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STS 2023 DAY 3 — Today is your chance to give input as cardiothoracic surgeons work to establish vital guidelines in pediatric surgery for congenital heart defects. Several of the nation's foremost surgeons will present their studies to date that will be the foundation for STS practice guidelines and consensus documents.  On Monday, January 23 at 11:55 a.m. PT, Jeffrey P. Jacobs, MD, a professor of surgery and pediatrics at the University of Florida in Gainesville, and Tara Karamlou, MD, MSc, from Cleveland Clinic in Ohio, will chair the highly collaborative session "It's All About the Data—Evidence Based Guidelines for Congenital Heart Surgery." These and other surgeons involved in the multi-institutional research want your feedback. This session will showcase the extensive research conducted to date by the Evidence Based Task Force for Congenital Heart Surgery and offer participants opportunities to contribute their own insights. Dr. Jacobs leads the task force, which is undertaking three projects where consensus on optimal care approaches does not exist: Strategies for Left Ventricular Recruitment in Neonates and Borderline in Left Heart Structures, chaired by Dr. Karamlou, Bahaaldin Alsoufi, Chief of Cardiothoracic Surgery at Norton’s Children’s Hospital in Louisville, Kentucky, and Eric Feins, MD, from Boston Children’s Hospital in Massachusetts. Management of Neonates and Infants with Coarctation, chaired by Elizabeth Stephens, MD, PhD from Mayo Clinic in Rochester, Minnesota, and Hani Najm, MD, from Cleveland Clinic in Ohio. Indications and Timing of Pulmonary Valve Replacement in Repaired Tetralogy of Fallot, chaired by Jennifer Nelson, MD, from Nemours Children’s Hospital in Orlando, Florida, and James St. Louis, MD, Section Chief of Pediatric and Congenital Heart Surgery from Children’s Hospital of Georgia in Augusta. "It has truly been an honor for me to observe the dedication and professionalism of these STS leaders as they pursued, with great scientific rigor, the best answers available to three very challenging clinical dilemmas," Dr. Jacobs says. "I am certain that the tremendous effort devoted to these studies will generate important knowledge that will ultimately improve the lives of many babies and children with congenital heart disease." These initiatives followed the call in 2022 by STS President John Calhoon, MD, to improve cardiothoracic surgery across the world. From there, the STS Workforce on Evidence Based Surgery created three Task Forces addressing some of the most pressing and unanswered surgical issues, including the congenital heart surgery group.    Research presented today will lead to publication of an STS Clinical Practice Guideline in The Annals of Thoracic Surgery and two STS Expert Consensus documents later this year.

The J. Maxwell Chamberlain Memorial Papers and the inaugural James S. Tweddell Memorial Paper in Congenital Heart Surgery were named yesterday morning at STS 2023. “Creation of a Novel Society of Thoracic Surgeons Adult Congenital Heart Surgery Mortality Risk Model" Jennifer Nelson, MD, MSc Nemours Children’s Health, Florida “Racial Disparities in Waitlist Outcomes of Patients Listed for Lung Transplantation” Isabella Florissi Johns Hopkins University "The COVID-19 Pandemic is Associated with Increased Cardiac Surgery Mortality, FTR, and Cost across All Socioeconomic Statuses” Raymond Strobel, MD University of Virginia “Contemporary Coronary Artery Bypass Grafting versus Multivessel Percutaneous Coronary Intervention in 100,000 Matched Medicare Beneficiaries” J. Hunter Mehaffey, MD, MSc West Virginia University

  An all-star panel oversaw the presentation and discussion of state-of-the-art techniques in "Robotic Cardiac Surgery Is Here to Stay."     Yesterday morning, STS Members' outstanding research and achievements were recognized with these prestigious awards: The Earl Bakken Scientific Achievement Award was established in 1999 through a grant from Medtronic, Inc., to honor individuals who have made outstanding scientific contributions that have enhanced the practice of cardiothoracic surgery and patients’ quality of life. The award was named for Medtronic co-founder Earl Bakken. Among numerous other achievements, Bakken developed the first wearable artificial pacemaker. 2023 Winner:  Bartley P. Griffith, MD University of Maryland School of Medicine Selected by the STS President, this award recognizes an outstanding scientific abstract by a lead author who is either a resident or a surgeon 5 years or less in practice. 2023 Winner:  Elizabeth H. Stephens, MD, PhD Mayo Clinic The Benson R. Wilcox Resident Award, offered by the Thoracic Surgery Directors Association, recognizes an exceptional scientific abstract presented by a cardiothoracic surgery resident. 2023 Winner:  Andrea L. Axtell, MD, MPH Massachusetts General Hospital   In his President's Address, "Three Score and More," Dr. John Calhoon related the decades of experience that shaped his values as a teacher and a learner, and on the importance of employing data to improve patient care and outcomes.     Hands-on experiences brought colleagues together for invaluable advice from veteran surgeons, demonstrations of new devices and techniques, and the thrill of working as a team.   After their last competitive round was stymied by hurricane conditions in Florida, the finalists for the CT Surgery Residents Showdown finally squared off for the last time yesterday at STS 2023.  

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 morning at STS 2023, surgeons will introduce the first-ever STS risk model that will help adults living with congenital heart disease better understand their risk of dying from a cardiac operation. “Patients who have repaired congenital conditions often need ongoing care throughout their lifetime,” said presenter Jennifer S. Nelson, MD, MS, from Nemours Children’s Health in Orlando, Florida. “Sometimes this care is for the congenital condition, but they can also develop acquired heart disease problems later in life, just like anyone else.” These patients may have different factors contributing to their mortality risk than the general adult cardiac patient population. But until now, the extent of risk from those factors hasn’t been comprehensively evaluated. While the STS Congenital Heart Surgery Database contains a trove of information about congenital surgery outcomes—and the STS Adult Cardiac Surgery Database captures nearly every adult heart surgery in the US—the former doesn’t capture adult risk factors such as hypertension and liver disease, and the latter doesn’t provide the fine details of congenital surgeries. So the extent to which risks overlap as a child “graduates” from a congenital registry to an adult registry has been difficult to mine. “With this project, we’ve been able to incorporate additional relevant preoperative risk factors with the types of procedures patients are having, to evaluate what seems to influence their risk for operative mortality,” Dr. Nelson said. To form the adult congenital heart disease (ACHD) model, Dr. Nelson’s team added 47 new variables, for procedures and diagnoses, to existing STS adult risk model variables. They were able to calibrate the model within demographic, procedural, and diagnosis subgroups, achieving excellent discrimination for operative mortality. The team also sought to make future data curation as easy for Database participants as possible, introducing a new adult congenital data collection module that will create an automatic destination in the congenital database for any patient aged 18 or older.   “Moving forward, we will be obtaining much more relevant information pertaining to adults with congenital heart disease,” said Dr. Nelson. “We’ll get the best of both worlds—details of congenital heart conditions and prior operations, and we’ll be able to understand more about hemodynamics and the impact of traditional cardiovascular risk factors on cardiac surgery outcomes for adults.” “It is not going to be a simple task to introduce a new data collection module,” Dr. Nelson continued. “But it’s really worth the investment of time and energy and we owe it to our patients. We’ve done a great job taking care of infants and children with congenital heart disease, we’ve helped them grow up. Now that they’re adults, they deserve the best ongoing care from us.”