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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]

Background: A neurocognitive decline is an undesirable event that can be observed in patients after cardiac surgery. It has been related to the use of cardiopulmonary bypass (CPB). Minor embolic or hyperinflammatory mechanisms are thought to be responsible. In this issue of the Journal of Cardiac Surgery, the neurocognitive decline was observed in 22 of 30 patients after cardiac surgery with CPB. Repeatable neuropsychological status tests were used and scores 4 days after surgery were 5%–15% lower than before. Mechanistic investigations with glycemic control and transcriptomic and cytokine analyses failed to provide an explanation but the frequency of this observation is worrisome. Discussion: However, available evidence suggests that neurocognitive dysfunction disappears within a few months, and later on no difference to controls that did not undergo surgery can be detected. In addition, similar degrees of neurocognitive dysfunction can be observed after noncardiac surgery and even after percutaneous coronary intervention (PCI). A most recent comparison of memory decline after CABG and PCI also suggests no difference between the two invasive treatment options for coronary artery disease. All these findings argue against a primarily CPB‐associated mechanism. Interestingly, test subjects from a consumer investigation showed a 10% decline in their working memory just by placing their cell phone on the table, suggesting that being distracted may also affect neurocognitive function. Given the reversibility of surgery‐ and intervention‐associated neurocognitive dysfunction, we question destructive, embolic, or inflammatory‐associated mechanisms. Distractive aspects of intervention‐associated stress may also play a role. Conclusion: In any case, neurocognitive decline after cardiac surgery does not appear to be surgery‐specific. [ABSTRACT FROM AUTHOR]

Background Isolated tricuspid valve (TV) surgery is considered a high risk-procedure. The optimal surgical approach is controversial. We analyzed our experience with isolated TV redo surgery performed either minimally invasively (redo-MITS) or through sternotomy. Methods We retrospectively analyzed all patients with previous cardiac surgery who underwent redo-MITS (n ¼ 26) and compared them to redo-Sternotomy (n ¼ 17). A group of primary-MITS (n ¼ 61) served as control. Results The redo-MITS approach consisted of a right anterolateral mini-thoracotomy, transpericardial right atrial access, and beating heart TV surgery without caval occlusion. Redo-MITS patients were oldest and had the most comorbidities (EuroScore II: 9.83 ± 6.05% versus redo-Sternotomy: 8.42 ± 7.33% versus primary-MITS: 4.15 ± 4.84%). There were no intraoperative complications or conversions to sternotomy in both MITS groups. Redo-Sternotomy had the highest 30-day mortality (24%), the poorest long-term survival, and the highest perioperative complication rate. Redo- MITS did not differ in perioperative outcome from primary-MITS. Multivariable logistic regression analysis identified redo-Sternotomy (odds ratio [OR] ¼ 9.76; 95% confidence interval [CI] 1.88-63.26), liver cirrhosis (OR ¼ 9.88; 95% CI 2.20-54.20), and body mass index (BMI) (OR ¼ 1.16; 95% CI 1.02-1.35) as independent predictors of 30- day mortality. The Cox model revealed redo-Sternotomy (hazard ratio [HR] ¼ 2.67; 95% CI 1.18-6.03), liver cirrhosis (HR ¼ 3.31; 95% CI 1.45-7.58), and pulmonary hypertension (HR ¼ 2.26; 95% CI 1.04-4.92) as risk factors for poor long-termsurvival. TV surgery significantly reduces NYHA class. Conclusion Minimally invasive, isolated TV surgery as reoperation without caval occlusion and on the beating heart can be safe and may improve clinical outcome. [ABSTRACT FROM AUTHOR]