The systemic inflammatory response syndrome is, at least partly, responsible for complications in children undergoing cardiac surgery with cardiopulmonary bypass (CPB), and has been the target of the prophylactic use of corticosteroids. The potential benefits and risks of corticosteroids remain controversial despite a widespread use for more than 30 years. Even though several trials demonstrated the ability of corticosteroids to modulate the inflammatory response related to CPB in children [1Schroeder V.A. Pearl J.M. Schwartz S.M. Shanley T.P. Manning P.B. Nelson D.P. Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression.Circulation. 2003; 107: 2823-2828Crossref PubMed Scopus (135) Google Scholar, 2Bronicki R.A. Backer C.L. Baden H.P. Mavroudis C. Crawford S.E. Green T.P. Dexamethasone reduces the inflammatory response to cardiopulmonary bypass in children.Ann Thorac Surg. 2000; 69: 1490-1495Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar], a pediatric meta-analysis published in 2007 [3Robertson-Malt S. El Barbary M. Prophylactic steroids for paediatric open-heart surgery: a systematic review.Int J Evid Based Healthc. 2008; 6: 391-395Crossref PubMed Scopus (7) Google Scholar] found no clinical benefit, and highlighted the paucity of data on adverse events, in particular sepsis and bleeding. A very recent publication by Clarizia and associates [4Clarizia N.A. Manlhiot C. Schwartz S.M. et al.Improved outcomes associated with intraoperative steroid use in high-risk pediatric cardiac surgery.Ann Thorac Surg. 2011; 91: 1222-1227Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] has reported a significant reduction in length of stay when 30 mg/kg methylprednisolone was given intraoperatively, and a further reduction in the duration of mechanical ventilation when additional corticosteroids were given preoperatively. These were consistent with previous reports in children [1Schroeder V.A. Pearl J.M. Schwartz S.M. Shanley T.P. Manning P.B. Nelson D.P. Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression.Circulation. 2003; 107: 2823-2828Crossref PubMed Scopus (135) Google Scholar], but what was new in the publication by Clarizia and colleagues [4Clarizia N.A. Manlhiot C. Schwartz S.M. et al.Improved outcomes associated with intraoperative steroid use in high-risk pediatric cardiac surgery.Ann Thorac Surg. 2011; 91: 1222-1227Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] was the targeted use of steroids in younger and more complex patients (Aristotle score above 10), suggesting steroids would provide the most spectacular effect in young patients subjected to considerable inflammatory responses. The present study of Heying and colleagues [5Heying R. Wehage E. Schumacher K. et al.Dexamethasone pretreatment provides antiinflammatory and myocardial protection in neonatal arterial switch operation.Ann Thorac Surg. 2012; 93: 869-877Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar] highlights a new aspect of the prophylactic use of corticosteroids in neonatal cardiac surgery: the protective myocardial effect. By showing lesser inflammation and lower cardiac troponin concentrations with the use of methylprednisolone, the present study directly relates post-CPB inflammation to myocardial protection. The present authors demonstrate the myocardial downregulation and upregulation of proinflammatory and antiinflammatory cytokines, respectively, with the prophylactic use of 1 mg/kg methylprednisolone given before CPB, and show effectiveness starting before onset of CPB and lasting throughout the procedure and the early postoperative period. We still have to answer the following questions: “What?,” “When?,” and “How much?,” especially as an international survey of 36 cardiac surgery centers revealed that despite the widespread use of corticosteroids in pediatrics, administration practices and dosing regimens are still the result of provider preferences [6Checchia P.A. Bronicki R.A. Costello J.M. Nelson D.P. Steroid use before pediatric cardiac operations using cardiopulmonary bypass: an international survey of 36 centers.Pediatr Crit Care Med. 2005; 6: 441-444Crossref PubMed Scopus (118) Google Scholar]. The steroid preparation responsible for fewer side effects, the best dosing regimen, and the best timing are still debated in pediatric cardiac surgery. Dexamethasone Pretreatment Provides Antiinflammatory and Myocardial Protection in Neonatal Arterial Switch OperationThe Annals of Thoracic SurgeryVol. 93Issue 3PreviewThis prospective double-blinded randomized study tested the hypothesis that preoperative treatment with dexamethasone would attenuate inflammatory priming of the myocardium, reduce the systemic inflammatory reaction upon cardiac operation, and provide organ protection in neonates. Full-Text PDF