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From August 22 - 25, 2024, 60 first-year cardiothoracic surgery residents took part in the STS Boot Camp in Chicago. Throughout the four-day program, leading CT surgeons from across the nation provided hands-on instruction as participants gained practical experience by simulating real-world cases and emergency scenarios.

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This year's Boot Camp covered training in cardiopulmonary bypass skills, vessel anastomosis, diagnostic and therapeutic endoscopies, open pulmonary lobectomy, TAVR, and wire skills. Residents also received instruction in mitral valve and aortic valve surgery, giving and receiving feedback in the operating room, and the importance of performing ablation.

“Over the next few days, you will receive expert instruction on how to manage real-world cases and emergency scenarios from CT surgeon leaders from around the country,” said STS President Jennifer Romano, MD, MS. “Our exceptional faculty, under the leadership of Dr. Jon Nesbitt and our subspecialty leads, developed an outstanding program with hands-on training in fundamental cardiothoracic surgical skills. Thank you for choosing to be part of our community.”

Here's what a few attendees said about the program:

• “It was great to have time with other fellows and to build camaraderie. The hands-on simulation sessions were excellent.  The coronary vessel anastomosis session and the CPB/echo room were outstanding.” 
• “The best parts of the Boot Camp were learning the basics of CT surgery, the vast topics covered (transthoracic echocardiogram, lobectomy, etc.) and getting to meet co-trainees from all across the country.” 
• “I will keep practicing my vascular anastomosis skills at home and keep in touch with the perfusionists at my institution to keep practicing my bypass skills.” 
• “The best part of @STS_CTsurgery Boot Camp was the people. Had so much fun having a weekend with my colleagues, reuniting with former fellows, and spending time with faculty who volunteer a weekend of their busy life to teach. Future is bright!” –  X, @katiewagnerMD
• “What an awesome day learning from @YihanLinMD, @SteveYangMD, @tygrenda, and so many others. Thanks to all the faculty, @STS_CTsurgery, @UCSFCTSurgery, @JennaRomanoMD, and so many others for the opportunity!!” – X, @BrianTillMD
• “Inspired time at #STSBootCamp! Grateful to the amazing faculty @STS_CTsurgery.” – X, @Gbale_Cruise

Best part of @STS_CTsurgery bootcamp was the people. Had so much fun having a weekend w my colleagues, reuniting with former fellows, and spending time with faculty who volunteer a weekend of their busy life to teach. Future is bright! @BrianTillMD @CDemarest_MDPhD @JennaRomanoMD pic.twitter.com/f2i2u1rw2S

— Katie Wagner, MD MSc (@katiewagnerMD) August 25, 2024

Check out additional photos in the STS Boot Camp photo gallery! 

Application Deadline for 2025 Thoracic Surgery Foundation Scholarships Is September 15, 2024

In 2023, Dr. Chizoba Efobi was awarded the Thoracic Surgery Foundation (TSF) International Medical Volunteer Scholarship and used it to participate in a surgical outreach trip to Kampala, Uganda.  

Dr. Efobi volunteered at the Uganda Heart Institute, located within the Mulago National Referral Hospital. There, he joined a medical mission group from the US to mentor local healthcare providers. Their goal was to help the local team become more efficient and increase the number of heart surgeries performed each year.

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According to Dr. Efobi, what made this mission unique was its capacity to involve the entire heart care team at the Uganda Heart Institute, including cardiology, anesthesia, nursing, and clinical administration. The focus was on teaching, training, and skills transfer rather than the volume of cases performed.

“I observed a different model of upscaling skills and training not limited to surgery, but across the entire field of heartcare,” explained Dr. Efobi. “In this case, skills and knowledge transfer were given the highest priority and guided other activities. The results of the sustained local capacity building were very evident.”

Bringing the Lessons Home
Upon returning home to Nigeria, Dr. Efobi’s participation in the TSF International Medical Volunteer Scholarship positively impacted his hospital, including the recommencement of the open-heart surgery program. Patients are now experiencing “uneventful perioperative periods” discharge within a week and satisfying recoveries.

Learn more about Dr. Efobi’s mission experience as a TSF International Medical Volunteer Scholar in his personal blog.

TSF, the charitable heart of the STS, is currently accepting applications for its 2025 awards season with nearly $1.7 million in available funding. Award categories include research, education, innovation, and humanitarian outreach. The application deadline for most awards is Sunday, Sept. 15, 2024. 
 

Coarctation, a condition which comprises 4-5% of all congenital heart disease cases, is the second most common congenital heart defect  requiring neonatal intervention. Yet there is a lack of guidance regarding aspects of its management in neonates and infants, primarily due to heterogeneity in phenotype, making consensus in management challenging.

Recently, the STS Workforce on Evidenced-Based Surgery and its Task Force on Congenital Heart Surgery formed a panel of congenital cardiac surgeons, cardiologists, and intensivists to provide guidance to specialists who manage isolated coarctation in neonates and infants¹. 

Methods

The multi-disciplinary Task Force members first identified key questions related to the care of these patients using the PICO Framework (Patients/Population, Intervention, Comparison/Control, Outcome). After performing a literature search for each question, practice guidelines were developed using a modified Delphi method with a “recommendation” classification and evidence level, which were graded using Class of Recommendations (COR) and Level of Evidence (LOE) based on AAC/AHA classification system².

Results

The following recommendations reached a “consensus,” which meant that 80% of panel members voted on them, and 75% of them agreed with these statements:  

• For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications for those with prematurity, low weight, or other risk factors for surgical intervention. 
• For patients with risk factors for surgery, medical management prior to intervention is reasonable. 
• For those without associated arch hypoplasia, repair via thoracotomy is indicated. 
• For those with associated arch hypoplasia that cannot be adequately addressed via thoracotomy, repair via sternotomy is preferable. 
• For those with bovine arch anatomy, repair via sternotomy may be reasonable given the potential increased risk of recoarctation with bovine arch anatomy repaired via thoracotomy
• For those undergoing repair via sternotomy, antegrade cerebral perfusion or limited duration deep hypothermic circulatory arrest may be reasonable
• For those undergoing repair via sternotomy, extended end-to-end, arch advancement (end-to-side reconstruction with ligation of isthmus), and patch augmentation are all reasonable techniques

Conclusions

After completing the evaluation, Task Force members concluded that surgery remains the standard of care for managing isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach rather than a thoracotomy approach. Significant opportunities remain to delineate management in these patients better.

Although these statements provide guidance considering the available data, they are not intended to be prescriptive, and practitioners should apply these based on their experience, as well as within the clinical setting in which they work.

"Some of these guidelines' most valuable aspects summarize the data related to thoracotomy vs. sternotomy, which is a continued area of debate," said the study's lead author, Dr. Elizabeth Stephens, associate professor of surgery at Mayo Clinic in Rochester, Minn.  "The decision is often relatively subjective and based on the surgeon's training and/or experience."

This paper reveals the many questions that still need to be studied and answered. "The good news is that we as a specialty have moved from ensuring survival in these patients to decreased morbidities related to surgery, but the next step is studying long-term outcomes and how to improve them, namely freedom from hypertension and late reintervention," added Dr. Stephens.

Read the Annals article, which will soon be published in the upcoming September 2024 issue (Vol 118, No. 3) of The Annals of Thoracic Surgery. 

References:

1. Stephens EH, Ahmad D, Alsoufi B, Anderson BR, Ashfaq A, Bleiweis MS, Dearani JA, d’Udekem Y, Feins EN, Jacobs JP, Karamlou T, Marino BS, Najm HK, Nelson JS, St. Louis JD, Turek JW, The Society of Thoracic Surgeons Clinical Practical Guidelines on the Management of Neonates and Infants with Coarctation, The Annals of Thoracic Surgery (2024)

2. Class of Recommendation (COR) and Level of Evidence (LOE); Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 67(13), 1572–1574. https://doi.org/10.1016/j.jacc.2015.09 

Two papers recently published in The Annals of Thoracic Surgery aim to guide the management of thymoma¹ and pleural drains following pulmonary lobectomy² – thoracic conditions and treatments that lack widely accepted guidelines. Recognizing this need, the Society of Thoracic Surgeons (STS) Workforce on Evidenced-Based Surgery convened a task force to develop expert consensus documents to help alleviate this knowledge gap.

Thymoma, a rare epithelial tumor – but also the most common anterior mediastinal tumor in adult patients – is a condition thoracic surgeons will likely encounter as clinicians. However, there is a lack of evidence covering all aspects of treatment due to its relatively low incidence. Managing pleural drains following pulmonary lobectomy is standard practice, yet there are no established guidelines on this topic despite abundant published literature.

Management of thymoma

The STS Workforce on Evidence-Based Surgery, which includes general thoracic surgeons with expertise in thoracic surgical oncology, and medical and radiation oncologists with expertise in neoadjuvant and adjuvant therapies, evaluated existing literature about surgical considerations in managing thymomas, such as:

•    Imaging characteristics
•    Diagnostic tests 
•    Staging 
•    Surgical approach and technique
•    Neoadjuvant and adjuvant therapy 
•    Surgery for advanced or recurrent disease, and 
•    Postoperative surveillance

Consensus statements were drafted using the modified Delphi method. Votes for each proposed statement were tallied using a 5-point Likert scale, with the option to abstain on those not within the specific authors’ expertise. Statements with 75% of responding authors selecting “agree” or “strongly agree” were considered to have reached a consensus. 

Unlike broader guidelines encompassing various aspects of thymoma management, including medical oncology, radiology, and pathology, this paper addresses thymoma from a surgical perspective by guiding surgical interventions, especially in metastatic and recurrent diseases.

"Given the scarcity of randomized controlled trials due to the rarity of thymoma, this document is framed as an expert consensus rather than strict evidence-based clinical practice guidelines," said the study's lead author, Dr. Douglas Liou, clinical associate professor at Stanford Medicine. "Our findings rely more heavily on the combined experience and judgment of experts in the field rather than solely on data from large-scale studies." 

Read the Annals article. 

Management of pleural drains following pulmonary lobectomy

Similarly, the consensus document developed by the STS Workforce on Evidence-Based Surgery to manage pleural drains includes:

•    Choice of drain, including size, type, and number
•    Management, such as use of suction versus waterseal and criteria for removal
•    Imaging recommendations, including the use of daily and post-pull chest x-rays
•    Use of digital drainage systems, and
•    Management of prolonged air leak

Workforce members reviewed existing literature on the condition. A consensus using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached, with a total of thirteen statements that encouraged standardization and stimulated additional research in this critical area. 

“Optimal management of these drains should reduce patient discomfort, length of stay, and complications.”  said study investigator Dr. Michael Kent, associate professor of surgery at Harvard Medical School. “However, despite how commonly chest tubes are used in practice, the literature must provide more clarity on this subject. Many important questions have yet to be addressed and may require well-designed, prospective randomized trials.”

Read the Annals article. 

1. Reference: Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas, The Annals of Thoracic Surgery (2024)

2. Reference: Kent MS, Mitzman B, Diaz-Gutierrez, I, Khullar OV, Fernando H, Backus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Worrell SG, Raymond DP, Schumacher L, Hayanaga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy, The Annals of Thoracic Surgery (2024)