Journal and News Scan

Infective endocarditis (IE) remains one of the most challenging diseases of modern times. It is associated with high mortality and morbidity despite significant improvements in diagnostic and surgical skills, and antibiotic pretreatment. 
 
Every study contributes to the knowledge of this often-lethal disease, but one of the ongoing challenges is determining which patients are likely to survive and how survival in general can be improved. Currently, between 52.9 percent and 58.9 percent of patients with IE have a theoretical indication for surgery. However, valve surgery is only performed in approximately 40 percent of cases. Several scoring systems, such as EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS, have been evaluated to assess the operability of a given patient, but the utility of these scores remains questionable. 
 
While 30-day mortality is considered an outdated tool for evaluating surgical quality, and abandoning this concept has been suggested as mortality seems to increase after 30 days, the authors decided to use it nonetheless, as none of the mentioned scores are sufficiently conclusive. To justify this approach, all-hospital death was also included in the analysis. Thus, a retrospective analysis of the endocarditis registry was performed to evaluate risk factors for 30-day mortality and, in turn, explore the question of operability and the potential benefit of surgical intervention for these critically ill patients. 

Proper preservation of the myocardium during intraoperative ischemia is a critical predictor of satisfactory clinical outcomes. However, there can be a wide degree of diversity in myocardial damage among patients receiving the same cardioplegic solution. The efficacy of cardioplegia-induced arrest can be affected by other factors, which may become apparent in more demanding clinical scenarios, such as in patients with impaired contractility at baseline. This study aims to identify these factors and assess their impact on postoperative myocardial damage. 
 
Cardioprotection is important in patients with heart failure, as the effects of inadequate cardioprotection are particularly pronounced in this patient population. Two well-established protocols are used for cardioplegia in these cases: del Nido cardioplegia (DN) and cold blood cardioplegia (CB).  Several prospective trials have evaluated the use of the del Nido protocol, but none specifically address patients with significantly impaired contractility. Therefore, current guidelines on cardiopulmonary bypass in adult cardiac surgery recommend applying the DN protocol in low-risk cases with short aortic cross-clamp times (CCTs) to minimize surgical interruptions caused by repeated perfusion of cardioplegia. Blood cardioplegia has a longer history, and its efficacy is well documented. Many surgeons consider it the most efficient protocol, particularly in ischemic or damaged myocardium, as supported by clinical studies. 
 
The decision on whether to use DN or CB is made by the surgeon, with each case treated individually. Factors that are taken into consideration include the complexity of the procedure, the estimated duration of the CCT, the risk of fluid overload in patients with heart failure or kidney disease, the potential for allergies to lidocaine, the rationale for additional cardioplegia doses (selective graft perfusion), and the patient's blood morphology parameters. 
 
Due to the differences in protocols, it is necessary to address the entire cohort and evaluate the impact of the analyzed determinants for each cardioplegia method separately. The leading hypothesis is that patients' baseline characteristics and operative determinants may impact the efficacy of cardioprotection during surgery, but this effect may vary depending on the solution used. 

This study analyzed the incidence of malperfusion in acute Type A aortic dissection using data from 9,958 patients in the Society of Thoracic Surgeons Adult Cardiac Surgery Database 2017-2020. Preoperative malperfusion occurred in 27.7 percent of cases and was linked to significantly higher operative morality, particularly for contrary and mesenteric malperfusion. The findings indicated that partial arch replacement did not increase mortality compared to ascending aorta or hemiarch replacement alone, regardless of malperfusion status.

In this study, the authors evaluated the organ-protective efficacy of postoperative glucocorticoid in patients with type A aortic dissection. Patients were randomly assigned to receive either postoperative glucocorticoid or standard-of-care treatment. Intravenous methylprednisolone was administered for three days. The primary outcome was the reduction of Sequential Organ Failure Assessment (SOFA) score on postoperative day four compared to baseline (on postoperative day one, before methylprednisolone administration). A total of 212 patients (106 patients in each group) were included in the intention-to-treat analysis. The primary outcome differed significantly between groups: SOFA score reduction was 3.16 plus or minus 2.52 in the control group versus 4.36 plus or minus 2.82 in the glucocorticoid group (absolute difference 1.20 [95 percent CI 0.52–1.93], P = 0.001). The glucocorticoid group showed markedly lower median high-sensitivity C-reactive protein levels compared to the control group (91.0 mg/l vs 182.0 mg/l; absolute difference: –91 [95 percent CI –122 to –57], P = 0.009) on postoperative day four. Fewer patients in the glucocorticoid group required continuous renal replacement therapy (8.5 percent vs 19.8 percent in the control group; absolute difference: –10.4 [95 percent CI –19.1 to –1.3], P = 0.03). These findings advocate for the implementation of glucocorticoids in the early phase after type A aortic dissection surgery for enhanced organ protection.