Adult Cardiac

Shortly after the 60th STS Annual Meeting began, a packed crowd attended the "Trends and Research from the STS Adult Cardiac Surgery Database (ACSD)" session, beginning with a presentation by Michael E. Bowdish, MD, of the Smid Heart Institute, Cedars-Sinai Medical Center. He looked back at the origins of the ACSD, which was established in 1989 to collect information on cardiac surgery procedures, track outcomes, and provide insights into opportunities for quality improvement. 

Today – more than three decades later – the Database offers more than nine million recorded procedures making it one of the most comprehensive, robust, and sophisticated contemporary clinical databases in use.   

For example, 95% of centers performing coronary artery bypass grafting (CABG) in the United States, and 97% of patients receiving CABG are included in the STS ACSD. Every year 10% of the participating sites undergo a data audit assessing data accuracy and completeness with strict thresholds to pass quality control. Continuous education of data managers is a further element to ensure data quality. 

"STS ACSD is a vital source of data for outcomes research quality improvement, with overall volumes that are stable with notable trends in aortic surgery," said Dr. Bowdish.

The STS ACSD has provided the foundation for national benchmarking in adult cardiac surgery through the development of regularly updated and recalibrated risk models and performance metrics, the availability of feedback reports to database participants and individual surgeons, quality-improvement efforts, voluntary public reporting, and comparative effectiveness research. 

On day one of STS 2024, meeting goers attended numerous sessions that explored the growing debate between SAVR and TAVR as treatment options,

"Improved Longitudinal Outcomes with Surgical Aortic Valve Replacement with Atrial Fibrillation Management over Transcatheter Aortic Valve Replacement Alone," part of the larger "Bring SAVR Back" session given by J Hunter Mehaffey, MD, unveiled Class I guideline recommendations that support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). And how recently, many low to intermediate risk patients with AF and aortic stenosis (AS) are managed by transcatheter aortic valve replacement (TAVR). And finally, they evaluated real-world longitudinal outcomes of TAVR vs SAVR with or without AF treatment. 

"We concluded that in Medicare beneficiaries with AF who required aortic valve replacement, SAVR with concomitant treatment of AF was associated with improved longitudinal survival and freedom from stroke compared to TAVR," noted Dr. Mehaffey. "Consideration should be given for SAVR with AF treatment as a first-line approach for patients with AF requiring aortic valve replacement." 

In his discussion of "Robotic Aortic Valve Replacement versus Transcatheter Aortic Valve Replacement: A Propensity Matched Analysis," Vikrant Jagadeesan, MD, presented findings on contemporary data that supports equipoise between surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) for the management of symptomatic severe aortic stenosis (AS). He further explained that controversy exists around the optimal management of patients in low to intermediate risk categories, and how the study compared outcomes of surgical robotic aortic valve replacement (RAVR) to TAVR. 

"Compared to TAVR, RAVR was associated with lower stroke and PPM rates, less PVL, and improved 1 year survival," said Dr. Jagadeesan. "And RAVR may provide a safe and effective minimally invasive first-line alternative for low to intermediate risk patients presenting with symptomatic AS."

In a late breaking session titled, "Cardiac Surgery after Transcatheter Aortic Valve Replacement: Trends and Outcomes," Michael Bowdish, MD, illustrated how his research team set out to document trends and outcomes in cardiac surgery following transcatheter aortic valve replacement (TAVR), a topic gaining importance as reports of subsequent cardiac operations and early TAVR explantations increase. Using the Society of Thoracic Surgeons Adult Cardiac Surgery Database, the study covers adult patients who underwent cardiac surgery after an initial TAVR from January 2012 to March 2023. 

"The study findings underscore the escalating need for both aortic and non-aortic valve cardiac surgeries following TAVR," explained Dr. Bowdish. "They note a substantial increase in the frequency of these surgeries, emphasizing the importance of understanding outcomes."  He observed elevated risk in these cases, as indicated by mortality and stroke rates, which calls for careful consideration, particularly given the expanding use of TAVR across a broader range of age and risk profiles. Finally, the study suggests the need for ongoing assessment and longitudinal evidence to inform decision-making in the evolving landscape of TAVR applications. 

This presentation on day one of STS 2024 will report on a comprehensive approach that focuses on maximizing survival and optimizing the utilization of donor hearts in patients with hypoplastic left heart syndrome (HLHS) and HLHS-related malformations with functionally univentricular ductal-dependent systemic circulation. 

“A Comprehensive Approach to the Management of Patients with HLHS and HLHS-Related Malformation” will begin at 9:45 a.m. CT in room Stars at Night 1.  The presentation is part of the STS “Cardiac Center in Evolution: Management of Single Ventricle” session.
  
Dr. Mark Bleiweis, from the University of Florida, will report on findings describing outcomes that resulted from using this approach in 100 consecutive neonates. During the talk, Dr. Bleiweis will detail how these neonates with HLHS and HLHS-related malformations, during an eight-year period, were stratified into three different pathways based on their risk factors, and mortality rates that resulted for these neonates.

“This study is based on the principle that some patients with HLHS or HLHS-related malformations are at very high-risk for Norwood (Stage 1) palliation or hybrid palliation secondary to important cardiac risk factors,” said Dr. Bleiweis.  

On Saturday, January 27 at 9:45 a.m. CT, Christopher Mehta, MD, from Northwestern Memorial Hospital in Chicago, will present “Age-Stratified Surgical Aortic Valve Replacement for Aortic Stenosis: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD).” 

The study is part of the STS 2024 session titled, “Trends and Research from the STS ACSD.” During his talk, Dr. Mehta will provide insight into how comprehensive data help inform multidisciplinary heart teams in making decisions between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) for patients. 

Attendees will learn how the national landscape for SAVR and TAVR changed between 2011 and 2022, as experts evaluated age-specific trends and outcomes in surgical aortic valve replacement (AVR) in patients with bicuspid (BAV) or tricuspid (TAV) aortic valve by analyzing data from the STS ACSD. 

Throughout the 11-year study, which followed more than 200,000 adult patients with BAV or TAV who underwent AVR for moderate and severe aortic stenosis, age-specific trends and outcomes were evaluated.