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Background Deep sternal wound infection (DSWI) is a devastating complication that increases morbidity and death in cardiac surgical patients. Vancomycin is often administered intravenously for antibiotic prophylaxis in cardiac operations. Many cardiac surgeons also apply vancomycin paste topically to the sternal edges. We examined the effect of vancomycin paste on the incidence of DSWI in patients undergoing elective cardiac operations. Methods We retrospectively reviewed the medical records of all patients from 2003 to 2015 who underwent coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve operations at a single institution. We derived The Society for Thoracic Surgeons (STS) DSWI risk index for each patient and systematically reviewed operative, pharmacy, microbiology, and discharge records to document DSWI in these patients. Multivariate analyses were used to identify predictors of DSWI in this cohort and to quantify the effect of vancomycin paste. Results Of the 14,492 patients whose records we examined, DSWI developed in 136 patients, resulting in an overall incidence of 0.9%. After multivariate analysis, body mass index, New York Heart Association Functional Classification, and the 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 during 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 operations was not associated with a reduced risk of DSWI.

Background Bioprosthetic aortic valve use has increased steadily according to The Society of Thoracic Surgeons (STS) database analyses. One of the momentums toward this trend is the future utilization of transcatheter valve-in-valve (TViV) techniques when bioprosthetic valves fail. We compared the results of reoperative TViV to surgical aortic valve replacement (SAVR) for degenerated bioprosthetic valves. Methods From January 2002 to January 2015, we identified 91 patients with degenerated bioprosthetic valves who underwent isolated AVR (SAVR n = 69, TViV n = 22). Patients with prior homografts or active endocarditis were excluded. The STS risk score was used to create 22 matched pairs of SAVR and TViV for comparison. Results Before matching, mean STS risk scores were 4.36 ± 3.1 and 7.54 ± 3.0 for SAVR and TViV, respectively ( p = 0.001), but were 7.70 ± 3.4 and 7.54 ± 3.0, respectively ( p = 0.360), after matching. Mean age was 74.5 ± 10.4 years for SAVR and 75.0 ± 9.6 years for TViV ( p = 0.749). Operative mortality was 4.3% (1 of 22) in the SAVR group and zero for TViV ( p = 1.00). Mean postoperative gradient was 13.5 ± 13.2 mm Hg for SAVR and 12.4 ± 6.2 mm Hg for TViV ( p = 0.584). There was no coronary obstruction in either group, but 22% of TViV (5 of 22) had mild paravalvular leaks versus none in the SAVR group ( p = 0.048). Postoperative stroke rate was 9% (2 of 22) for SAVR and zero for TViV ( p = 0.488). The TViV group had shorter median length of stay (5 versus 11 days, p = 0.001). Actuarial survival at 3 years was 76.3% (95% confidence interval: 58.1 to 94.5) versus 78.7 (95% confidence interval: 56.2 to 100) for SAVR and TViV, respectively ( p = 0.410). Conclusions 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.

Background The current study assesses outcomes and risk factors for aortic valve replacement (AVR) for aortic regurgitation (AR) in the setting of markedly reduced left ventricular (LV) function compared with moderately reduced LV function and preserved LV function. Methods Between January 2002 and June 2013, 485 consecutive patients underwent AVR for severe AR. Overall, 37 of 485 patients (8%) had an LV ejection fraction (EF) less than or equal to 35% (low EF) with median of 30%; 141 of 485 patients (27%) had an LVEF of 36% to 50% (moderate) with median of 45%, and 307 of 485 patients (65%) had an LVEF greater than 50% (preserved) with median of 60%. Results Preoperative characteristics were similar across groups, except patients with low EF were older (67.4 ± 12.1 years versus moderate [58.6 ± 15.0 years], p = 0.003 versus preserved [56.9 ± 14.3 years], p = 0.001), more often had reoperations (35.1% versus preserved 19.9%, p = 0.054), and had more concomitant coronary artery bypass grafts (37.6% versus preserved 14.3%, p = 0.001). Operative mortality for the entire cohort was 1.9% (9 or 485) and was similar across groups, 0% in the low EF group, 2.1% (3 of 141) in the moderate group, and 2.0% (6 of 307) in the preserved group (all p > 0.5). Cox proportional hazard modeling indicated that age (hazard ratio [HR] 1.061, p ≤ 0.001), preoperative creatinine (HR 1.478, p ≤ 0.014), history of atrial fibrillation (HR 1.920, p = 0.095), and New York Heart Association class III/IV (HR 2.127, p = 0.004) predicted survival. At median follow-up of 26 months, in the low EF group, the mean LVEF at follow-up was 49.5% ± 10.2% versus baseline 30% ± 4.6% ( p ≤ 0.001). Conclusions In this series, patients with markedly reduced LV function (LVEF ≤35%) had similar postoperative outcomes and survival as patients with moderate LV dysfunction or preserved LV function.