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STS 2023 Day 1 — Avoiding unnecessary perioperative opioids remains imperative, and today’s “Contemporary Operative Pain Management” session is essential for surgeons to glean the latest opioid-sparing approaches to pain management. The session will be presented on Saturday, January 21, at 11 a.m. PT and is moderated by Daniel Engelman, MD, from Baystate Medical Center, professor of surgery at the University of Massachusetts Chan Medical School in Springfield, Massachusetts, and Alison Ward, MD, from Emory Healthcare, assistant professor of surgery at Emory University School of Medicine in Atlanta, Georgia. “This session will be a truly multidisciplinary session drawing from the expertise of surgeons, anesthesiologists, and physiotherapists to discuss optimizing post-operative pain management,” Dr. Ward says. Acute, post-operative pain from heart surgery is inevitable and can result from a variety of causes. However, there is a growing concern regarding the incidence of new, persistent opioid use following cardiac surgery, which research has shown may still happen in up to 15 % of patients. The session will showcase alternative approaches to opioid-based analgesia for pain control that also facilitates patient mobility. These include multimodal analgesia involving more than one class of medication to target different receptors along the pain pathway. In addition, the rapidly expanding options in regional anesthesia for cardiothoracic surgery, such as nerve blocks, will be discussed for integration into the overall pain management plan. The Contemporary Operative Pain Management session includes six presentations:          New Persistent Opioid Use After Cardiac Surgery          Sternotomy Without Mobility Restrictions          Does Surgical Approach Impact Postoperative Pain?          Cardiac Surgery Without Opioids          Non-Pharmaceutical Approaches to Pain Management         Panel Presentation with Open Audience Discussion Dr. Engelman is President of the Enhanced Recovery After Surgery Cardiac Society and Senior Perioperative Editor of The Annals of Thoracic Surgery. He says he especially looks forward to the open exchange of ideas during the panel portion of the session. STS 2023 attendees will bring novel approaches to pain management back to their institutions, broadening their pain control strategies and employing new techniques that can decrease or even end the root causes of their patients’ pain and symptoms, as well as reduce length of hospital stay. 

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

STS 2023 Day 1 — General thoracic surgeons should not miss this presentation that challenges lobectomy as the gold standard treatment for patients with smaller lung tumors. Surgical segmentectomy, as opposed to lobectomy, should be considered for patients whose lung cancer has been downstaged following neoadjuvant chemoimmunotherapy, STS 2023 presenters say. On Saturday, January 21 at 9:45 a.m. PT, Charles Logan, MD, from Northwestern University Feinberg School of Medicine in Chicago, will present “Pathologic Downstaging Following Neoadjuvant Chemoimmunotherapy for Locally Advanced Lung Cancer is Associated with Survival Comparable to Early Stage-Matched Disease.” The study is part of the STS 2023 session “Is the Hype Real? Targeted and Immunotherapy in Resectable Non-Small Cell Lung Cancer.” Recent randomized clinical trials suggest that a lung resection accomplished by segmentectomy may be the best approach for treating small tumors in early-stage, non-small cell lung cancer (NSCLC). This study takes the investigation further by suggesting that patients with stage IIIA cN2 lung cancer downstaged after neoadjuvant chemoimmunotherapy and lobectomy have similar survival to patients with small tumors who undergo segmentectomy. Those who receive segmentectomy may benefit from improved quality of life and greater ability to tolerate toxic adjuvant suppressive immunotherapies—compared to patients with small tumors who undergo lobectomy. “We hope to spark a discussion among those who care for lung cancer patients whether patients whose malignancies have been downstaged after neoadjuvant therapy should be candidates for segmentectomy. We think the available data point toward ‘yes,’ but a randomized clinical trial may be needed to answer this definitively,” Dr. Logan says. Segmentectomy potentially offers other advantages over lobectomy for these patients because a smaller resection minimizes the amount of functional lung tissue removed. Research into targeted therapies for NSCLC has also escalated, offering the possibility that more patients will be downstaged after neoadjuvant treatment and may not need to have an entire lobe removed. Dr. Logan is a postdoctoral research fellow and surgery resident at Northwestern, and senior study co-authors Samuel Kim, MD, Ankit Bharat, MD, and David Odell, MD, MMSc, are also from Northwestern.

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.

Investigators will discuss the real—yet easily identified—risk that living in a food desert may have on patients recovering from esophagectomy on Day 1 of STS 2023. Mortality risks for patients with colon and breast cancers who live in food deserts have been reported in recent years as part of a large administrative database review. On Saturday, January 21 at 1:25 p.m. PT, surgeons from six high-volume medical centers will present the first multi-institutional research that identifies patients who undergo tri-modality therapy for esophageal cancer have increased risk of readmission following surgery. Joseph Phillips, MD, from Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, will present the study exploring the association between food deserts and patient re-hospitalizations after esophagectomy.  In this retrospective research, surgeons reviewed records from a diverse US patient population that underwent neoadjuvant chemoradiation followed by esophagectomy. Of 425 patients included, 73 lived in a food desert, which are areas where access to nutritious foods is inadequate. The study found that patients from food deserts were twice as likely to be readmitted to the hospital for any reason within 30 days post-surgery. The study also found that these patients had significantly lower median household incomes, although this was not a factor when patients were stratified by readmission status. No differences were found in length of stay, complications, or 30-day mortality between patients who lived or did not live in food deserts. “Living in a food desert is an easily identifiable risk factor that should alert surgeons that pre- and post-surgical interventions may be needed to improve outcomes,” Dr. Phillips says. Food deserts, as defined by the United States Department of Agriculture (USDA), are low-income census tracts where a substantial number of residents have low access to grocery stores. The USDA identifies about 6,500 tracts in urban and rural areas as food deserts, where 13.5 million people don’t have a supermarket nearby. Aside from scarcity of nutritious food, residing in a food desert is also often an indicator of low incomes and inadequate healthcare access. The study authors also postulate that patients receiving tri-modality therapy for esophageal cancer may benefit from early referral to resources such as social workers and dieticians for intervention prior to and during treatment. Furthermore, these patients may benefit from more directed post-discharge care to avoid unnecessary readmissions to the hospital.

A must-see session for pediatric surgeons will showcase the first study that analyzes multiple factors impacting survival of young patients with ventricular assist devices (VADs) over the last decade.  “Variables Affecting Survival in Pediatric Patients Supported with VADs: A Special Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report,” will be presented at 11:30 a.m. PT on Sunday, January 22, 2023, during the STS Annual Meeting. The presentation is part of the STS “Current Controversies in Congenital Transplantation and Mechanical Circulatory Support” session. Awais Ashfaq, MD, from Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, will report on findings. Although 10 leading children’s hospitals conducted the study, the analysis includes all 47 hospitals in the Pedimacs database of children and adolescents under age 19.  The group reviewed Pedimacs data back to the registry’s inception in 2012 through the end of December 2021, covering 1,109 patients, and identified that illness at time of VAD implantation, diagnosis, support strategy, and VAD device type all affected mortality. This study is the first step to create evidence-based guidance on VAD device choices and other decisions in care management. For instance, one finding indicates that infants and older pediatric patients with paracorporeal continuous device support, congenital heart disease, biventricular support, and Intermacs profile 1 (cardiogenic shock) had worse overall survival after six months. "For anyone in our field, and especially for those who have an interest in pediatric mechanical support, Pedimacs is invaluable,” Dr. Ashfaq says. “There is so much to learn from the data available in the database.” Pedimacs became part of The STS National Database™ in 2018 and is a joint effort among the National Heart, Lung, and Blood Institute, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and others. The North American clinic registry includes patients who receive an FDA-approved mechanical circulatory support device to treat advanced heart failure. Due to its exponential growth in terms of participation and stature, the STS National Database has become the gold standard for clinical outcomes registries among health care administrators, government officials, and payers. Dr. Ashfaq adds that the group will be taking their results and expanding them into a web-based tool to help physicians decide if patients will benefit from VADs and which device to choose.