News & Media

STS News, Winter 2021 — Over the past several years, STS member involvement in advocacy has grown considerably. In fact, advocacy participation in nearly every category of grassroots activity has increased by more than 40% since 2018. The Society also is active in a number of coalitions, including the Surgical Care Coalition, of which STS is a founding member. The result? Increased opportunities for the Society and its members to make a meaningful impact in Washington on behalf of cardiothoracic surgery and its patients. As more members get involved, the specialty earns a bigger seat at the table in Washington, ultimately leading to better outcomes for patients.     STS Surgeon Participation Facilitates Advocacy Wins In 2021, the Society—thanks to the help of STS members from across the country—made measurable progress on four of the five advocacy priorities established by the Workforce on Health Policy, Reform, and Advocacy. These priorities include: STS was instrumental in the introduction of the Meaningful Access to Federal Health Plan Claims Data Act of 2021 (H.R. 5394). The bill, introduced by Rep. Larry Bucshon, MD (R-IN) and Kim Schrier, MD (D-WA), guarantees clinician-led clinical data registry access to federal health plan claims data and preserves the authority of the Centers for Medicare & Medicaid Services (CMS) to require coverage with evidence development. The language also was included in the 21st Century Cures Act 2.0 package, recently introduced by Rep. Diana DeGette (D-CO) and Rep. Fred Upton (R-MI), which is expected to pass next year. The Society consistently has worked to avoid cuts to Medicare reimbursement for cardiothoracic surgeons. Congress passed legislation in December that will mitigate a nearly 10% cut to Medicare reimbursement for the specialty. Instead, cardiothoracic surgeons will experience a phased reduction in reimbursement over the next 6 months, averaging out to a 2% cut for 2022. This is a critical victory for the specialty and cardiothoracic surgery patients. The goal was to eliminate 100% of the pending cuts; the Society succeeded in reducing the anticipated cuts by 80% and carved a path for future engagement with legislators. STS, in collaboration with the Surgical Care Coalition, continues to push Congress and CMS for a long-term solution that does not pit physicians against each other and ensures access to care for patients across the country. Other advocacy victories include: Sustained funding for the Agency for Healthcare Research and Quality Increased funding for the National Institutes of Health and Centers for Disease Control and Prevention Preservation of coverage with evidence development 1,000 additional Medicare-supported graduate medical education slots Reversal of payment cuts for extracorporeal membrane oxygenation Tobacco purchasing age raised to 21 years old Reauthorized funding for the Patient-Centered Outcomes Research Institute STS Adult Cardiac Surgery Database quality measures added to the Bundled Payments for Care Improvement Advanced model Improved aortic grafting procedure coding Launching in 2022: Key Contact Leaders Program In 2022, the STS Government Relations team plans to launch a new program to help STS members further enhance their relationships with Members of Congress. The Key Contact Leaders Program will recognize top advocates from each state to serve as leaders in cardiothoracic surgery advocacy. Key Contact leaders will have many opportunities to build their skills as advocates and serve as the faces of STS in Washington. They also will serve as mentors for newer advocates and help with recruitment and coordination to ensure participation in advocacy continues to strengthen and expand. More information about the Key Contact Leaders Program will be available soon. Interested in getting involved in the program? Contact advocacy@sts.org. Advocate for Your Passions The Society always is looking for advocates to bring their own interests to the table. Meetings with legislators are not only an opportunity to highlight the advocacy priorities of STS, but also a chance for STS members to share their personal experiences. If you have experienced something that is impacting your practice and believe it needs to see action from Congress, speak up! The Government Relations team can help you investigate issues and effectively discuss potential solutions with legislators. All STS Members Can Be Advocates No matter where you are in your career, there is a place for you in advocacy. Congress handles issues that impact every aspect of cardiothoracic surgery and its patients—from graduate medical education to access to care. Because of this wide range of issues, legislators value hearing from as many constituents in the specialty as possible. STS encourages you to get involved in any way that you can. For more information, visit sts.org/grassroots. Get Involved Now STS can help you with scheduling and provide briefing materials. Schedule a phone call with your representatives or members of their health care policy teams to discuss important issues impacting the specialty and patients. Sit down with your lawmakers at their district offices and discuss potential legislative solutions that they can support. Invite your legislators to visit your workplace and show them the value of the services that you and your team provide. Once scrubbed in, it’s impossible to ignore your message. Contact advocacy@sts.org for more information and assistance.

Sean C. Grondin, MD, MPH, FRCSC STS News, Winter 2022 — The Society of Thoracic Surgeons has a longstanding history of impactful interactions and collaborations with surgeons and associations based outside North America. These partnerships include, but are not limited to, providing global leadership in cardiothoracic surgery education, research, and quality initiatives. As a means of recognizing and enhancing these partnerships, the STS Board currently includes a Canadian Director (Dr. Marc Ruel), as well as two international Directors (Drs. Alan Sihoe and Rafa Sádaba). These Board members provide invaluable perspectives that help guide STS in developing educational curricula and directing patient care initiatives. Expanding collaborative activities with our international colleagues and associations has been a key priority in 2021, leading to consideration of adding a third International Director position to the STS Board in 2022. Great examples of STS efforts to expand global educational relationships come from the STS Workforce on International Meetings (chaired by Dr. Wilson Szeto). Populated by surgeon leaders with diverse international backgrounds, this Workforce has provided exemplary leadership in developing cardiothoracic surgery educational content addressing the specific needs of surgeons, trainees, and allied health professionals around the globe. The following is a brief overview of several important activities currently occurring in conjunction with our valued international partner organizations. Europe The European Society of Cardio-Thoracic Surgeons (EACTS) and STS share a commitment to professional excellence in the field of cardiothoracic surgery. This joint commitment to cardiothoracic surgeons, allied health professionals, and patients, led STS and EACTS to forge a 5-year strategic partnership in 2019. The agreement seeks to provide joint innovative educational programming during both organization’s annual meetings, as well as participation by STS in the inaugural EACTS Aortic Forum that was held in Bologna, Italy, during November 2021. In addition, the two organizations also are exploring collaboration on quality initiatives involving outcomes registry coordination and/or variable harmonization. STS and the European Society of Thoracic Surgeons (ESTS) also have exchanged programs at their respective annual meetings for several years. These well-attended sessions have led to stimulating discussions on patient care. Future meetings with ESTS leadership are planned to expand our collaborations in other areas such as online teaching. Asia We highly value our collaborations with Asian cardiothoracic surgery organizations such as the Asian Society for Cardiovascular and Thoracic Surgery (ASCTVS). Participation in our respective meetings has been strong, with co-sponsored programs planned for the STS Annual Meeting in Miami Beach and the ASCVTS Annual Meeting in Nara, Japan. In the fall of 2021, a virtual meeting cosponsored by STS and Chinese cardiothoracic surgery associations was hugely successful, with additional webinars and meetings planned for 2022. Latin America Through the STS leadership of Drs. Joe Bavaria and Vinod Thourani and EACTS representatives, successful Latin America Cardiovascular Conferences were held annually from 2017-2020. Due to COVID concerns, the 2020 meeting was postponed and subsequently shifted to a free virtual meeting in 2021, which was highly regarded and involved 459 participants from 63 countries. The organizing team looks forward to presenting an in-person meeting in late 2022. The in-person 2020 STS/EACTS/ESTS Latin America General Thoracic Surgery Conference also was postponed due to COVID. Despite this minor setback, the desire to collaborate remained strong, resulting in a highly attended virtual Latin America Thoracic Surgery Symposium this past November, attracting 452 attendees from 71 countries. Africa Along with the American Association for Thoracic Surgery, ASCVTS, EACTS, and the World Heart Federation, STS was a founding member of the Cardiac Surgery Intersociety Alliance (CSIA), which was established as a result of the 2018 Cape Town Declaration. The Declaration called for significantly expanding access to rheumatic heart disease treatment in developing countries. CSIA has identified two pilot sites in Africa that it hopes to nurture into sustainable programs where underserved patients can receive surgical therapies for rheumatic heart disease. Canada Interactions between STS and the two cardiothoracic organizations in Canada, the Canadian Association of Thoracic Surgeons (CATS) and Canadian Society of Cardiac Surgeons (CSCS) continue to grow. The three organizations have exchanged distinguished speakers at their respective society meetings and have co-sponsored traveling fellowships for both attending staff and trainees. CATS also has been working with STS to harmonize variables in their respective outcomes databases and further expand the power of these registries to improve patient care. Furthermore, efforts by STS leaders and major cardiothoracic surgery centers in Canada seek to expand the footprint of the STS Adult Cardiac Surgery Database in Canada. These ongoing collaborations will remain strong under the current leadership of these organizations, with additional collaborations on the way such as the STS Coronary Congress, which is planned to take place in Ottawa in the spring of 2022. Summary In alignment with one of the key priorities in the STS Strategic Plan, expanding educational and research/quality collaborations with our valued international surgical colleagues has been an ongoing Society emphasis. I invite you to look out for future co-sponsored meetings, joint webinars, and shared programming at association meetings, as well as collaborations that involve the writing of clinical practice guidelines, expert consensus documents, and editorials. I also invite you to join me and our colleagues from around the world at the STS Annual Meeting, January 29-31, in Miami Beach, Florida (see page 12). I look forward to this opportunity to be together again, sharing our global experiences, interactions, and perspectives; I hope you do, too. It has been a pleasure serving you as STS President.

STS News, Winter 2022 — Projects funded through the Society’s charitable arm, The Thoracic Surgery Foundation (TSF), are igniting discoveries that improve the lives of patients and keep cardiothoracic surgeons at the helm of research. TSF research grant recipient Paul Chun Yung Tang, MD, PhD, is utilizing the lab at the University of Michigan Frankel Cardiovascular Center in Ann Arbor, to explore a better way to ensure that donor hearts serve their recipients well after transplant. “Currently—and this has been the case for decades—when you want to preserve hearts, you use a specific formulation of electrolytes and buffers to keep them cold and stop it from beating,” Dr. Tang said. “We stop the heart from beating so it’s using less energy, and we hope that we’ve achieved a state of cryostasis. Our research has shown that’s probably not entirely the case. There are a lot of molecular events slowly happening while in ice and the heart may be programmed to misbehave even before you put it in.” During transport and cold storage, donor hearts may suffer from the stress of lost blood flow, and consequentially from deprivation of oxygen and nutrients. This stress can result in oxidative stress and the release of inflammatory molecules that may inhibit the heart’s function once blood flow is restored. Dr. Tang’s team proposed that infusing valproic acid (VPA), a histone deacetylase inhibitor, into donor hearts during the harvesting process could reduce oxidative stress and inhibit the release of inflammatory molecules during storage, resulting in improved function when the heart resumes beating. To explore this proposition, Dr. Tang needed a laboratory, he needed hearts, and he needed funding. The Frankel Cardiovascular Center has an excellent environment for the development of clinical and translational science programs, Dr. Tang explained in his TSF grant proposal. He identified The Gift of Life Michigan organ procurement facility in Ann Arbor, a 15-minute drive from the lab, as a resource that could provide approximately 50 human donor hearts per year for research purposes. And in 2018, Dr. Tang was awarded a TSF Southern Thoracic Surgical Association Resident Research Award, which supplied $25,000 toward the project. Dr. Tang’s team worked on pig hearts and also collected human donor hearts with a left ventricular ejection fraction between 50% and 65%, but not suitable for clinical transplantation due to issues such as advanced donor age or cardiac hypertrophy. They then preserved the hearts with either traditional histidine-tryptophan-ketoglutarate (HTK) solution alone or with HTK plus VPA. At various points during cold preservation and mechanical arrest, the investigators collected left ventricular (LV) and right ventricular (RV) tissue samples, and they performed RNA sequencing and differential gene analysis to characterize gene expression and regulation in the two groups. They examined responses related to muscle contraction, cardiac conduction, and gluconeogenesis, as well as cellular apoptosis, innate immune responses, and metabolomic processes. “We discovered that VPA was able to intervene in some of the metabolic processes and selectively harness the protective metabolites that make the heart more resilient to ischemic injury,” Dr. Tang said. “VPA treatment downregulated the expression of apoptosis-related genes and the expression transcripts related to immune activation during the hypothermic preservation. And it was able to upregulate antioxidant proteins, which would predict improved cardiac function,” continued Dr. Tang. “So VPA appears to have highly beneficial effects in terms of gene expression.” For measuring cardiac performance after revival, the team used human and pig hearts, perfused with HTK solution with or without VPA. “Our experiments showed that, in the heart that was only cold preserved with HTK solution for a prolonged period, there was poor contractility and frequent arrhythmias,” Dr. Tang noted. “It required multiple shocks throughout the ex-vivo perfusion run because we had repeated episodes of ventricular fibrillation and tachycardia. After 2 to 3 hours, this heart was unable to maintain a sinus rhythm and continually fibrillated.” The pig heart treated with both HTK and VPA, on the other hand, stayed strong after revival, maintaining a sinus rhythm. “It was shocked once at the very beginning of ex-vivo perfusion and reanimation, and it maintained a good rhythm and contractility for the perfusion period,” said Dr. Tang. These promising initial results have spurred additional experiments. Also, Dr. Tang is assembling a proposal for further funding from the National Institutes of Health, and he emphasizes that receiving initial seed funding from programs like TSF—and having intriguing preliminary research funded through this pathway—make him a more attractive candidate for larger-scale grants. “It’s critical to seek out a program that’s supportive of translational research, and that’s willing to provide the initial funds to at least get your lab started,” Dr. Tang added. “If research is a worthwhile avenue for you, any dedicated research time you can get will help you advance your goals.” Scan the QR code to watch the researchers' videos of reanimated hearts with and without molecular modulation. Virtual Fun Run Merges Charity with Camaraderie The TSF Virtual Fun Run & Walk, held in conjunction with STS 2022 in Miami Beach, Florida, gives attendees and supporters an exciting way to support the Foundation and compete with colleagues. This virtual race allows participants to join the fun from anywhere in the world, anytime from January 21–February 1. Runners and walkers can complete the challenge solo or as part of a team—and teams can be groups of patients, hospital employees, friends, family, exhibitors, or corporate staff. All are welcome. Individuals can register for $50 USD, and a Team Captain Sponsorship of $500 USD may include up to 11 registrations. All proceeds will benefit TSF cardiothoracic research programs. Participants can track their time and compete with other individuals and teams, or complete the course at their own pace. Race results will be displayed on the STS leaderboard and shared on social media with the #STS2022 and #TSF5K hashtags.

STS News, Winter 2022 — Amidst personal suffering, one STS member’s introspection allowed her to prioritize what she needs from her career and her life—and to recognize that her talent gives her the leverage to say so. Sharon Ben-Or, MD, a thoracic surgeon specializing in robotics at the University of Kansas Health System (UKHS) in Kansas City, Kansas, recalls feeling her plans and goals slipping from her grasp when she received a breast cancer diagnosis in 2017. It was detected on her first mammogram—ever—at age 40, and she’d set it up with a radiologist friend. It was this friend who delivered the news. Dr. Ben-Or completed her final chemotherapy session on December 11, 2017. Thus began a cycle of surgery, complications, and chemotherapy, during which Dr. Ben‑Or returned to work intermittently, then at Greenville Health System in South Carolina. Understandably, her illness contributed to strained relationships with friends and family, though she was sometimes surprised at which individuals were supportive and which were not. Over the course of her treatment and recovery, Dr. Ben-Or found herself growing weary of the “You’ve got this!” attitude she encountered from her loved ones and health care providers. She discovered that what she needed wasn’t toxic positivity and cheerleading, but for her peers to understand that the process was painful, exhausting, and fraught with grief. Ultimately, she articulated this to her surgeon. “I realized that I resented him,” Dr. Ben-Or said. “And what I needed was for him to acknowledge that, yeah, this does suck. When I admitted that to him, he respected it and thanked me for telling him.” That admission was a milestone move in a series of assertions, through which Dr. Ben-Or found that she has the prerogative to dictate what she will and will not accept in the course of her professional and personal life. What she did accept was her current position at UKHS in January 2021. She was “aggressively recruited” by her former attending surgeon, Nirmal K. Veeramachaneni, MD, who emphasized that he’d wanted her to join his team for years. In January 2021, Dr. Ben-Or joined the UKHS team, accepting the position on her own terms. Armed with the knowledge that she was in high demand, Dr. Ben-Or negotiated a contract that made her expectations clear—allowing for flexibility should she need to take time away for her health, as well as to welcome an adopted child, a process she started in 2020. The team at UKHS maintains what they call a “break your hip fund,” Dr. Ben-Or explained. “The surgeons put their money in a kind of slush fund, so that if someone requires medical leave we’re able to compensate for that. We also had a long conversation about reproductive issues and taking time off for parental leave, and the departmental stance on that was great.” She recalls feeling for the first time that she wasn’t being interviewed, but that she was interviewing the institution, and that sense of being “wanted” gave her influence. “I made that clear before I signed the contract,” she said. “It’s just a job. There’s no emotionality to it—I don’t have a problem saying no.” The first US-born member of her family, Dr. Ben-Or is the daughter of a Mexican concert pianist and an Israeli veteran who carved out a business niche in electronics stores. She discovered her knack for medicine while keeping her uncle company on a ski trip as he studied for the MCAT. Growing up in Baltimore and training in Philadelphia, she experienced a unique melting pot of cultures, but until she joined the Greenville staff those experiences were distinctly Northern. She’s since had her share of adjustment to lingering cultural perceptions. “I’ve been fired by patients because they don’t want a female surgeon; I’ve had a patient tell me I’m going to hell because I’m Jewish. And when it comes to time off, the concept of ‘parental leave’ isn’t widely accepted—only maternity leave,” she said. Dr. Ben-Or’s renewed empathy for patients manifests in moments such as “prescribing” a puppy. But with the vast majority of procedures she performs being lobectomies for lung cancer, Dr. Ben-Or has had unique opportunities to connect more deeply. “I’m from the North, so I don’t know how to bless your heart,” she said. “And I don’t always tell patients I’ve had cancer, but with some I do share because it helps them take the next step in healing. I may not understand exactly what they’re going through, but I can acknowledge the feelings of fear, anger, and loss of control, and treat them the way I wanted to be treated when I got my diagnosis.” In addition to her OR duties and her interest in outcomes research, Dr. Ben-Or dedicates time to teaching medical students and residents about burnout, work/life balance, the doctor-patient relationship, and gender inequity. In March, she will be a guest on the STS “Same Surgeon, Different Light” podcast, in which she shares her personal and professional insights with host David Tom Cooke, MD (see page 2). If you know of a unique member experience that should be featured in STS News, contact stsnews@sts.org.

STS News, Winter 2022 — Audit results for the STS Adult Cardiac Surgery Database (ACSD) are set to be released in January 2022, and a Database audit policy now formalizes expectations for all Database components and helps participating sites complement their internal quality controls. “It’s important to note the high bar we set for these data—sites are expected to have greater than 98% accuracy in outcome measures of operative mortality and major complications,” said Felix G. Fernandez, MD, MSc, who chairs the STS Workforce on National Databases and leads the audit initiative. “Early results show that the data managers have done an amazing job despite the challenges brought by COVID. Some were reassigned, many were working remotely or even furloughed.” Through two external auditing partners, STS periodically evaluates data to ensure that patients, participants, stakeholders, and oversight bodies receive data that are accurate, complete, consistent, and high-quality, Dr. Fernandez said. “Right now, for the ACSD, we’re seeing greater than 97% agreement rates in the cardiac audit, which is phenomenal. And, with 97% of sites contributing across the country, it’s truly nationally representative.” The Society also recently published the STS National Database Audit Policy, detailing expectations for all four Database components—not only to monitor accuracy but also to alert sites to any dips in accuracy and give them the guidance they need to get back on track. The policy doesn’t contain anything particularly “new,” Dr. Fernandez explained. “It has really just formalized the standards that STS has had in place for years.” Audited sites must capture the minimum number for each procedure specified.  Each year, approximately 10% of participating sites are selected at random for audit. To be included in the audit pool, a site must be an active Database participant for all 12 months of the audited time period, have not successfully completed an audit in the past 3 years, and must have performed a specified number of procedures during that period. “All the wonderful things that we do with the Database—risk models, research, performance measures that are reported to the public—are practice changing,” said Dr. Fernandez. “Data used for device surveillance impact policy on the national level. But these attributes are really of no value if the data are not high quality.” And this is why the audit is critical, he explained—the backbone of the Database is the quality of the data, and the assurances provided by the audit are what give the community confidence. “We have made tremendous enhancements to the Database over the years, with a cloud-based platform, interactive dashboards, real-time access, and greater ease in data entry—and we have many more coming,” said Dr. Fernandez. “All these wonderful features help our participants improve their practice and make care safer for their patients.” Read the published Database Audit Policy.