Teaching for Tomorrow
Together

On Saturday, Jan. 31 at 2:45 p.m., during the “Adult Congenital Heart Disease” session, Jennifer Nelson, MD, of Nemours Children’s Hospital will present Indications and Timing of Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. Her talk will highlight a new, comprehensive body of work designed to bring greater clarity and consistency to decision-making around pulmonary valve replacement (PVR) for one of the largest populations of patients living with repaired congenital heart disease.

Image

PVR is a common and critical intervention for patients with repaired tetralogy of Fallot (TOF) and clinically significant pulmonary regurgitation; however, indications and timing have varied widely across practice settings. To reduce this variability, The Society of Thoracic Surgeons (STS), in collaboration with the World Society of Pediatric and Congenital Heart Surgery (WSPCHS) and the European Congenital Heart Surgeons Association (ECHSA), developed a three-part series of complementary clinical practice documents: Clinical Practice Guidelines, a pediatric-focused Expert Consensus Document, and an Expert Opinion paper on the role of exercise testing.

Developed through a rigorous literature review, adherence to PRISMA methodology, and a modified Delphi consensus process, these documents synthesize available evidence and expert judgment to establish practical, consensus-based recommendations.

Key considerations include symptoms, MRI-based ventricular assessment, arrhythmia risk, and procedural factors, emphasizing individualized, data-driven decisions over single thresholds. “Routine, standardized measurement during long-term follow-up is essential,” says Dr. Nelson, who also highlights the role of multidisciplinary review and exercise testing in revealing unrecognized functional limitations.

The new guidance incorporates emerging MRI-based evidence linking ventricular changes to mortality and supports earlier consideration of pulmonary valve replacement in select asymptomatic adults. It also emphasizes that arrhythmia risk persists after intervention, reinforcing the need for continued surveillance.

Together, this three-part series provides an updated framework to guide clinicians caring for children and adults with repaired TOF, balancing evolving evidence with real-world clinical complexity. “These recommendations matter because they should change practice,” Dr. Nelson adds. “They help clinicians better identify the right patient and the right time for pulmonary valve replacement, with the goal of improving long-term outcomes while minimizing unnecessary risk.”

On day two of the 62nd Annual Meeting in New Orleans, co-lead authors Subhasis Chatterjee, MD, of Baylor College of Medicine, and Stefano Schena, MD, PhD, of the Medical College of Wisconsin, presented a summary of The Society of Thoracic Surgeons’ (STS) 2026 Clinical Practice Guidelines for the Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation after Cardiac Surgery. Their presentation highlighted a comprehensive, surgery-specific framework designed to address new-onset postoperative atrial fibrillation (POAF), the most common complication following cardiac surgery.

To develop the guidelines, the STS Workforce on Evidence-Based Surgery convened a multidisciplinary panel to review contemporary evidence and generate practical, consensus-based recommendations focused specifically on POAF after cardiac surgery. Using a phase-based approach that spans the preoperative, intraoperative, and postoperative periods, the group synthesized data from randomized and observational studies and graded recommendations using standardized methods based on AATS/EACTS/ESTS/STS harmonization guidelines¹.

The final document includes a total of 15 recommendations: eight on preventive strategies, three on intraoperative adjunctive procedures, and four on postoperative management. Key guidance includes two Class I recommendations addressing perioperative oral amiodarone and rhythm cardioversion for hemodynamically unstable POAF. Two Class IIa recommendations supporting posterior pericardiotomy and perioperative beta-blockers. Eight Class IIb recommendations reflected areas of uncertainty and limited data. Three Class III recommendations addressed therapies without demonstrated benefit.

Image

A central theme of the guidelines is transparency around uncertainty and an emphasis on meaningful patient outcomes. “One of the goals of these guidelines was not to promote a single dominant therapy,” said Dr. Chatterjee, “but to provide a structured, phase-based approach that can reduce unwarranted practice variation while still allowing clinical judgment.” He emphasized that POAF should be viewed as a marker of perioperative vulnerability rather than an isolated rhythm disturbance, identifying patients at higher risk for complications and future atrial arrhythmias. This perspective supports targeted surveillance and follow-up rather than reflexive escalation of therapy.

The document also underscores that POAF is distinct from preexisting atrial fibrillation, with different mechanisms, natural history, and management implications. Core strategies include careful rhythm monitoring, early rate or rhythm control, and individualized anticoagulation decisions, while acknowledging persistent uncertainty around optimal anticoagulation timing and duration, arrhythmia burden, and the role of adjunctive surgical interventions.

Image

Dr. Schena highlighted how the guideline development process itself reshaped the panel’s collective thinking. “When we started this project, all nine members had their own way to address atrial fibrillation occurring de novo after cardiac surgery,” he said. “The time spent discussing and reviewing helped us recalibrate our stance and recognize how limited the evidence truly is for many commonly used interventions.” He noted that while no single strategy eliminates POAF, its clinical impact can be significantly reduced through a combination of measures applied across the preoperative, intraoperative, and postoperative phases of care. He also emphasized that the long-term implications of POAF in patients without prior atrial fibrillation remain uncertain and must be weighed against individual patient risk factors.

Together, the guidelines provide a pragmatic framework that clinicians can operationalize across the surgical continuum. By emphasizing evidence-based practices, openly acknowledging uncertainty, and discouraging ineffective interventions, the document aims to support thoughtful clinical decision-making and improve outcomes for patients undergoing cardiac surgery.

1: Milojevic, M., Freemantle, N., Hayanga, J. A., Kelly, R. F., Myers, P. O., Petersen, R. H., ... & Bakaeen, F. G. (2025). Harmonizing guidelines and other clinical practice documents: A joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS). The Journal of thoracic and cardiovascular surgery, 169(1), 170-185.

On Friday, Jan. 30, at 9:30 a.m., Stephanie Worrell, MD, of the University of Arizona, presented STS Perforation Guidelines during the "Esophageal Perforation Management" session. Her talk introduced a new Society of Thoracic Surgeons (STS) Expert Consensus Document designed to improve the diagnosis and management of esophageal perforation, a rare but potentially fatal condition.

Image

Esophageal perforation, often a complication of endoscopic procedures, requires early diagnosis, as mortality and morbidity increase if treatment is delayed beyond 24 hours. Despite advances in treatment, management remains inconsistent due to the condition’s rarity and limited clinical data.

To address this gap, the STS convened a multidisciplinary panel of thoracic surgeons and gastroenterologists, who reviewed studies from the past 14 years to develop consensus statements on diagnosis, treatment, and long-term care. For stable patients with confirmed perforation, the consensus supports endoscopic therapies when matched appropriately to anatomy and operator expertise. Surgical intervention remains essential for unstable patients or complex cases.

In her talk, Dr. Worrell discussed how the guidelines provide clarity in clinical scenarios that often prompt uncertainty. “These recommendations clarify when further investigation is appropriate and when it’s safe to observe or discharge,” she said. She notes that the guidelines are particularly valuable for conditions like spontaneous pneumomediastinum where further workup may be unnecessary. Additionally, there is now strong data for CT esophagrams and growing evidence for endoscopic approaches that are not yet used consistently.