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This document is a reply to a letter from Dr. Condello regarding a review on myocardial protection. The authors of the review agree with Dr. Condello's comments on technical aspects such as post-conditioning, the impact of aortic regurgitation on cardioplegia delivery, and differences in delivery routes. They also acknowledge that there are other factors to consider, such as the timing and temperature of cardioplegia delivery. However, the authors emphasize that none of these individual factors have been shown to make a significant difference in myocardial protection. They believe that the quality of myocardial protection is more related to the surgeon's attention to avoiding damage rather than one specific aspect. The authors appreciate the discussion and consider it valuable for surgeons to adapt their myocardial protection strategies as needed. [Extracted from the article]

Open in new tab Download slide Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20–20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions. [ABSTRACT FROM AUTHOR]

The article discusses the importance of valve competence in heart surgery and its impact on patient life expectancy. It explains that the mechanical correction of valve competency is a focus of therapy because medical treatment is unable to cure the problem. The article compares the durability of repair strategies for functional and structural regurgitation and suggests that the lack of repair durability in functional regurgitation may be responsible for the inability to demonstrate a survival impact. The article also presents a technique for repair of functional tricuspid regurgitation that potentially improves durability. Overall, the article emphasizes the need for lasting repair successes in valve surgery to improve patient outcomes. [Extracted from the article]

Open in new tab Download slide OBJECTIVES Multi-organ failure is one of the leading causes of mortality after cardiac surgery for infective endocarditis (IE). Although the randomized evidence does not support the use of haemoadsorption during cardiac surgery for IE, observational studies suggest a beneficial effect in selected patient groups. Staphylococcus aureus is the most common pathogen, and its presence is an independent mortality predictor. We aimed to analyse the effect of haemoadsorption in patients with IE caused by S. aureus. METHODS This is a post hoc analysis of the REMOVE trial that randomized 288 patients with IE who underwent cardiac surgery with haemoadsorption using CytoSorb® or control. The primary outcome was ΔSequential Organ Failure Assessment (SOFA), defined as the difference between the mean total postoperative and baseline SOFA score within 24 h of surgery. RESULTS Among the total of 282 patients included in the modified intention-to-treat analysis of the REMOVE trial, 73 (25.9%) had S. aureus IE (38 patients in the haemoadsorption group and 35 patients in the control group). The overall ΔSOFA did not differ between the intervention groups in patients with S. aureus IE (mead difference = −0.4, 95% confidence interval −2.3 to 1.4, P  = 0.66) and neither did 30-day mortality (hazard ratios = 1.32, 95% confidence interval 0.53–3.28, P  = 0.55). No differences were observed with regard to any of the other secondary outcomes. CONCLUSIONS Based on a post hoc analysis from REMOVE trial, the intraoperative use of haemoadsorption in patients with S. aureus IE was not associated with reduction of postoperative organ dysfunction, 30-day mortality or other major clinical end points. [ABSTRACT FROM AUTHOR]