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Background: Debate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses., Methods: Adults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes., Results: Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P = .5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P = .3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P < .001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P < .0001). After adjustment, structural deterioration was associated with younger patient age (P < .001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P < .001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P = .007)., Conclusions: This study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I 2 ) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multisocietal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multifocal or diffuse heterogenous intense 18 F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more., (Copyright © 2024 by the American Society of Nuclear Cardiology, the American College of Cardiology, Heart Rhythm Society, and the Infectious Diseases Society of America. Published by Elsevier on behalf of the American Society of Nuclear Cardiology, the American College of Cardiology, Heart Rhythm Society, and by Oxford University Press on behalf of the Infectious Diseases Society of America. Published by Elsevier Inc. All rights reserved.)

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I 2 ) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18 F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more., (Copyright © 2024 2024 The American Society of Nuclear Cardiology, the American College of Cardiology, Heart Rhythm Society, and the Infectious Diseases Society of America. Published by Elsevier on behalf of the American Society of Nuclear Cardiology, the American College of Cardiology, Heart Rhythm Society, and by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. Published by Elsevier Inc. All rights reserved.)

Background: The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach., Methods: Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes., Results: Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001)., Conclusions: For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown., Objectives: To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE., Methods: Two independent reviewers screened abstracts and full text for inclusion and independently extracted data., Data Sources: MEDLINE, Embase, and Web of Science., Study Eligibility Criteria: Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included., Assessment of Risk of Bias: As this was a scoping review, risk of bias assessment was not performed., Methods of Data Synthesis: Descriptive data was reported., Results: We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294)., Conclusions: While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure., (Copyright © 2023 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings., Methods: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis., Results: Inclusion criteria were met by 524 393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3)., Conclusions: There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE)., Methods: The Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression., Results: From 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P < .001) with a concurrent decrease in operative mortality (PVE, 22.5% to 10.4%; P < .001; NVE, 10.9% to 8.5%; P < .001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P < .001), aortic root replacement (50.1% vs 12.8%; P < .001), homograft implantation (27.2% vs 4.1%; P < .001), and operative mortality (12.2% vs 6.4%; P < .001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; P < .01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P < .001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; P < .001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P < .001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P < .001) correlated with a higher operative mortality, whereas prosthesis type (P = .68) was not an independent predictor., Conclusions: IE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Coronary endarterectomy (CE) is an uncommon and often unplanned technique used to approach difficult targets during coronary artery bypass grafting (CABG). We evaluated the outcomes of CABG with CE (CE-CABG) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database., Methods: All isolated, first-time, elective or urgent CABG cases from July 2011 to September 2019 in the Adult Cardiac Surgery Database were retrospectively reviewed. Because of a higher risk profile in the patients undergoing CE-CABG, we performed propensity score matching. Primary outcomes included operative mortality and postoperative myocardial infarction. For patients ≥65 years, long-term mortality and rehospitalization were evaluated using linked data from Centers for Medicare and Medicaid Services., Results: Of the total 1 111 792 patients included, 32 164 (2.9%) had CE-CABG and 1 079 628 (97.1%) underwent CABG alone. The majority of CE-CABG involved a single-vessel endarterectomy (86.9%; n = 27 945); the left anterior descending was most common (40.9%; n = 13 161). Compared with propensity score-matched CABG, CE-CABG had increased operative mortality (3.2% vs 1.7%; P < .0001; odds ratio, 1.81; 95% CI, 1.63-2.01) and postoperative myocardial infarction (6.8% vs 3.9%; P < .0001; odds ratio, 1.80; 95% CI, 1.68-1.93). CE-CABG had higher risk of mortality in the first year and rehospitalization for myocardial infarction in the first 3 years but was comparable to CABG alone thereafter. Subgroup analysis showed no difference between CE-CABG of the left anterior descending compared with CE-CABG of other coronary arteries., Conclusions: This analysis demonstrates that CE-CABG has acceptable long-term outcomes and serves as a benchmark for what can be expected when this rare procedure is used., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Female patients with coronary artery disease have inferior outcomes compared with male patients, including higher mortality after coronary artery bypass graft surgery (CABG). We aimed to evaluate the association of female sex with the use of guideline-concordant CABG revascularization techniques., Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for adult patients who underwent first-time isolated CABG in the United States from 2011 to 2019. The association between female sex and the odds of (1) receiving a left internal mammary artery graft for revascularization of the left anterior descending artery, (2) undergoing complete revascularization, and (3) undergoing multiarterial grafting was assessed, adjusting for procedural anatomy., Results: Among 1,212,487 patients meeting inclusion criteria, 75% were male (n = 911,178) and 25% were female (n = 301,309). Female sex was associated with lower unadjusted rates of revascularization with an internal mammary artery graft (93.9% vs 95.9%, P < .001), bilateral internal mammary artery graft (2.9% vs 5.6%, P < .001), or radial artery graft (3.2% vs 5.6%, P < .001). After adjustment, female patients had lower odds than males of receiving a left internal mammary artery graft to the left anterior descending artery (adjusted odds ratio 0.79; 95% confidence interval, 0.75 to 0.83; P < .001), undergoing complete revascularization (adjusted odds ratio 0.86; 95% confidence interval, 0.83 to 0.90; P < .001), and undergoing multiarterial grafting (adjusted odds ratio 0.78; 95% confidence interval, 0.75 to 0.81; P < .001)., Conclusions: Female sex was associated with 14% to 22% lower odds of undergoing guideline-concordant revascularization including left internal mammary artery to left anterior descending artery grafting, multiarterial grafting, and complete revascularization. Further investigation is necessary to determine why revascularization approaches differ by sex and to what degree sex disparities in coronary artery disease outcomes are due to surgical approach., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum., Methods: A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics., Results: Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P = .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P = .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P = .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P = .02)., Conclusions: Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The rise in the number of valve operations performed for infective endocarditis (IE) due to drug use is an important manifestation of the opioid epidemic. This study characterized national trends and outcomes of valve surgery for drug use-associated IE (DU-IE)., Methods: Adults undergoing valve surgery for active IE in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database between July 2011 and June 2018 were stratified as DU-IE and non-DU-IE. Trends and clinical profiles were analyzed. Early outcomes were assessed. The association of DU-IE with outcomes was analyzed with multivariable regression, adjusting for STS Valve Risk model covariates., Results: There were 34,905 valve operations performed for IE, of which 33.7% were for DU-IE. DU-IE operations increased 2.7-fold during the study period. There was considerable regional variability in DU-IE operations, ranging from 28% to 58% of all IE surgeries in 2018, with highest rates observed in East South Central and South Atlantic regions. DU-IE patients were younger and had fewer cardiovascular comorbidities. Risk-adjusted major morbidity and in-hospital mortality were significantly higher in the DU-IE group. Redo valve procedures in DU-IE patients were associated with worse outcomes, compared with those receiving a first valve operation., Conclusions: Operations for DU-IE have increased sharply in the United States during the last several years, exhibiting substantial regional variability. DU-IE patients have unique clinical profiles, and worse risk-adjusted outcomes. This demonstrates the significant impact of the opioid epidemic on endocarditis surgeries and punctuates the urgent need for multidisciplinary regional and national efforts to reverse this trend., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Current guidelines for gastrointestinal cancer surgical intervention in high-risk patients recommend postoperative venous thromboembolism (VTE) chemical prophylaxis for 4 weeks with low-dose unfractionated heparin or low-molecular-weight heparin, but specific guidelines for esophagectomy are lacking. This survey identified the clinical patterns affecting postesophagectomy VTE chemoprophylaxis use among general thoracic surgeons., Methods: General Thoracic Surgery Club members were invited to complete an online survey on VTE prophylaxis to analyze clinical factors affecting their choices., Results: Seventy-seven surgeons (37% membership) responded; of these, 94% (72 of 77) completed fellowships, and 76% (58 of 77) worked at universities. VTE chemoprophylaxis administration varied widely in drug, dosing, and duration, with 30% using suboptimal dosing of unfractionated heparin (every 12 hours). Participants agreed that esophagectomy patients are at high VTE risk, yet 29% (22 of 76) of surgeons delay VTE chemoprophylaxis until postoperative day 1. Only 13% (10 of 77) prescribe postdischarge chemoprophylaxis. Minimally invasive surgeons (>90% of cases) were more likely to prescribe postdischarge prophylaxis (p = 0.007). Epidurals, routinely used by 65% (51 of 78), led to less compliance with recommended dosing. Only 53% (27 of 51) of pain teams allow unfractionated heparin every 8 hours, yet 73% (37 of 51) allow suboptimal dosing (every 12 h). Postoperative major complications were identified as a VTE risk factor by only 21% (15 of 72) of surgeons. Most (92% [68 of 74]) would follow esophagectomy-specific guidelines, if developed., Conclusions: Thoracic surgeons agree that VTE chemoprophylaxis is necessary for esophagectomy, yet substantial variability exists in current practice. A noteworthy proportion use suboptimal dosing, and very few choose postdischarge prophylaxis. To improve postesophagectomy morbidity and mortality outcomes, thoracic surgeons are willing to follow evidence-based guidelines for VTE chemoprophylaxis., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Minimally invasive approaches to diaphragm plication for eventration include thoracoscopic and laparoscopic techniques. The elevated hemidiaphragm and ribs limit thoracoscopic techniques. We report our modification of the laparoscopic approach using robotic assistance with the da Vinci Surgical System, (Intuitive Surgical Inc, Sunnyvale, CA) to avoid single-lung ventilation, facilitate exposure, and allow more precise placement of plication sutures to achieve an even tension and maximum plication. Critical steps include creation of a small defect in the diaphragm to equalize pressures between cavities and placement of multiple, pledgeted interrupted horizontal mattresses., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study analyzed 30-day hospital readmissions after aortoiliac (AI) and infrainguinal (II) revascularization to further characterize readmissions and to identify modifiable targets for reducing readmission rates., Methods: We performed a retrospective analysis of the large, multicenter, prospectively collected American College of Surgeons National Surgical Quality Improvement Program data set from 2011. Readmissions were categorized as planned or unplanned and related or unrelated to the index procedure. The primary end point was unplanned readmissions for open and endovascular AI and II procedures. Multivariable logistic regression was performed to determine independent demographic and preoperative clinical and intraoperative risk factors for unplanned readmissions related to the procedure., Results: A total of 8414 patients were discharged after AI or II revascularization with a 30-day readmission rate of 16.5%. Ninety percent of all readmissions were unplanned and 54% were unplanned and related to the index procedure. Reasons for unplanned readmissions related to the procedure were infection (43.1%), diabetic/ischemic wound complications (16.5%), graft complications (13.6%), cardiac events (3.6%), neurologic events (2.9%), and deep venous thrombosis/pulmonary embolism (2.4%). Procedures were performed in the minority of all readmissions (7.7%) and included vascular intervention (28.7%), amputation (24%), débridement (14%), and incision and drainage (10%). The rate of related readmission for open revascularizations (10.9%) was double the rate for endovascular revascularizations (4.7%). Multivariate analysis identified several independent risk factors associated with unplanned readmissions related to the procedure: open procedure (odds ratio [OR], 1.53; P = .43), operative time of more than 260 minutes (OR, 1.66; P < .002), blood transfusion (OR, 1.24; P = .021), body mass index 30 to 35 (OR, 1.56; P < .001), and preoperative open wound/infection (OR, 1.23; P = .12). Interestingly, length of hospital stay and age were not independent predictors of unplanned readmissions related to the procedure., Conclusions: AI and II revascularization procedures result in readmission of 16.5% of patients. The most frequent reason for readmission was surgical site infection. Interventions focused on wound care management and avoidance of infectious complications could help reduce readmission rates., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)