, given our role as a major cardiac arrest center. Interestingly, the emergency patient cohort transferred from the Karl-Leisner-Klinikum demonstrated a notably lower in-hospital mortality rate. This discrepancy may be explained by significant differences in patient selection and timing. In particular, the patients referred emergently from external hospitals were usually hemodynamically stabilized prior to transport, and resuscitated patients were typically not transferred unless a return of spontaneous circulation (ROSC) had been achieved and a certain degree of neurological prognosis could be anticipated. Additionally, the Karl-Leisner-Klinikum lacks a dedicated cardiac arrest center, which may have led to a different triage and referral strategy, focusing more on potentially salvageable patients with a better short-term prognosis. Consequently, while the clinical severity of transferred patients was still high, the proportion of high-risk, non-survivable emergencies may have been lower compared to the in-house emergency population at the tertiary center.

The stepwise development of the program allowed for iterative improvements in communication, triage, and transport logistics [11]. Trends across the five-year period demonstrated a gradual shift toward a higher proportion of urgent admissions, reflecting growing confidence and reliance on the transfer protocol by referring clinicians. The stability of emergent case proportions, along with consistent transport durations, indicates that the program successfully maintained efficiency under varying clinical loads. CABG remained the predominant surgical procedure, especially among emergent patients, emphasizing the program’s responsiveness to ischemic heart disease [12, 13]. The relatively short median time to surgery for emergent cases (4 h) reflects a high level of logistical coordination between the hospitals, from transfer initiation to operative readiness, this factor was crucial to consider in the study, as the duration of the operation is a well-known predictor of outcomes [14, 15]. Telemedicine integration represents the next logical evolution for this program. Real-time virtual consultations can facilitate early triage decisions, optimize patient stabilization prior to transfer, and reduce unnecessary referrals, the efficacy of such programs was also demonstrated in Morh et al. study [16]. Standardized digital documentation and dedicated transfer coordination teams may further streamline operations, decrease time to surgery, and improve outcomes.

The findings of this study provide actionable insights into optimizing IHT programs for cardiac surgical patients. The demonstrated ability to transfer emergent patients with a median time-to-surgery of only 4 h confirms that well-structured interfacility logistics can meet the critical time demands of life-threatening cardiac conditions. This supports the broader implementation of time-targeted transfer protocols, particularly for patients at high risk for preoperative shock or myocardial infarction. Furthermore, the observed trend toward increased urgent referrals over time suggests that program transparency and reliability foster greater trust among referring clinicians—a factor that may enhance early identification and mobilization of at-risk patients. The stable proportion of emergent cases, despite rising volumes, highlights the system’s resilience and scalability. These results argue for wider adoption of standardized triage tools and escalation pathways within regional hospital networks. Integration of telemedicine and dedicated transfer coordinators, as proposed, would not only improve clinical decision-making but also reduce time-to-treatment disparities—an especially relevant factor in geographically distributed healthcare systems.

Notably, several measures could further enhance the IHT process:

• Implementing standardized triage criteria across referring centers [17].

• Establishing dedicated IHT coordinators [18].

• Enhancing pre-transfer stabilization protocols [19].

• Incorporating predictive risk stratification tools to assist with surgical prioritization [20].

The Spanish-German engineering company Siemens Gamesa has decided to shelve plans for an offshore wind turbine nacelle factory at the Port of Esbjerg in Denmark.

Siemens Gamesa told offshoreWIND.biz that the Port of Esbjerg remains a key hub for its offshore wind activities and that the company continues to assess potential investment options there.

“Siemens Gamesa has maintained a longstanding presence at the Port of Esbjerg, which is a strategically important location for our offshore wind operations, also in the future. Like in any other place, we continue to evaluate potential investment opportunities,” said the spokesperson.

“ However, given the current market conditions, any such decision will require greater clarity and stability in the industry.”

In 2022, Siemens Gamesa announced that it would be the first tenant to Port of Esbjerg’s new warehouse facility, planned to handle components used in the offshore wind market.

The 35-metre-high hall is capable of accommodating port-related and assembly activities.

Siemens Gamesa will supply SG 14-236 DD turbines to the 1.1 GW Thor offshore wind in Denmark. Wind turbine installation is scheduled to start next year and will be carried out from the Port of Esbjerg.

Last week, another wind turbine manufacturer, Vestas, announced that it would put its plans to open a factory in Poland on hold.

The facility would produce blades for its flagship offshore wind turbine, the V236-15.0 MW.

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This meta-analysis demonstrates that SGLT2 inhibitors confer significant benefit in patients with HFpEF by reducing the composite outcome of cardiovascular death or hospitalization for heart failure. These findings align with major trials such as EMPEROR-Preserved and DELIVER [5, 8]. The reduction in HF hospitalization is particularly meaningful, reflecting an important improvement in morbidity for this complex patient population.

The lack of a statistically significant effect on all-cause mortality, despite a favorable trend, merits careful interpretation. This observation likely reflects the heterogeneity of HFpEF phenotypes and the limited modulation of natriuretic peptides observed in this subgroup, as noted in recent evidence.¹⁷ Even in advanced HFrEF, where stronger mortality signals have been observed, SGLT2 inhibitors may exert their benefits predominantly through metabolic and renal pathways rather than direct hemodynamic effects. This underscores the complexity in translating mechanistic improvements into mortality reductions, particularly in HFpEF [20, 21].

The use of an LVEF > 40% threshold in our inclusion criteria, though broader than the conventional ≥ 50% definition, was deliberately chosen to reflect contemporary trial designs and clinical practice patterns. This approach facilitates methodological consistency with EMPEROR-Preserved and DELIVER [5, 8]. and ensures that our findings are applicable to both HFpEF and the adjacent HFmrEF population; a clinically relevant spectrum where therapeutic options have historically been limited.

Recent meta-analytic data further illuminate the potential role of SGLT2 inhibitors in promoting favorable cardiac remodeling. Fan and Guo demonstrated that SGLT2i therapy significantly reduced left ventricular mass index, left atrial volume index, and E/e′ ratio, while modestly improving LVEF and lowering NT-proBNP levels [22]. Additional studies by Moras et al. and Alcidi et al. reinforce these findings, suggesting improvements in global longitudinal strain, myocardial mechanics, and diastolic function [21, 23]. While these surrogate endpoints do not directly translate into mortality reductions, they provide compelling mechanistic support for the clinical utility of SGLT2 inhibitors [21].

The modest improvement in KCCQ scores observed in our analysis complements the reduction in HF hospitalization risk and highlights the multidimensional benefit profile of SGLT2 inhibitors. The pooled mean difference of approximately + 1.8 points, while small, suggests a consistent effect on patient-reported symptoms and function, reinforcing their therapeutic relevance beyond hard clinical endpoints [2,3,4].

Our findings must be interpreted in the context of several limitations. We did not perform formal subgroup or sensitivity analyses by diabetes status, type of SGLT2 inhibitor, geographic region, or baseline patient characteristics, as stratified data were inconsistently reported across trials. This limitation reflects the inherent constraints of study-level meta-analysis and highlights the need for future patient-level meta-analytic approaches to assess potential treatment effect heterogeneity. Additionally, variability in baseline patient characteristics and trial inclusion criteria may have contributed to moderate statistical heterogeneity observed for the primary composite outcome.

In terms of potential bias, most included trials were methodologically rigorous with adequate randomization and allocation concealment. The principal sources of potential bias included incomplete outcome data from loss to follow-up and lack of blinding of outcome assessors, though these risks were generally low or moderate.

The absence of a significant effect on all-cause mortality contrasts with the substantial mortality reductions observed in large HFrEF trials such as DAPA-HF and EMPEROR-Reduced [4, 5], further underscoring differences in disease biology and therapeutic responsiveness between HF phenotypes. The benefits observed in these HFrEF trials, including reductions in cardiovascular death and HF hospitalization and improvements in KCCQ scores, provide important context for interpreting the more modest-but still clinically meaningful; effects seen in HFpEF [18].