STS 2023 Daily Bulletin: January 22, 2023

  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.  

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.”

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.