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Cardiac surgery involves some of the most intensive and at-risk surgical procedures. Various factors, such as surgical trauma, and the extracorporeal circulation, induce complex systemic inflammatory response as well as organ-specific perioperative morbidity and mortality. Despite advancements in surgical techniques and cardiopulmonary bypass (CPB) technologies over the previous decades, cardiac surgery continues to be associated with these significantly fatal complications (
These complications are further aggravated in other complex procedures and affected by the increasingly aging population presenting for cardiac surgery. The major knowledge gaps in the prevention of these complications as well as monitoring and recovery of these at-risk patients necessitate the need for further research and innovation within these areas.
Various theories regarding the causes of these complications have emerged. The most common of these, identify inflammation, oxidative stress and ischaemia-reperfusion injury as the fundamental mechanisms underlying the pathogenesis of adverse events (
Tremendous progress has been made in this field; from understanding molecular mechanisms to discovering effective interventions in the laboratory and pre-clinical set up. However, limited data exists on the translation of these insights into everyday clinical practice. We have launched this article collection with an aim to provide a broad overview of the current and emerging research on the role of inflammation in cardiac surgery as well as the definition of best practices in this field.
This special issue on Inflammation and Heart Surgery comprises 11 papers, including 9 original articles, 1 systematic review, and 1 narrative review. The papers cover a broad range of topics focusing on current and emerging research on the role of inflammation in cardiac surgery. The original articles evaluate role of inflammation in perioperative neurocognitive decline, acute kidney injury, endothelial dysfunction, acute type A aortic dissection (ATAAD), mediastinitis, and acute lung injury (ALI) after cardiac surgical interventions. Two original articles evaluate devices while the narrative review gives a comprehensive overview of inflammation after cardiac surgery on cardiopulmonary bypass and strategies to attenuate it. Finally, the systematic review evaluates all currently available infective endocarditis (IE) risk scores to establish effectiveness of existing scores.
The spectrum of manuscripts in this special issue clearly suggests that a lot of research is going on in the arena of inflammation and heart surgery in different research avenues, all of them equally exhilarating and pertinent. However, they also highlight that we are at crossroads advancing the theory, expanding the translational evaluation, and leveraging fundamental basic science into clinical patient benefit.
The spectrum of basic science or translational research manuscripts in this collection demonstrates some exciting progress but we are still far from a comprehensive understanding of the principle dilemmas. There is no doubt, that all patients experience a degree of systemic inflammatory response with oxidative stress, leukocyte, and mediator activation but we still have not identified the global transcriptomic, proteomic and metabolic shifts that can differentiate mild and transient responses from those contributing significantly to postoperative complications. Similarly, we do not have a clear handle of patients’ perioperative phenotypes that underpin susceptibility and predisposition of some patients for a higher inflammatory response with pathogenic contribution. While a multimodality approach is advocated targeting multiple steps in the inflammatory response, such an effort will only be successful if the component contribution is relevant.
Thus, in the era of global genetics, personal phenotyping, unparallelled bioinformatics repertoire, and artificial intelligence, there is an urgent need to fully uncover the precise interactions between genetic predisposition and the multiple environmental exposure modulating the patients' biochemical and immunological responses to perioperative trauma and operative procedural factors in causing clinical harm in high risk patients. We are of the opinion that this hugely important topic has not yet mobilised the greatest partnership between basic scientists and clinicians at national and international levels to place systemic inflammatory response syndrome (SIRS) on top of the agenda of surgical sciences. We advocate bringing together the leading force of basic scientists in the field of oxidative stress, immunology, and inflammation and clinical academics covering the full perioperative spectrum of cardiac surgery to fully define what needs to be done to decode the mechanisms, mediators, effector pathways, and the most sophisticated means to target these for clinical benefit. This now needs leading international co-operation between academia, clinicians, and industry under the auspices of major international professional societies.
Lots of work has been done and we are at the crossroads of SIRS research. This special issue collates some of these research activities focusing on new research lines and potential therapeutic targets emphasising the need for international consensus development.
SR: Conceptualization, Writing – original draft, Writing – review & editing. UB: Writing – review & editing. NM: Writing – original draft, Writing – review & editing.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
The handling editor GA declared past co-authorships with the author UB.
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