Impact of perioperative liver dysfunction on in-hospital mortality and long-term survival in infective endocarditis patients

European System for Cardiac Operative Risk Evaluation II and Liver Dysfunction

Background: The importance of liver dysfunction in predicting mortality in patients undergoing cardiovascular surgery is an important topic due to the general desire to improve current risk scores such as EUROSCORE II (European System for Cardiac Operative Risk Evaluation), with EUROSCORE III being currently under development. The model for End-Stage Liver Disease (MELD) Score has already proven its utility in predicting outcomes for patients undergoing abdominal, cardiovascular or urological surgery. In the present study, we want to see its usefulness in proving the postoperative mortality in patients undergoing coronary artery bypass surgery. Methods: This was a retrospective study, and it included 185 patients, with 93 survivors being randomly chosen from a total of 589 surviving patients using age, emergency and the weight of cardiac procedures as criteria to match the 92 deceased patients during hospitalization in the postoperative period who underwent coronary artery bypass grafting (CABG) alone or CABG and other concomitant cardiovascular interventions during a 10-year period of time. We calculated for all these patients, at the time of admission, the MELD Score and EUROSCORE II, and we analyzed the predictive performance of the two scores and their constituents. Results: In the multivariable model, patients with a MELD Score ≥ 5.54 had a 2.38-fold increased risk of death (95% C.I.: 1.43-3.96, p = 0.001), while those with a EUROSCORE ≥ 10.37 had a 8.66-fold increased risk of death (95% C.I.: 3.09-24.29, p < 0.001). After combining the two scores, the conditional scenario achieved a high overall accuracy of 84.32% (p < 0.001) in predicting mortality. Conclusions: Patients with a MELD Score ≥ 5.54, had good sensitivity and a very good specificity in terms of mortality prediction, but the conditional scenario, leveraging both risk scores, i.e., the MELD Score and EUROSCORE, offers the highest utility in terms of enhancing mortality prediction regarding these patients.

Isolated mitral valve endocarditis: Patient, disease, and surgical factors that influence outcomes

OBJECTIVE

The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis.

METHODS

From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning.

RESULTS

Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival.

CONCLUSIONS

A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement.

Risk Factors and Outcomes of Postoperative Hepatic Dysfunction After Lung Transplantation

BACKGROUND

Hepatic dysfunction is a morbid complication of lung transplantation. Little is known about risk factors for postoperative hepatic dysfunction or its impact on survival after lung transplantation.

METHODS

This retrospective analysis of 1406 adult lung transplant recipients was performed at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania between January 1, 2007 and December 1, 2019. Patients were excluded for redo lung transplantation, concomitant cardiac surgery, or concurrent solid organ transplantation. Postoperative liver dysfunction was classified as either ischemic liver injury or nonischemic dysfunction (transaminitis, hyperbilirubinemia).

RESULTS

Among the 1155 primary lung transplant recipients included, postoperative hepatic dysfunction developed in 96 (8.3%) after lung transplantation. A history of liver disease was the greatest predictor of postoperative hepatic dysfunction (odds ratio, 6.19; CI, 2.13-17.4; P < .001). Patients with postoperative hepatic dysfunction had a greater need for intraoperative blood products (ischemic, 12 U [range, 6-21 U]; nonischemic, 10 U [range, 4-28 U]; vs none, 4 U [range, 1-12 U]; P < .001) and an increased need for postoperative circulatory support (ischemic, 16 [76%]; nonischemic, 25 [33%]; none, 117 [11%]; P < .001). Both ischemic liver injury and nonischemic dysfunction were associated with diminished 1-, 3-, and 5-year term survival (ischemic, 27.5%, 16.5%, and 0%, respectively; nonischemic, 60%, 49.6%, and 46.9%, respectively; none, 87.3%, 72.3%, and 59.5%, respectively; P < .001).

CONCLUSIONS

Hepatic dysfunction after lung transplantation is associated with significant morbidity and mortality. A history of liver disease was the best positive predictor for postoperative dysfunction. Additional studies are necessary to identify the best treatment algorithm to avoid hepatic dysfunction more effectively in the postoperative setting after lung transplantation.

Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation

Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.

Association of liver dysfunction with outcomes after cardiac surgery-a meta-analysis

OBJECTIVES

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Epigallocatechin-3-gallate ameliorates liver injury secondary to Pseudomonas aeruginosa pneumonia

Pseudomonas aeruginosa is a dangerous pathogen causing nosocomial pneumonia. P. aeruginosa infection-induced liver damage is another fatal threat, and antibiotic treatment is not effective in relieving P. aeruginosa virulence-triggered damage. We here evaluated the protective effect of epigallocatechin gallate (EGCG), a substance that inhibits virulence of P. aeruginosa through quorum quenching, on liver damage secondary to P. aeruginosa infection. Mice were pretreated with EGCG (20, 40, and 80 mg/kg) for 3 days, and then infected with P. aeruginosa through intratracheal instillation to model acute pneumonia. The mice were sacrificed after 24 h of infection, and samples were harvested for subsequent analysis. EGCG significantly decreased the serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Histopathological changes of liver were significantly ameliorated by EGCG. It also significantly reduced oxidative stress that induced liver damage in P. aeruginosa infection, which relied not on the activation of the Nrf2-HO-1 pathway but on the upregulation of the activity of antioxidative enzymes. Then, the inflammatory response in the liver was tested. EGCG inhibited the release of pro-inflammatory cytokines (TNF-α, IL-1β, and IL-6) by blocking the inflammation regulating signaling of the TLR4-myD88-NF-κB pathway. EGCG upregulated the activation of nuclear receptors to stronger the liver protective activity against P. aeruginosa infection. Conclusively, EGCG exhibited a significant hepatoprotective effective against P. aeruginosa infection.

Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients

Organ dysfunction or overt failure is a commonplace event in the critically ill affecting up to 70% of patients during their stay in the ICU. The outcome depends on the resolution of impaired organ function, while a domino-like deterioration of organs other than the primarily affected ones paves the way for increased mortality. “Acute Liver Failure” was defined in the 1970s as a rare and potentially reversible severe liver injury in the absence of prior liver disease with hepatic encephalopathy occurring within 8 weeks. Dysfunction of the liver in general reflects a critical event in “Multiple Organ Dysfunction Syndrome” due to immunologic, regulatory and metabolic functions of liver parenchymal and non-parenchymal cells. Dysregulation of the inflammatory response, persistent microcirculatory (hypoxic) impairment or drug-induced liver injury are leading problems that result in “secondary liver failure,” i.e., acquired liver injury without underlying liver disease or deterioration of preexisting (chronic) liver disease (“Acute-on-Chronic Liver Failure”). Conventional laboratory markers, such as transaminases or bilirubin, are limited to provide insight into the complex facets of metabolic and immunologic liver dysfunction. Furthermore, inhomogeneous definitions of these entities lead to widely ranging estimates of incidence. In the present work, we review the different definitions to improve the understanding of liver dysfunction as a perpetrator (and therapeutic target) of multiple organ dysfunction syndrome in critical care.

Graphic Abstract

The prognostic significance of postoperative hyperbilirubinemia in cardiac surgery: systematic review and meta-analysis

Background

Hyperbilirubinemia following cardiac surgery is a common phenomenon and is of emerging interest in prognostic factor research. This systematic review and meta-analysis evaluated the association between post-operative hyperbilirubinemia (PH) and mortality and morbidity in cardiac surgery patients.

Methods

Ovid Medline and Ovid Embase were searched from inception to July 2020 for studies evaluating the prognostic significance of PH following cardiac surgery. Maximally adjusted odds ratios (OR) with associated confidence intervals were obtained from each study and pooled using random effects inverse variance modelling to assess in-hospital mortality. Standardised mean differences were pooled to assess Intensive Care Unit (ICU) and hospital length of stay (LOS). Qualitative analysis was performed to assess ventilation requirements and long-term mortality. Meta-regression was used to assess inter- and intra-study heterogeneity.

Results

3251 studies satisfied the selection criteria, from which 12 studies incorporating 3876 participants were included. PH significantly predicted in-hospital mortality with a pooled OR of 7.29 (95% CI 3.53, 15.09). Multiple pre-defined covariates contributed to the prognostic significance of PH, however only aortic cross-clamp time (p < 0.0001) and number of transfusions (p = 0.0001) were significant effect modifiers. PH significantly predicted both ICU LOS (Mean difference 1.32 [95% CI 0.04–2.6]) and hospital LOS (Mean difference 1.79 [95% CI 0.36–3.21]). Qualitative analysis suggested PH is associated with increased post-operative ventilation requirements and reduced long-term survival rates.

Conclusions

Hyperbilirubinemia is a cost-effective, widely available prognostic marker of adverse outcomes following cardiac surgery, albeit with residual sources of heterogeneity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01870-2.

Impact of Valve Culture Positivity on Prognosis in Patients with Infective Endocarditis Who Underwent Valve Surgery

Introduction

Infective endocarditis (IE) is a severe and fatal infection with high in-hospital and overall mortality rates of approximately up to 30%. Valve culture positivity was associated with in-hospital mortality and postoperative complications; however, few studies have analyzed the relationship between valve cultures and overall mortality over a long observation period. This study aimed to compare the association of valve culture positivity with overall mortality in patients with IE who underwent valve surgery.

Methods

A total of 416 IE patients admitted to a tertiary hospital in South Korea from November 2005 to August 2017 were retrospectively reviewed. A total of 202 IE patients who underwent valve surgery and valve culture were enrolled. The primary endpoint was long-term overall mortality. Kaplan–Meier curve and Cox proportional hazards model were used for survival analysis.

Results

The median follow-up duration was 63 (interquartile range, 38–104) months. Valve cultures were positive in 22 (10.9%) patients. The overall mortality rate was 15.8% (32/202) and was significantly higher in valve culture-positive patients (36.4%, p = 0.011). Positive valve culture [hazard ratio (HR) 3.921, p = 0.002], Charlson Comorbidity Index (HR 1.181, p = 0.004), Coagulase-negative staphylococci (HR 4.233, p = 0.001), new-onset central nervous system complications (HR 3.689, p < 0.001), and new-onset heart failure (HR 4.331, p = 0.001) were significant risk factors for overall mortality.

Conclusions

Valve culture positivity is a significant risk factor for long-term overall mortality in IE patients who underwent valve surgery. The importance of valve culture positivity needs to be re-evaluated, as the valve culture positivity rate increases with increasing early surgical intervention.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

The risk factors and outcomes of preoperative hepatic dysfunction in patients who receive surgical repair for acute type A aortic dissection

Background

Hepatic dysfunction (HD) is a common complication that can occur after surgical repair of acute type A aortic dissection (ATAAD) and is associated with poor prognosis. However, the incidence of early preoperative HD and the associated risk factors in patients with ATAAD have not been fully elucidated.

Methods

A total of 984 ATAAD patients who received surgical repair within 48 hours of symptom onset at our department from January 2014 to December 2019 were retrospectively analyzed. Patients were divided into the non-HD group and the HD groups according to the Model of End-Stage Liver Disease (MELD) score before surgery. The clinical parameters and clinical outcomes of the 2 groups were collected and compared.

Results

Preoperative HD was detected in 268 patients (27.2%). The incidence of in-hospital complications, including the need for dialysis (34.0% vs. 9.2%; P<0.001), was significantly higher in patients with HD compared to patients without HD (69.8% vs. 51.0%; P<0.001). Patients with HD had a higher 30-day mortality rate compared to patients without HD (20.1% vs. 8.4%; P<0.001). Multivariate analysis demonstrated that preoperative cardiac tamponade, preoperative serum creatinine levels, and serum troponin T levels upon admission were independent predictors for preoperative HD in patients with ATAAD. Interestingly, even though preoperative HD was associated with an increased 30-day mortality rate, it did not significantly affect the long-term mortality rate (log-rank P=0.259).

Conclusions

Early HD before surgery was commonly observed in patients with ATAAD and was associated with increased in-hospital complications after surgery, but did not significantly affect long-term survival.

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

BACKGROUND

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE.

METHODS

We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan-Meier survival estimates.

RESULTS

CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82-1.23, p = 0.998).

CONCLUSION

In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.

Using Machine Learning to Predict Postoperative Liver Dysfunction After Aortic Arch Surgery

OBJECTIVES

The study compared machine-learning models with traditional logistic regression to predicting liver outcomes after aortic arch surgery.

DESIGN

Retrospective review from January 2013 to May 2017.

SETTING

Fuwai Hospital.

PARTICIPANTS

The study comprised 672 consecutive patients who had undergone aortic arch surgery.

MEASUREMENTS AND MAIN RESULTS

Three machine-learning methods were compared with logistic regression with regard to the prediction of postoperative liver dysfunction (PLD) after aortic arch surgery. The perioperative characteristics, including the patients' baseline medical condition and intraoperative data, were analyzed. The performance of the models was assessed using the area under the receiver operating characteristic curve. Naïve Bayes had the best discriminative ability for the prediction of PLD (area under the receiver operating characteristic curve = 0.77) compared with random forest (0.76), support vector machine (0.73), and logistic regression (0.72). The primary endpoint of PLD was observed in 185 patients (27.5%). The cardiopulmonary bypass time, long surgery time, long aortic clamp time, high preoperative bilirubin value, and low rectal temperature were strongly associated with the development of PLD after aortic arch surgery.

CONCLUSION

The machine-learning method of naïve Bayes predicts PLD after aortic arch surgery significantly better than traditional logistic regression.

Association between high dose catecholamine support and liver dysfunction following cardiac surgery

BACKGROUND

Cardiac surgery using cardiopulmonary bypass is a well-established procedure. However, up to 20% to 30% of patients require high dose vasopressor or inotropic support following surgery, enhancing the risk of organ dysfunction and impacting mortality. Nonalcoholic fatty liver disease (NAFLD) is a frequent finding in these patients and may be involved in the pathophysiology of vasoplegia and cardiac failure.

METHODS

Retrospective analysis of 463 patients undergoing elective cardiac surgery in 2014 at our institution. NAFLD was defined using the NAFLD fibrosis score and the vasoactive-inotropy score was used to determine postoperative vasopressor and inotropic dependency.

RESULTS

Patients with NAFLD more often presented with high vasopressor or inotropic support compared to patients without NAFLD, resulting in significant differences after 6 hours (n = 20 [27.0%] of 74 patients), 12 hours (n = 20 [27.0%] of 74 patients), and on the first postoperative day (n = 12 [16.4%] of 73 patients) of intensive care unit (ICU) treatment. Multivariate analysis revealed time of catecholamine application (P = .001), preoperative left ventricular ejection fraction (P = .001), type of surgery (P = .001), model of endstage liver disease on hospital admission (P = .002), pre-existing pulmonary hypertension (P = .004) and NAFLD-time interaction (P = .05) as independent predictors of high vasopressor and inotropic support. Patients with NAFLD had higher degrees of extrahepatic organ dysfunction, were more dependent on hemodialysis, spent more days in the ICU and within the hospital. Patients with NAFLD and high catecholamine support had the highest mortality rates among the study population.

CONCLUSIONS

NAFLD is a common finding in elective cardiac surgery patients. Anesthesiologists and intensivists should be sensitive for the specific risk profile of this population.

Changes in inflammatory and vasoactive mediator profiles during valvular surgery with or without infective endocarditis: A case control pilot study

Background

More than 50% of patients with infective endocarditis (IE) develop an indication for surgery. Despite its benefit, surgery is associated with a high incidence of multiple organ dysfunction syndrome (MODS) and mortality, which may be linked to increased release of inflammatory mediators during cardiopulmonary bypass (CPB). We therefore assessed plasma cytokine profiles in patients undergoing valve surgery with or without IE.

Methods

We performed a prospective case-control pilot study comparing patients undergoing cardiac valve surgery with or without IE. Plasma profiles of inflammatory mediators were measured at 7 defined time points and reported as median (interquartile). The degree of MODS was measured using sequential organ failure assessment (SOFA) score.

Results

Between May and December 2016 we included 40 patients (20 in each group). Both groups showed similar distribution of age and gender. Patients with IE had higher preoperative SOFA (6.9± 2.6 vs 3.8 ± 1.1, p<0.001) and operative risk scores (EuroSCORE II 18.6±17.4 vs. 1.8±1.3, p<0.001). In-hospital mortality was higher in IE patients (35% vs. 5%; p<0.001). Multiple organ failure was the cause of death in all non-survivors. At the end of CPB, median levels of following inflammatory mediators were higher in IE compared to control group: IL-6 (119.73 (226.49) vs. 24.48 (40.09) pg/ml, p = 0.001); IL-18 (104.82 (105.99) vs. 57.30 (49.53) pg/ml, p<0.001); Mid-regional pro-adrenomedullin (MR-proADM) (2.06 (1.58) vs. 1.11 (0.53) nmol/L, p = 0.003); MR- pro-atrial natriuretic peptide (MR-proANP) (479.49 (224.74) vs. 266.55 (308.26) pmol/l, p = 0.028). IL-1β and TNF- α were only detectable in IE patients and first after starting CPB. Plasma levels of IL-6, IL-18, MRproADM, and MRproANP during CPB were significantly lower in survivors than in those who died.

Conclusion

The presence of infective endocarditis during cardiac valve surgery is associated with increased inflammatory response as evident by higher plasma cytokine levels and other inflammatory mediators. Actively reducing inflammatory response appears to be a plausible therapeutic concept.

Trial registration

ClinicalTrials.gov, ID: NCT02727413.

Effect of conjugated bilirubin on clinical outcomes in infective endocarditis

Liver dysfunction is associated with adverse events in infective endocarditis (IE). However, few studies have explored the predictive value of conjugated bilirubin (CB) in IE. We aimed to investigate the nature of the link between CB and adverse prognosis in patients with IE. Consecutive patients with IE between January 2009 and July 2015 were enrolled. Multivariate analysis was performed to confirm whether CB was an independent risk factor for adverse outcomes. In all, 1010 patients were included and divided into two groups according to admission CB level (μmol/L): normal (≤ 7.0, n = 820) and elevated (> 7.0, n = 190) CB groups. In-hospital mortality (5.0% vs. 22.1%, p < 0.001) and major adverse cardiac events (16.8% vs. 36.3%, p < 0.001) were significantly higher in patients with increased CB. A possible J-shaped relationship was found between CB and in-hospital events. Further, CB had more predictive power than total bilirubin in predicting in-hospital death (AUC 0.715 vs. 0.674, p = 0.010). Elevated CB was an independent predictor of in-hospital death (adjusted OR = 2.62, 95%CI 1.40-4.91, p = 0.003). Moreover, CB (increment 1 μmol/L) was independently associated with higher long-term mortality. Kaplan-Meier curves indicated that patients with elevated CB were associated with higher cumulative rate of long-term death (log-rank = 21.47, p < 0.001). CB, a biomarker of liver function, was a relatively powerful predictor of in-hospital and long-term adverse prognosis of IE and could likely comprise a novel risk evaluation strategy.

Cardiac surgery 2017 reviewed

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term "cardiac surgery". This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

S. aureus endocarditis: Clinical aspects and experimental approaches

Infective endocarditis (IE) is a life-threatening disease, caused by septic vegetations and inflammatory foci on the surface of the endothelium and the valves. Due to its complex and often indecisive presentation the mortality rate is still about 30%. Most frequently bacterial microorganisms entering the bloodstream are the underlying origin of the intracardiac infection. While the disease was primarily restricted to younger patients suffering from rheumatic heart streptococci infections, new at risk categories for Staphylococcus (S.) aureus infections arose over the last years. Rising patient age, increasing drug resistance, intensive treatment conditions such as renal hemodialysis, immunosuppression and long term indwelling central venous catheters but also the application of modern cardiac device implants and valve prosthesis have led to emerging incidences of S. aureus IE in health care settings and community. The aetiologic change has impact on the pathophysiology of IE, the clinical presentation and the overall patient management. Despite intensive research on appropriate in vitro and in vivo models of IE and gained knowledge about the fundamental mechanisms in the formation of bacterial vegetations and extracardiac complications, improved understanding of relevant bacterial virulence factors and triggered host immune responses is required to help developing novel antipathogenic treatment strategies and pathogen specific diagnostic markers. In this review, we summarize and discuss the two main areas affected by the changing patient demographics and provide first, recent knowledge about the pathogenic strategies of S. aureus in the induction of IE, including available experimental models of IE used to study host-pathogen interactions and diagnostic and therapeutic targets. In a second focus we present diagnostic (imaging) regimens for patients with S. aureus IE according to current guidelines as well as treatment strategies and surgical recommendations.