The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.

No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.

For degenerated bioprosthetic aortic valves, TViV has similar operative mortality, strokes rates, and survival as SAVR in this high-risk cohort. Therefore, TViV is a viable alternative to SAVR, although studies using registry data are needed to establish noninferiority.

A re-MVR is a high-risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long-term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve-in-valve/ring replacement.

IMPORTANCE Questions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).OBJECTIVE To examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric. DESIGN, SETTING, AND PARTICIPANTSThis nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019.EXPOSURES Hospitals were ranked into top-(10%), middle-(80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. MAIN OUTCOMES AND MEASURESChanges in hospital performance rankings at 90 days and 1 year and correlation of 30-and 90-day mortality with 1-year mortality were examined.RESULTS A total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point. CONCLUSIONS AND RELEVANCEThe findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.

Background Deep sternal wound infection (DSWI) is a devastating complication that increases morbidity and mortality in cardiac surgery patients. Vancomycin is often administered intravenously for antibiotic prophylaxis in cardiac surgery. Many cardiac surgeons also apply vancomycin paste topically to the sternal edges. We examined the effect of vancomycin paste upon the incidence of DSWI in patients undergoing elective cardiac surgery. Methods We performed a single institution, retrospective medical record review of all patients from 2003 to 2015 who underwent CABG, valve or CABG/valve surgery. We derived the Society for Thoracic Surgeons (STS) DSWI risk index for each patient and performed a systematic review of operative, pharmacy, microbiology and discharge records to identify patients that developed DSWI. Multivariate analyses were used to identify predictors of DSWI in this cohort and to quantify the effect of vancomycin paste. Results 14,492 patients were examined, of whom 136 patients developed DSWI, resulting in an overall incidence of 0.9%. After multivariate analysis, body mass index, NYHA class and STS DSWI risk index remained statistically significant and associated with DSWI. Although the incidence of DSWI decreased over time, the use of vancomycin paste was not associated with a reduced incidence of DSWI. Conclusions There was a marked decrease in the incidence of DSWI over the study period, concurrent with institutional implementation of revised STS antibiotic dosing guidelines in 2007 and other strategies. However, the application of vancomycin paste to the sternal edges of patients undergoing cardiac surgery was not associated with a reduced risk of DSWI.

Background: Contemporary options for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). As evidence accrues for TAVR in high and intermediate risk patients, some clinicians advocate that all patients aged over 80 years should only receive TAVR. Our aim was to investigate the utility of SAVR and minimally invasive AVR (mAVR) among octogenarians in the current era of TAVR. Results: Compared to SAVR patients, TAVR patients were relatively older (86.2 versus 84.2 years) with co-morbidities such as chronic kidney disease (CKD), diabetes mellitus (DM), cerebrovascular disease (CVD), and prior myocardial infarction (MI), all P<0.05. The mean STS-PROM for the TAVR group was statistically higher, 6.81 versus 5.58 for the SAVR group (P<0.001). The median in-hospital LOS was statistically higher for the SAVR group (P<0.05). Cox proportional hazard modeling, adjusted for temporal differences in procedure and patient selection, identified age, New York Heart Association (NYHA) class III/IV, preoperative creatinine, severe chronic lung disease, prior cardiac surgery as significant predictors of decreased survival (all P<0.05), while type of intervention (approach) was non-contributory. Adjusted operative mortality stratified by procedure approaches was similar between full sternotomy SAVR and mAVR, and between alternative access and transfemoral TAVR.Conclusions: After adjusting for confounders, TAVR (regardless of approach), SAVR, and mAVR had comparable operative mortality and mid-term survival. Treatment decisions should be individualized with consensus from a multi-disciplinary heart team, taking into account patient co morbidities, frailty, and quality of life. We believe certain patient groups will still benefit from SAVR even in this elderly population.

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