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STS 2023, SAN DIEGO—Frailty in patients has existed as a nebulous marker of a patient’s physiological ability to tolerate surgery, but a simple visual assessment at the bedside is not reliable. Surgeons at STS 2023 urged others to go beyond the “eyeball” test. This issue is taking on increased importance as our large, Baby Boomer population and older patients reach a point when they may have severe disease and need cardiothoracic surgery. Physicians have long believed that a measurement of frailty is useful, but agreement remains elusive on how to best measure it. Armir Kiankhooy, MD, from Adventist Health in St. Helena, California, added that physicians’ implicit biases about age, obesity, and other characteristics may creep into and skew quick visual assessments, when in fact the assessment may be inaccurate. For instance, a higher level of frailty has been found in young adults than previously suspected, and frailty permeates all age groups.  Indicators of frailty can include malnutrition, cognitive and speech impairment, ambulatory ability, sarcopenia, and others. “If you are not doing some kind of assessment for your patients in frailty or other vulnerabilities, you are probably only seeing half the risk in your patients,” said Rakesh Arora, MD, from University Hospitals in Cleveland, Ohio. “We need a more comprehensive plan. We need to know how quickly they will bounce back from the stress of surgery.” Tools to assess frailty are increasing, and Dr. Arora recommended the Clinical Frailty Scale, a comprehensive assessment of 70 variables, but acknowledged that it may be too time- consuming for institutions with more limited resources. Instead, he advised that clinicians assess the frailty factors that are more manageable. These can include gait speed, chair rises, balance tests, and grip strength assessment for physical abilities, and potentially a Mini-COG test for memory loss and other indicators of cognition. “If you do the chair rise test, some basic cognitive assessment, a baseline hemoglobin, and a baseline serum, that probably is just as good as a more comprehensive test,” Dr. Arora said. All is not lost for patients with suboptimal frailty scores to undergo surgery. “Pre-habilitation” can help them improve their health through targeted exercise, nutrition and assistance with psychosocial issues and better prepare them for the OR.

STS 2023, SAN DIEGO – “Quality people, consistency, communication, and collaboration” were declared the winning combination in the debate “For the Post-operative Patient in the ICU, Who Is in Charge and Who Is the Consultant? Surgeon or Intensivist?” on Day 1 of STS 2023. Over the last two decades, changing reimbursements, time demands on surgeons, and hiring practices have pushed surgeons and intensivists together for post-surgical care of patients—not always with the best results. Today, with a host of different circumstances at different institutions, significant variations in post-operative critical care exist across the country. Moderator Joseph Zwischenberger, MD, a cardiothoracic surgeon at University of Kentucky HealthCare in Lexington, stood ready to blow his harmonica in case tempers flared. While there were distinct differences of opinion, Andrea J. Carpenter, MD, PhD, a cardiothoracic surgeon and Assistant Dean for Health System Science at University of Texas Health Science Center in San Antonio (UTHSC) and Martin Zammert, MD, a surgical critical care physician who heads the cardiothoracic unit at Lahey Hospital & Medical Center in Burlington, Massachusetts, also highlighted the vital need for true surgeon-intensivist partnership. “The surgeon knows the patient’s anatomy, physiology, and social issues best,” Dr. Carpenter said. “It is the surgeon who takes responsibility and criticism for poor outcomes. So in those cases where there is not clear agreement on what the next best step is, the ultimate decision needs to be made by the surgeon.” A clear answer to the question posed did not emerge from the research both experts presented on length of stay, in-hospital mortality, and readmission rates. They turned to their real-life experiences to make their cases about the best direction and who should have ultimate authority in the ICU—where patient status can change rapidly and quick decisions need to be made about everything from mechanical ventilator support to choice of statins and vasopressors to care withdrawal. Dr. Zammert had another perspective. “Bad outcomes in the ICU are mainly non-surgical, so I don’t think the question should be ‘Who is in charge?’ I think the question we should ask ourselves is, what kind of intensivists do we want in our units?” Both agreed that cardiac critical care is distinct from other intensive care, and that intensivists need training in identifying and avoiding the postoperative complications that commonly occur following cardiac surgery. Intensivists need specific proficiencies in cardiac intensive care, and surgeons need to understand ICU post-operative care in order to foster mutual trust and respect. Dr. Zammert added that understanding how each type of specialist thinks and reasons, and keeping each other informed, create a foundation for a good relationship. “We are here to be a partner with you, not an opponent,” Dr. Zammert added. “This should never be an arranged marriage.” Along with audience members, both discussants advocated for structured rotations and experiential cross-learning for both specialties in the ICU and the OR. Dr. Carpenter, who is also Residency Program Director of Integrated Thoracic Surgery at UTHSC’s Long School of Medicine, noted that in this effort nationwide, “some programs are doing it better than others.”

A packed house at an STS 2023 scientific session yesterday illustrated the robustness and relevance of the STS National Database™ for gleaning real-time outcomes analysis. “Virtually all cardiac operations in the United States are captured by our database,” said Ram Kumar Subramanyan, MD, PhD, from the University of Southern California’s Keck School of Medicine, who presented a report on trends in the Congenital Heart Surgery Database (CHSD) component. In addition to notable trends from each component—adult cardiac, general thoracic, congenital, and Intermacs—presenters hosted a panel discussion with questions from the audience. Participants then heard the latest findings about the performance of frozen elephant trunk (FET) versus traditional limited repair in acute type I aortic dissection as well as in postcardiotomy shock and 30-day outcomes among patients with severe left ventricular systolic dysfunction. Kyle Miletic, MD, from Henry Ford Hospital in Detroit, Michigan, unveiled findings that suggest that hemiarch plus FET was a safe operation that does not increase rates of mortality, stroke, paraplegia, or length of stay, though the investigators observed modest increases in circulatory arrest and bypass times. “While several smaller, single-center studies have shown the efficacy of the use of FET for DeBakey I aortic dissection, concerns of complications remain with this technique,” said Dr. Miletic. Therefore, his team aimed to analyze the outcomes of traditional hemiarch repair with and without FET. The STS Adult Cardiac Surgery Database was the research team’s source for a wealth of data, which they queried for all patients who underwent DeBakey I aortic repair between January 2017 and December 2020. They included all patients presenting with aortic dissection with extension distal to zone 1, excluding those who had previous aortic surgeries or total arch repairs. Patients were divided into two groups: Hemiarch and Hemiarch + FET. Dr. Miletic’s team used propensity scores to assemble a matched cohort in which those with and without FET would be balanced on key measured baseline characteristics. A multivariable logistic regression model with baseline characteristics that were different between groups was used to estimate propensity scores. Subsequent outcome analyses were based on the matched cohort. They found that there was no significant difference between the groups in 30-day mortality, stroke, paralysis, and ICU or total length of stay, and that there were fewer readmissions in the Hemiarch + FET group. Moderated by Karen Kim, MD, and Felix Fernandez, MD, MSc, the session, titled “The State of Cardiothoracic Surgery: Data and Practice Trends from the STS National Database,” also featured comments from STS President John H. Calhoon, MD, who said that it was energizing to have everyone in the room focused on improving safety and outcomes, thanking the council members, presenters, and STS staff who help to manage and curate the Database. “This is the future of STS,” Dr. Calhoon said, “and we’ve got to get this right.”

  At a celebratory breakfast with more than 290 registrants, STS's Extraordinary Women in Cardiothoracic Surgery Award was presented to Leah M. Backhus, MD, MPH, from Stanford University; Jennifer L. Ellis, MD, MBA, from NYU Langone Health; and Betty C. Tong, MD, MHS, MS, from Duke University Medical Center.     This year's Vivien T. Thomas Lecture was "Lessons From My Ancestors - A Path Towards Excellence," presented by Francisco G. Cigarroa, MD.     After 2 years of virtual-only meetings, STS 2023 attendees are able to once again meet in person with colleagues and friends, and to enjoy hands-on experiences that are better than ever.     At the Presidents Reception, attendees enjoyed stunning coastal views and celebrated the term of STS President John H. Calhoon, MD, as well as the legacies of Joseph A. Dearani, MD, and the late Sean C. Grondin, MD, who led the STS community through the COVID-19 lockdown with wisdom and grace.  

In today’s Vivien T. Thomas Symposium at STS 2023, attendees will hear how they can help to mitigate disparities in care for patients undergoing congenital surgery—and how these steps can make a difference in care throughout patients’ lifetimes. “Clearly, health equity is one of the most important drivers of outcomes across a lifetime,” said Tara Karamlou, MD, MSc, who will present during today’s Vivien Thomas Symposium. “If you’re 80 and part of an underserved population, living below the poverty line, you’ve lived your life to that point. For a child in that situation, we as healthcare providers have a responsibility to address inequities in care, and to understand that some populations are uniquely at risk.” An important step in addressing patient care disparities lies in tackling provider disparities, Dr. Karamlou points out. “We know from extensive literature that if women take care of women, if African Americans take care of African Americans, the outcomes are better. If a provider is culturally competent, they can relate to those patients such that they come back for their visits, they stay in touch with their health care team.” Dr. Karamlou noted the importance of recognizing social determinants of health as new tools—such as the new STS adult congenital surgery risk model, which will be unveiled this morning at STS 2023—are implemented in the clinical setting. “Going forward, in addition to capturing mortality, factors such as quality of life and other patient-reported outcomes will need to be folded into the risk model,” she said. Whether attendees are adult cardiac surgeons, congenital cardiac surgeons, or thoracic surgeons, it’s critical to understand that adult congenital surgery is one of the most rapidly growing fields in the specialty, and that patients who have congenital conditions have unique risk factors. “Those patients circumscribe the entire cardiothoracic care spectrum,” Dr. Karamlou said. “An adult congenital patient is still an adult congenital patient, whether they’re undergoing CABG, a pulmonary valve repair, a diaphragm plication, or a lung transplant, you need to adequately capture and adjust for the risk of your patients.” “Whatever specialty you’re in, more accurately doing that among this growing population is going to pay dividends not just for you as a surgeon, but also for your program,” Dr. Karamlou added, “so that you can adequately get credit for the complexity of your operation.” “Social Determinants of Health: Mitigating health disparities across a patient’s lifespan in congenital cardiac surgery” will be presented today as part of the Vivien Thomas Symposium, beginning at 2:45 p.m. PT.  

STS 2023 DAY 1 — Watch surgeons and intensivists square off about who’s in charge in the ICU as STS hosts a friendly debate bringing two top specialists together to help attendees develop the best care models for their institutions.  On Saturday, January 21 at 9:45 a.m. PT, a multidisciplinary panel will present the CT Ethics Forum, “For the Post-operative Patient in the ICU, Who Is in Charge and Who Is the Consultant? Surgeon or Intensivist?” As reimbursement changed for surgeons outside the OR, and as surgeons’ time for ICU care became unpredictable, intensivists began to enter the post-operative ICU arena. Andrea J. Carpenter MD, PhD, a cardiothoracic surgeon and Assistant Dean for Health System Science at University of Texas Health Science Center in San Antonio, will advocate for surgeon-directed management. Martin Zammert, MD, a surgical critical care physician who heads the cardiothoracic unit at Lahey Hospital & Medical Center in Burlington, Massachusetts, will make the case for intensivist-directed management. Both physicians will seize their best chance to persuade attendees about the merits of their specialty informing decision-making in a critical care setting. From their perspectives, a spectrum of opportunities will emerge for attendees to create the best care model at their institutions within available resources. “The bottom line is that the best model is a well-managed, protocol-driven team with clear lines of communication and shared responsibility. The caveats are challenging and involve deep respect and trust among the caregivers,” says debate moderator Joseph Zwischenberger, MD, a cardiothoracic surgeon at University of Kentucky HealthCare in Lexington. “Titles, egos, zealous trainees, and nursing bias can foil the best laid plans.” Dr. Zwischenberger adds that this ideal state is a delicate balance, reached by well-trained intensivists, surgeons and nurses, robust protocols, and buy-in from all concerned.

Tomorrow at STS 2023: A study of more than 100,000 patients reveals that, for patients with blockages in multiple arteries, those who opt for coronary artery bypass grafting (CABG) are less likely to die from their condition, less likely to need additional surgery, and less likely to have a heart attack than patients who choose to undergo a stent procedure. “The findings of our study were very convincing,” said J. Hunter Mehaffey MD, MSc, from the Department of Cardiovascular and Thoracic Surgery at West Virginia University. “The singular message to the public is that the optimal treatment for multivessel coronary artery disease—to improve not only long-term survival but also lower your risk of complications—is coronary artery bypass surgery.” The results from the study, “Contemporary Artery Bypass Grafting versus Multivessel Percutaneous Coronary Intervention in 100,000 Matched Medicare Beneficiaries,” will be presented at 9:05 a.m. PT on Sunday, January 22, during STS 2023. The background and rationale for this research project started with the publication of the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, Dr. Mehaffey explained. “The cardiac surgery world was really shocked, because the guidelines downgraded the indications for CABG from a class 1 recommendation to a class 2B.” “Much of this decision to downgrade was based on the guideline committee’s goals to focus on the most recent data, to ensure that they were capturing contemporary stent technology, so they only evaluated studies published within the past 5 years,” continued Dr. Mehaffey. “Therefore, these guidelines relied heavily on the recently publicized ISCHEMIA trial, which looked at medical therapy in coronary artery disease, comparing an initial invasive approach versus a conservative approach to patients who had stable coronary artery disease.” The problem that arises when using ISCHEMIA to compare CABG to stenting is that the majority of patients in the ISCHEMIA trial were not representative of patients undergoing CABG in the US. Therefore, the study didn’t fully represent the comparative benefits for patients who had multiple blockages in their coronary arteries.   Dr. Mehaffey’s team sought to conduct a large contemporary analysis that more fully represented this population, comparing patients undergoing bypass surgery with those undergoing stenting. They, too, wanted to ensure that the study included only the most contemporary technology, so their longitudinal analysis captured outcomes over a 3-year period, 2018 to 2020. “We used one of the largest and most inclusive databases of patients hospitalized in the US, including all patients over the age of 65 on Medicare,” Dr. Mehaffey explained. “We performed a very robust statistical analysis including propensity score balancing to help ensure that the groups of patients who underwent stenting versus those who underwent bypass surgery were well matched and well balanced in order to compare their outcomes.” The population included more than 100,000 patients with multivessel coronary disease, with 51,000 patients undergoing CABG and 52,000 undergoing stenting. Analysis was performed by a multidisciplinary team that included cardiac surgeons, cardiologists, and researchers at West Virginia University. The analysis demonstrated a significantly lower hospital mortality for the patients who underwent CABG compared to those who underwent stenting. Additionally, the researchers found a marked reduction in both 30-day and 3-year readmissions for myocardial infarction. CABG patients were also significantly less likely to need any additional stenting or intervention on their coronary arteries during those 3 years, and—most significantly—those who underwent CABG had a nearly 60% reduction in death at 3 years compared to those who had stenting. “Regardless of your specialty, these data demonstrate the importance of assessing longitudinal outcomes to help ensure we’re making optimal treatment recommendations for our patients,” Dr. Mehaffey said. MORE ON THIS TOPIC AT STS 2023 To fully understand the implications of the latest science--which demonstrates that CABG is superior to stenting in multivessel coronary artery disease, don't miss: C. Walton Lillehei Lecture by Peter K. Smith: "Treatment Selection for Coronary Artery Disease: The Collision of a Belief System with Evidence" Monday, 9:00 a.m. PT "The ISCHEMIA Study Does Not Reflect Patients Undergoing Coronary Surgery: An STS Adult Cardiac Surgery Database Analysis" by Joseph F. Sabik III, MD Monday, 11:30 a.m. PT

A scientific session devoted to identifying and closing gaps in health care will take place on Saturday at STS 2023. The session, beginning at 2:45 p.m. PT on January 21, will highlight evidence-proven programs that have not only identified disparities in health screening and treatment, but have successfully improved care for patients regardless of demographics, emphasized moderator Cherie P. Erkmen, MD, director of the lung screening and thoracic surgery residency programs for the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania. Dr. Erkmen said, “One of the things we struggle against in the realm of diversity, equity, and inclusion is that people are tired of just hearing, ‘There’s disparity, there’s inequity, there’s a problem.’ But then—what do we do? That’s part of the focus of this session—health equity in practice and people who have embraced it, successfully increasing their volumes and improving patient outcomes.” Assembled by Dr. Erkmen and Sara Pereira, MD, from the University of Utah Health, presentations within the Symposium include a report on gender outcomes in coronary bypass grafting, racial disparities in the inpatient management of ischemic heart disease, increasing health equity in the heart and lung transplant arenas, mitigating disparities across the lifetimes of patients who have undergone congenital cardiac surgery, and strategies to improve adherence to lung cancer screening guidelines in underserved communities, based on researchers’ experience in rural South Carolina. “Dr. Tara Karamlou has examined the entire continuum of congenital cardiac surgery, from diagnosis through adulthood, and has opened her doors to understand a very challenging population,” Dr. Erkmen explained. “Dr. Yoshiya Toyoda is a transplant surgeon at a very underserved, ‘safety net’ hospital, yet he’s the number one lung transplanter in the country for several years straight, accepting people across the whole socioeconomic spectrum.” “We have a thoracic surgeon, Dr. Ian Bostock, who’s looking at diversity in lung cancer screening—understanding where the disparities lie and lowering the barriers to screening so that they can get through the door and to the next step, which is lung cancer treatment,” Dr. Erkmen continued. “The last speaker, Dr. Martha McGilvray, has been awarded the podium for her research on racial disparities in the management of ischemic heart disease.” Stepping in as co-moderator is Clauden Louis, MD, MS, from Brigham and Women’s Hospital in Boston, Massachusetts. “I’m excited to be considered to represent such a name—the story of Vivien Thomas is incredibly important,” Dr. Louis said. “I think STS is taking a stand toward valuing our patients and valuing representation, understanding that outcomes are improved when the people taking care of you also have an understanding or a similarity, and are able to represent the population.” The session is named for Vivien T. Thomas, a Black laboratory supervisor who worked with famed physician Alfred Blalock, MD, at Vanderbilt University in the 1940s. When Johns Hopkins recruited Dr. Blalock, he refused to move unless Thomas accompanied him as a “package deal.” Thomas worked as part of Dr. Blalock's surgical team, helping develop the procedure used in the landmark 1944 "blue baby" operation. Despite his integral role in Dr. Blalock’s pioneering work, Thomas was hired and paid as a janitor and was not allowed to use the main entrance to Johns Hopkins. “He’s someone who could’ve been me,” Dr. Louis said. In addition to the Symposium, the third annual Vivien T. Thomas Lecture will take place at STS 2023. This year, the lecture is presented by Francisco G. Cigarroa, MD, and will mark the commencement of the annual meeting on Saturday morning at 8:00 a.m. “I’m excited about getting interest and participation from our thoracic surgery residents and our junior faculty,” Dr. Erkmen said. “And it's also important for people to know that there is an enduring workforce from the STS headed up by Dr. David Tom Cooke. Under his steady leadership, we've been able to accomplish many, many additions to the cardiothoracic surgery community, including workforce publications, looking at workforce disparity and health disparity, and also coordinating with other committees to make sure that diversity is always in mind as we legislate ourselves and create a program like the STS Annual Meeting.” On Monday at STS 2023, Dr. Erkmen also will present “The Cost of Being a Woman in Academic Surgery,” a session that analyzes rank and salary throughout women surgeons’ careers and demonstrates the additional hurdles they face. “We know that there is a difference in care when you are focused on the end goal—better access for everyone,” Dr. Louis said. “I’m excited to represent Dr. Vivien Thomas as a moderator for this session. And I’m excited to meet my colleagues in San Diego.” STS is still accepting registrations for the annual meeting, offering both an in-person experience and a virtual option, Plenary Livestream-Plus, which allows registrants to stream select meeting content and plenary sessions—including the Thomas Lecture—from anywhere in the world. STS 2023 is the premier forum for presenting new science, techniques, and technology in cardiothoracic surgery. Learn more at STS.org/AnnualMeeting.

“In the OR with” encounters, live exhibitor symposia, and extraordinary social events await attendees at the STS Annual Meeting in San Diego. “Attendance figures look as good as ever, but what is most energizing is the program,” said STS President John H. Calhoon, MD. “It is designed to give attendees some time … to not just talk about work/life balance, but to actually live it a bit.” STS 2023 registrants are highly encouraged to add ticketed “extras” to their registration, including the Presidents Reception and the Extraordinary Women in Cardiothoracic Surgery Awards Breakfast. The morning of Saturday, January 21 kicks off with the breakfast event, which will honor women surgeons who have achieved excellence in clinical practice and demonstrate integrity, leadership, creativity, and expertise in carrying out day-to-day duties and supporting the specialty. On Saturday evening, the Presidents Reception will be held at Coasterra, a bayfront restaurant and cocktail venue featuring a floating reception hall and a skyline lounge. Guests will make memories reuniting with—and meeting new—friends and colleagues. The event will celebrate not only the term of current STS President John H. Calhoon, MD, but also the legacies of Past Presidents Sean C. Grondin, MD, and Joseph A. Dearani, MD, who oversaw the Society’s governance with innovation and grace during the peak of the COVID-19 pandemic. “We have lost several admired colleagues in recent times, including Dr. Tweddell, Dr. Pagano, and Dr. Grondin,” said S. Adil Husain, MD, chair of the STS Workforce on Annual Meeting. “We will value our ability to celebrate their contributions to our subspecialty as well as to acknowledge the loss of other cherished members within our Society.” Space is limited for the reception and the breakfast, and attendees must add them to their carts during registration or to an existing registration. STS 2023 also heralds the return of live product demonstrations, with 150 exhibitors showcasing the latest tools and technologies for surgical practice. Industry symposia—both offsite and at the convention center this year—afford rare opportunities to practice new techniques, and product theaters let attendees experience devices and software hands-on. Between the conclusion of afternoon sessions and the Presidents Reception on Saturday, attendees can browse an exhibit hall opening reception and view presentations of scientific posters alongside their colleagues. Two half-hour coffee breaks on Sunday, January 22 give attendees more designated time to explore the exhibits and socialize at their leisure. “In the OR with …” experiences return with an added dimension of virtual reality, during which attendees can don headsets and virtually stand side-by-side with a master surgeon as they perform real-life operations including complex aortic arch reconstruction, uniport segmentectomy and left lower lobectomy, the Ross procedure, and minimally invasive mitral valve repair. Watch a teaser video.  There’s still time to register, add ticketed events, and start planning your San Diego experience at sts.org/annualmeeting.