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Background: Coronary revascularization with bilateral internal mammary arteries is associated with increased long-term survival, but underutilized due to sternal wound infection concerns. Dedicated bilateral mammary grafting programs are typically high-volume academic or private practices, rather than lower-volume federal institutions whose results are not captured in the Society of Thoracic Surgeons database. Our institution used only single internal mammary arterial grafting in the year prior to implementing a dedicated bilateral grafting program using skeletonized technique. We describe our experience transitioning to bilateral mammary grafting and its impact on sternal wound infection., Methods: Retrospective cohort study at San Francisco Veterans Affairs Medical Center in 200 patients undergoing first-time isolated, multi-vessel coronary artery bypass from August 2014 to October 2017. Sternal wound infection was defined broadly to include any patient receiving antibiotics for suspicion of sternal infection. Patients were followed for wound complications until 3 post-operative months., Results: Of 200 total patients, 45.5% (n=91) were diabetic, 44% (n=88) had BMI >30, and 61.5% (n=123) underwent bilateral mammary grafting. Bilateral mammary grafting population had 2.4% (n=3/123) deep sternal wound infection with 1.6% (n=2/123) requiring sternal reconstruction while single mammary population had 1.3% (n=1/77, p=1.0). Bilateral mammary grafting population had 6.5% (n=8/123) superficial sternal wound infection compared to 5.2% (n=4/77, p=0.77) in single mammary grafting population., Conclusions: Transitioning to high rates of bilateral mammary utilization was possible in a year with low rates of complications. Based on our experience, surgeons should consider adopting a skeletonized bilateral mammary grafting approach given potential long-term survival benefit., Competing Interests: No conflicts of interest to disclose.

Background: Transcatheter aortic valve replacement (TAVR) is a widely established alternative to surgery in intermediate- and high-risk patients. TAVR program development within the Veterans Affairs (VA) system has been previously described. However, national TAVR registries do not capture VA outcomes data, and few data have been reported regarding TAVR outcomes at lower-volume federal institutions. The study aim was to demonstrate the evolution of a successful VA TAVR program., Methods: A retrospective analysis was performed of the first 100 TAVR patients at San Francisco VA Medical Center. Mortality and major complications were evaluated., Results: Between 25th November 2013 and 31st August 2016, a total of 100 TAVR procedures was performed at the authors' institution. The mean patient age was 79.7 ± 8.7 years. Patients underwent TAVR via percutaneous-transfemoral (n = 90), surgical cutdown-transfemoral (n = 8), or transapical (n = 2) approaches. The valve systems employed were Edwards SAPIEN (n = 16), SAPIEN XT (n = 31), SAPIEN 3 (n = 23), and Medtronic CoreValve (n = 16) and CoreValve Evolut R (n = 14). The overall device success was 96%. TAVR-in-TAVR was required in the remaining 4% of patients, and was successful. All-cause procedural mortality was 1%. Complications included tamponade (1%), stroke (2%), temporary hemodialysis (1%), vascular injuries requiring intervention (4%), and permanent pacemaker implantation (14%). There were no conversions to surgical aortic valve replacement. Twenty-two (22%) patients had mild, two (2%) had moderate, and none (0%) had severe paravalvular leakage. The post-procedure aortic valve gradient by echocardiography was 8.6 ± 4.5 mmHg. Follow up was 100% complete and survival was 99%, 93%, and 89% at one, six, and 12 months, respectively., Conclusions: Successful outcomes were demonstrated for a VA TAVR program that compared favorably with benchmarks established by the National Transcatheter Valve Therapies Registry. These results provide a necessary transparency of TAVR outcomes at a federal institution.