A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In low-risk patients aged >70–75 with severe aortic stenosis, is transcatheter superior to surgical aortic valve replacement in terms of reported composite outcomes and survival? More than 73 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The only low-risk randomized control trial to date [Nordic Aortic Valve Intervention (NOTION)] regarding an elderly population did not show a statistically significant difference between the 2 approaches regarding the composite endpoint of death, stroke or myocardial infarction. A subgroup analysis of elderly patients in the 2 main low-risk randomized control trials did not yield statistically different results from those of the overall population; the results indicated the superiority of transcatheter aortic valve implantation regarding the composite of death, stroke or rehospitalization at 1 year [The Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis (PARTNER 3)] and non-inferiority regarding a composite of death or stroke at 2 years [Medtronic Evolut Transcatheter Aortic Valve Replacement in Low-Risk Patients (Evolut LR)]. The results from lower evidence studies are largely consistent with these findings. Overall, there is no compelling evidence indicating that older age should be an isolated criterion for the choice between transcatheter aortic valve replacement and surgical aortic valve replacement in otherwise low-risk patients. The superiority of either technique regarding the aforementioned composite short-term outcomes in this particular subgroup of patients is unclear.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Are NOACs as safe and efficient as vitamin K antagonist regarding thromboembolic prophylaxis and major bleeding in patients with surgical bioprosthesis and atrial fibrillation within 3 months of surgery?’ Altogether more than 324 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The RIVER and ENAVLE trials showed non-inferiority of rivaroxaban (regarding mean time free from composite of death, major cardiovascular events or major bleeding at 12 months) and edoxaban (composite of death, clinical thromboembolic events or asymptomatic intracardiac thrombosis; and major bleeding) when compared with vitamin K antagonist. These studies include a low number of patients within 3 months of index surgery and overall low statistical power regarding this particular subgroup of patients. Data derived from lower evidence studies are compatible with the aforementioned findings. The available evidence suggests that non-vitamin K antagonist anticoagulants are as safe and as efficient as vitamin K antagonist regarding thromboembolic prophylaxis and bleeding event rates in patients with surgical bioprosthesis and atrial fibrillation within 3 months of bioprosthesis implantation. However, this evidence is derived from a limited number of studies with important methodological limitations. Expanding non-vitamin K antagonist anticoagulant recommendation to the early postoperative period warrants more confirmatory research.
Summary
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Does routine topical antimicrobial administration prevent sternal wound infection (SWI) after cardiac surgery? Altogether >238 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several different antimicrobial agents, dosages and application protocols were found in the literature. Regarding topical vancomycin use, a meta-analysis by Kowalewski et al. demonstrated a 76% risk reduction in any SWI. Collagen-gentamicin sponge application was associated with a 38% risk reduction in SWI in another meta-analysis by Kowalewski et al., which included 4 randomized control trials and >23 000 patients. Lower evidence observational studies found benefit in the use of different regimes, including: combination of vancomycin paste and subcutaneous gentamycin; combined cefazoline and gentamicin spray; isolated cefazolin; bacitracin ointment; and rifampicin irrigation. We conclude that, in light of the body of evidence available, topical antibiotic application prevents SWI, including both superficial and deep SWI. The strongest evidence, derived from 2 meta-analyses, is related to the use of gentamicin-collagen sponges and topical vancomycin. Heterogeneity throughout studies regarding antibiotic agents, dosages, application protocols and SWI definition makes providing general recommendations challenging.
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