Background: Intracranial hemorrhage (ICH) is one of the main causes for lack of surgery in patients with infective endocarditis (IE), despite the presence of surgical indications. We aimed to evaluate the impact of early surgery in patients with IE and with ICH on postoperative neurological deterioration and all‐cause mortality and to elucidate the risk of 30‐day mortality in patients who were denied surgery. Methods and Results: Three libraries (MEDLINE, EMBASE, and Cochrane Library) were assessed. The primary outcome was all‐cause mortality, and the secondary outcome was neurological deterioration. Inverse variance method and random model were performed. We identified 16 studies including 355 patients. Nine studies examined the impact of surgical timing (early versus late) and were included in the meta‐analysis. Only one study examined the fate of patients with IE and with ICH who were treated conservatively despite having an indication for cardiac surgery, showing higher mortality rates than those who underwent surgery (11.8% versus 2.5%). We found no significant association between early surgery, regardless of its definition, and a higher mortality (odds ratio [OR], 1.69; 95% CI, 0.95–3.02). Early surgery was associated with higher risk for neurological deterioration (OR, 2.00; 95% CI, 1.10–3.65). Conclusions: Cardiac surgery for IE within 30 days of ICH was not associated with higher mortality, but with an increased rate of neurological deterioration. The 30‐day mortality in patients with IE and with ICH who were denied surgery has not yet been sufficiently investigated. This patient group should be analyzed in future studies in more detail.

The aim of this study was to perform a meta-analysis of studies reporting outcomes in patients with liver dysfunction addressed by the model of end-stage liver disease and Child–Turcotte–Pugh scores undergoing cardiac surgery. A systematic literature search was conducted to identify contemporary studies reporting short- and long-term outcomes in patients with liver dysfunction compared to patients with no or mild liver dysfunction undergoing cardiac surgery (stratified in high and low score group based on the study cut-offs). Primary outcome was perioperative mortality. Secondary outcomes were perioperative neurological events, prolonged ventilation, sepsis, bleeding and/or need for transfusion, acute kidney injury and long-term mortality. A total of 33 studies with 48 891 patients were included. Compared with the low score group, being in the high score group was associated with significantly higher risk of perioperative mortality [odds ratio (OR) 3.72, 95% confidence interval (CI) 2.75–5.03, P < 0.001]. High score group was also associated with a significantly higher rate of perioperative neurological events (OR 1.49, 95% CI 1.30–1.71, P < 0.001), prolonged ventilation (OR 2.45, 95% CI 1.94–3.09, P < 0.001), sepsis (OR 3.88, 95% CI 2.07–7.26, P < 0.001), bleeding and/or need for transfusion (OR 1.95, 95% CI 1.43–2.64, P < 0.001), acute kidney injury (OR 3.84, 95% CI 2.12–6.98, P < 0.001) and long-term mortality (incidence risk ratio 1.29, 95% CI 1.14–1.46, P < 0.001) The analysis suggests that liver dysfunction in patients undergoing cardiac surgery is independently associated with higher risk of short and long-term mortality and also with an increased occurrence of various perioperative adverse events.

Background: Infective endocarditis represents a life‐threatening disease with high mortality rates. A fraction of patients receives exclusively conservative antibiotic treatment due to their comorbidities and high operative risk, despite fulfilling criteria for surgical therapy. The aim of the present study is to compare outcomes in patients with infective endocarditis and indication for surgical therapy in those who underwent or did not undergo valve surgery. Methods and Results: Three databases were systematically assessed. A pooled analysis of Kaplan–Meier–derived reconstructed time‐to‐event data from studies with longer follow‐up comparing conservative and surgical treatment was performed. A landmark analysis to further elucidate the effect of surgical intervention on mortality was carried out. Four studies with 3003 patients and median follow‐up time of 7.6 months were included. Overall, patients with an indication for surgery who were surgically treated had a significantly lower risk of mortality compared with patients who received conservative treatment (hazard ratio [HR], 0.27 [95% CI, 0.24–0.31], P <0.001). The survival analysis in the first year showed superior survival for patients who underwent surgery when compared with those who did not at 1 month (87.6% versus 57.6%; HR, 0.31 [95% CI, 0.26–0.37], P <0.01), at 6 months (74.7% versus 34.6%) and at 12 months (73.3% versus 32.7%). Conclusions: Based on the findings of this study‐level meta‐analysis, patients with infective endocarditis and formal indication for surgical intervention who underwent surgery are associated with a lower risk of short‐ and long‐term mortality when compared with conservative treatment.

Summary: 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.

Mitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan-Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p = 0.024, n = 3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p = 0.991, n = 620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p = 0.116, n = 1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p = 0.211, n = 288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p = 0.663, n = 3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted.

Objective: This study aimed to compare postoperative outcomes and 30-day mortality in patients with reduced ejection fraction (<40%) who underwent isolated coronary artery bypass grafting (CABG) with (ONCAB) and without (OPCAB) the use of cardiopulmonary bypass. Methods: data from four university hospitals in Germany, spanning from January 2017 to December 2021, were retrospectively analyzed. A total of 551 patients were included in the study, and various demographic, intraoperative, and postoperative data were compared. Results: demographic parameters did not exhibit any differences. However, the OPCAB group displayed notably higher rates of preoperative renal insufficiency, urgent surgeries, and elevated EuroScore II and STS score. During surgery, the ONCAB group showed a significantly higher rate of complete revascularization, whereas the OPCAB group required fewer intraoperative transfusions. No disparities were observed in 30-day/in-hospital mortality for the entire cohort and the matched population between the two groups. Subsequent to surgery, the OPCAB group demonstrated significantly shorter mechanical ventilation times, reduced stays in the intensive care unit, and lower occurrences of ECLS therapy, acute kidney injury, delirium, and sepsis. Conclusions: the study’s findings indicate that OPCAB surgery presents a safe and viable alternative, yielding improved postoperative outcomes in this specific patient population compared to ONCAB surgery. Despite comparable 30-day/in-hospital mortality rates, OPCAB patients enjoyed advantages such as decreased mechanical ventilation durations, shorter ICU stays, and reduced incidences of ECLS therapy, acute kidney injury, delirium, and sepsis. These results underscore the potential benefits of employing OPCAB as a treatment approach for patients with coronary heart disease and reduced ejection fraction.