Clinical Decision-Making

On Thursday, January 29, the Society of Thoracic Surgeons (STS), in collaboration with the International Society for Heart and Lung Transplantation (ISHLT), hosted the inaugural STS/ISHLT Lung Transplantation Symposium as part of the STS 62nd Annual Meeting. This full-day specialty session provided a practical, multidisciplinary review of contemporary lung transplantation, covering donor selection through long-term management with an emphasis on intraoperative decision-making and complex clinical scenarios.

“Through its practical, comprehensive approach, the symposium offered attendees an in-depth perspective on modern lung transplantation,” said organizing chair Kewal Krishan, MD. “The program equipped surgeons and care teams with strategies for both routine and highly complex cases.”

The program combined didactic lectures, live debates, and case-based panels to highlight advances in donor management, organ preservation, surgical techniques, and perioperative care. Attendees earned CME credits while engaging in detailed discussions of common challenges in lung transplantation surgery.

Sessions delivered a case-based overview across the operative spectrum—from donor management and organ preservation to complex intraoperative rescue. Faculty reviewed retrieval strategies in donation after brain death and circulatory death, surgical implantation techniques, perioperative anesthesia and hemodynamic management, and the use of ECMO or cardiopulmonary bypass. Advanced scenarios, including robotic, redo, and heart–lung transplantation, concluded with interactive discussions focused on real-world, high-risk cases.

As the population undergoing mitral valve surgery continues to age, the choice between repair and replacement has taken on new urgency. At the "Masters of the Mitral Valve" session on Thursday, Jan. 29 at 10:10 a.m., Dr. Allen Razavi of Cedars-Sinai Medical Center will address this issue in the Is Degenerative Mitral Valve Repair Superior to Replacement in Patients Aged >65 Years? presentation.

Image

Drawing from a large national cohort within the Society of Thoracic Surgeons Adult Cardiac Surgery Database linked with Medicare data, Dr. Razavi and his team compared long-term outcomes for patients aged 65 and older who underwent mitral valve repair with those who received mitral valve replacement. Their objective was to evaluate differences in survival, major complications, and the need for future mitral valve interventions across treatment strategies.

The study found that mitral repair was associated with significantly improved long-term survival compared with replacement, with benefits persisting across much of the older age spectrum. Patients who underwent repair also experienced lower rates of heart failure readmission, stroke, and major bleeding. While overall reintervention rates were similar between groups, repair patients tended to require earlier surgical reintervention, whereas replacement patients were more likely to undergo late transcatheter procedures.

Dr. Razavi will present findings showing how evolving treatment options and advances in repair techniques prompted the team to reassess outcomes in this population. The growth of transcatheter mitral therapies and improvements in surgical durability have heightened the need to revisit traditional assumptions about when repair should be favored over replacement.

The Richard E. Clark Memorial Paper on day one of STS 2026, Optimal Management for Moderate Aortic Stenosis at the Time of Coronary Artery Bypass Grafting, will be featured during the “Optimizing AVR: Aiming for Perfection” session on Thursday, Jan. 29, at 11:00 a.m. In this presentation, Pey-Jen Yu, MD, of Northwell Health, will explore how best to manage moderate aortic stenosis (AS) in patients undergoing coronary artery bypass grafting (CABG), a question that has grown increasingly important as transcatheter approaches continue to reshape treatment pathways.

Image

Drawing from a large cohort in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD), linked with national inpatient records, Dr. Yu and colleagues compared outcomes for patients who had isolated CABG versus those who received CABG combined with aortic valve replacement (AVR). The goal was to understand both the immediate risks and the longer-term implications of addressing—or deferring—valve intervention in patients with moderate AS.

The study found that patients undergoing CABG alone experienced slightly lower operative risk, but they were more likely to require later aortic valve intervention and were at increased risk for readmission related to heart failure. Meanwhile, those who underwent concomitant AVR faced a higher initial risk but significantly lower likelihood of needing future valve procedures. Importantly, mid-term survival was similar between the two groups.

In her presentation, Dr. Yu will highlight how the rapid expansion of transcatheter valve therapies served as a key motivation for this work, prompting the team to revisit longstanding assumptions about when to intervene on a moderately stenotic valve during open-heart surgery.
 

During the "Diagnosing Patients: Do You Know Before You Go?" session on day one of STS 2026 at 10:15 a.m., Talal Alzghari, MD, of One Brooklyn Health-Brookdale University Hospital Medical Center, will present Oncological and Surgical Outcome Differences in Never-Smoker Women Compared to Ever-Smoker Women and Men. In this presentation, Dr. Alzghari examines how gender and smoking status independently shape surgical and long-term outcomes following lung cancer resection—an increasingly important question as lung cancer rates continue to rise among women.

Image

Although smoking remains the leading risk factor for lung cancer, prior studies have shown conflicting results regarding its impact on postoperative outcomes when gender is considered. To clarify these relationships, Dr. Alzghari and colleagues analyzed national registry data to compare perioperative and oncologic outcomes among women and men with differing smoking histories who underwent resection for non-small cell lung cancer (NSCLC).

Analyzing more than 145,000 elective NSCLC resections from the Society of Thoracic Surgeons General Thoracic Surgery Database, the investigators found that never-smokers are becoming more common over time in both men and women. Never-smoker women emerged as a distinct group with fewer comorbidities, lower perioperative risk, and the most favorable long-term survival, while ever-smoker men experienced the highest complication rates and poorest survival. These differences persisted after risk adjustment, highlighting the independent influence of both gender and smoking status on surgical and oncologic outcomes..

In his presentation, Dr. Alzghari will discuss how these findings can inform preoperative counseling, risk stratification, and treatment planning for patients undergoing lung cancer surgery. He emphasizes that understanding the combined effects of gender and smoking history is essential to delivering more personalized, data-driven care for patients with NSCLC.

Breakthrough research to be presented at the 2026 Society of Thoracic Surgeons (STS) Annual Meeting suggests that more comprehensive lymph node assessment during surgery is critical to accurately staging and treating patients with clinically node-negative non-small cell lung cancer (NSCLC). Christopher Seder, MD, thoracic surgeon and professor of surgical sciences at Rush University Medical Center, will present the J. Maxwell Chamberlain Memorial Paper in General Thoracic Surgery, Association Between Nodal Assessment, Upstaging, and Survival in Resected Clinically Node-negative Non-small Cell Lung Cancer, on Saturday, Jan. 31, at 7:35 a.m. during the “Research in Focus: Distinguished Abstracts” session.

Image

Although imaging may indicate that NSCLC has not spread to lymph nodes, global surgical standards vary widely regarding how many nodes should be removed and evaluated. In North America, guidelines introduced in 2021 recommend assessment of one N1 node in the hilar or root of the lung and three N2 nodes in the mediastinum. Using data from the STS General Thoracic Surgery Database, researchers found that this approach may miss disease spread, as cancer was more frequently identified in N1 nodes than in N2 nodes, with many metastatic nodes located adjacent to the bronchi. The study recommends removal and evaluation of more than one N1 node in addition to at least three N2 nodes.

The analysis examined a large, multi-center cohort of clinically node-negative NSCLC patients treated over a three-year period. Patients underwent wedge resection, segmentectomy, or lobectomy, and a meaningful proportion were upstaged after surgery when lymph node dissection revealed more advanced disease than initially diagnosed. Patients who received neoadjuvant therapy, underwent preoperative mediastinoscopy, lacked PET-CT imaging, or had incomplete pathology data were excluded. Expanded nodal assessment improved detection of occult disease, enabling more accurate staging and more appropriate use of chemotherapy and additional treatments.  

“We are narrowing down the best techniques for lymph node dissections in patients with lung cancer to give the best chance of identifying any cancer that is there and improving survival,” says Dr. Seder. “The onus here is not only on surgeons to dissect out more lymph nodes, but on pathologists to take this lung specimen we give them and do a very thorough evaluation of that lung specimen to get all the additional lymph nodes with cancer that are hiding in the specimen.”
 

During the Saturday, Jan. 31, 7:50 a.m. presentation of the James S. Tweddell Memorial Paper for Congenital Heart Surgery, Elaine Griffeth, MD, of Mayo Clinic, will present new research as part of the “Research in Focus: Distinguished Abstracts” session at the 2026 Society of Thoracic Surgeons (STS) Annual Meeting. Her talk, Extended Validation of an Institutional Machine Learning Model for Postoperative Morbidity and Mortality Risk in Adult Congenital Heart Disease Patients Undergoing Cardiac Reoperation, will explore how advanced risk modeling can better inform surgical decision-making for adults with congenital heart disease (CHD).

Image

Adults with CHD represent a growing and medically complex population. Most were born with structural heart defects and underwent surgery early in life, yet many require additional cardiac operations as adults. Prior surgeries, evolving anatomy, and long-term health challenges make it difficult to accurately estimate operative risk using existing tools designed for the broader adult cardiac surgery population, highlighting the need for a CHD-specific national risk assessment model.

The study analyzed cases from the STS Adult Cardiac Surgery Database spanning several years, building on prior Mayo Clinic work using machine learning and logistic regression. Seven factors were strongly associated with postoperative morbidity and mortality: sex, age, single-ventricle physiology, surgical urgency, kidney function, ejection fraction, and prior heart operations.  

“This is a work in progress,” says Dr. Griffeth. “We want to have high reliability in the surgeries we are offering, and we are trying to tailor this model with data from past patients. The more informed patients are about their risks for surgery, the better.”
 

New findings slated for presentation at the 2026 Society of Thoracic Surgeons (STS) Annual Meeting suggests that aortic hemiarch reconstruction provides outcomes comparable to more complex extended arch reconstruction in patients over age 65 with acute type A aortic dissection (ATAAD). John Spratt, MD, clinical assistant professor of thoracic and cardiovascular surgery at University of Florida Health, will present Extended Arch Reconstruction for Acute Type A Dissection Does Not Impact Long-Term Survival or Reoperation in Patients Over Age 65: An STS-CMS Longitudinal Analysis during Sunday’s 11:15 a.m. adult cardiac session, “Tips & Tricks to Get Through Any Dissection.”

Image

The study used a risk-adjusted analysis of patients from the STS Adult Cardiac Surgery Database, which includes millions of adult cardiac surgery records. Patients underwent surgery at U.S. hospitals over several years, with most receiving aortic hemiarch reconstruction and the remainder undergoing extended arch reconstruction. Researchers evaluated postoperative mortality, stroke, and the need for reintervention for aortic disease and found no significant differences in these outcomes among patients ages 65 and older.

Extended arch reconstruction is a more complex operation that includes replacement of the aortic valve and repair of the ascending aorta, aortic arch, and the major arteries branching from the arch. Hemiarch reconstruction, by comparison, involves replacement of the aortic valve and repair of the ascending aorta and the underside of the aortic arch. Because aortic dissections most commonly affect older adults and require emergency surgery, surgeons must weigh the benefits of a more extensive repair against increased operative time, longer heart-lung bypass duration, and greater neurologic risk—factors that older patients often tolerate less well than younger individuals.  

“You have to balance what a patient may need on paper, compared with what their overall risk profile is,” says Dr. Spratt. “The majority of patients age 65 and older will be fine with hemiarch reconstruction and have the same outcomes as they would with a higher-risk procedure.”
 

The Society of Thoracic Surgeons hosted an early career webinar, How to Maximize Your First Six Months of Training, facilitated by Sandeep Bharadwaj, MD, Northwestern University, and featuring insights from faculty, fellows, and recent graduates, including Sara Pereira, MD, Indiana University School of Medicine; Irbaz Hameed, MD, Yale University School of Medicine; Allison Davila, MD, Lurie Children’s Hospital of Chicago; Kathleen Banfield, MD, University of Washington; and Rachel Schenkel, MD, University of Minnesota. The session focused on how residents and fellows can set themselves up for success during the critical early months of cardiothoracic surgery training.

Here are the five key takeaways:

1. Preparation and Attention to Detail Build Trust

Panelists emphasized that preparation begins with knowing the patient thoroughly through indications, imaging, labs, and prior operative notes. Because each attending has different preferences, keeping a running document of techniques and nuances is invaluable. Remembering even small details, such as how a surgeon places retraction stitches, signals meticulousness and builds early trust.

Tip: Take notes or create personalized preference cards after each case. Reviewing them before scrubbing in demonstrates initiative and reliability.

Panelists also talked about the importance of using medical journals and resources strategically. For example, the Annals of Thoracic Surgery was highlighted as the most commonly read journal, with additional helpful content sometimes found in cardiology-focused publications such as Circulation or JACC. Apps like the older CSAT versions can also be valuable if still available.

2. Maximize Rotations Beyond the Operating Room

Early in training, residents should take advantage of rotations in anesthesia, perfusion, and imaging. These experiences provide foundational knowledge about cardiopulmonary bypass, echocardiography, and perioperative care that will make OR time more meaningful later.

Advice from faculty: “You’ll have plenty of opportunities for cardiac and thoracic cases. Early on, prioritize learning the physiology, imaging, and team dynamics that support those operations.”

3. Presence Matters More Than Case Volume

Technical milestones in the first six months vary widely and depend largely on faculty trust. Rather than focusing on how many sternotomies or cannulations you log, concentrate on showing up prepared and present. Double-scrubbing, even when you’re not the primary, provides an opportunity to observe technique, communication, and decision-making without the pressure of leading the case. 

Key reminder: “It isn’t always about doing, it’s about being present and understanding the flow of the operation.”

4. Clarify Communications, Manage Expectations, and Avoid Comparisons

Many trainees struggle with self-doubt when their technical skills don’t advance as quickly as their peers’ skills. Faculty urged residents not to compare themselves to others or to what’s portrayed on social media. Everyone progresses at a different pace, and impostor syndrome is common. Define communications protocols. Different institutions use pagers, texts, WhatsApp, Epic chat, or Teams messages. Trainees should learn the preferred hierarchy of communication (e.g., page - call vs. text - call) and align with their team’s expectations. Junior residents are also encouraged to err on the side of overcommunication with seniors and attendings. If you’re unsure whether to call, the safe rule is that you should.

Practical step: Check in regularly with program directors or attendings. Structured feedback often reveals that you’re performing at or above expectations, even if you feel behind.

5. Develop a Study System That Works for You

Learning outside the OR is just as important as time inside it. Some panelists recommended structured reading plans, such as committing to one textbook in the first year, while others suggested journaling surgical techniques or building photo libraries of operative steps. The method matters less than consistency.
Advice from the panel: Identify a study routine early and stick to it, whether through textbooks, operative atlases, or case-based reviews. Over time, selective reading and case preparation will sharpen your clinical judgment.

The first six months of cardiothoracic surgery training are about more than technical skills. They are about building trust, cultivating presence, and laying the foundation for a lifelong career. By preparing thoroughly, engaging fully in every rotation, and giving themselves grace, residents can maximize this critical period.

More than 300 attendees from around the world gathered in Seoul, Korea, on September 12–13 for the 2025 Heart Valve Disease Forum (HVDF), which was co-hosted by The Society of Thoracic Surgeons and the Korean Society for Thoracic and Cardiovascular Surgery (KTCVS). This year’s forum, centered on the theme “The Wonderland of the Tricuspid Valve: Unraveling Its Secrets,” offered an in-depth exploration of tricuspid valve disease, from anatomical foundations to advanced treatment strategies.

Image

The immersive, two-day event featured leading faculty from around the world and provided a multidisciplinary platform to examine the latest trends in diagnosis, surgical innovation, and clinical management of tricuspid valve pathology.

“This year’s HVDF covered the latest insights into the anatomic and physiologic basics, causes, diagnosis, treatment, and future of valve diseases, featuring scholars from various fields,” said HVDF President Kyung Hwan Kim, MD, PhD. “We facilitated discussion among experts, covering everything from foundational concepts to the latest trends in tricuspid valve research, including emerging surgical and treatment methods.”

Expert-Led Training and Hands-On Education

The program featured a comprehensive series of sessions, including mentorship programs, abstract presentations, poster sessions, and scientific debates, designed to foster both technical skill development and collaborative exchange. Hands-on wet labs allowed participants to practice complex procedures under expert guidance, while breakout discussions provided tailored instruction on topics such as tricuspid valve repair and the management of regurgitation in patients with atrial fibrillation.

“This year, we highlighted a particularly relevant topic: managing tricuspid valve disease in the setting of atrial fibrillation,” said Christopher Malaisrie, MD, of Northwestern Medicine. “The conference reflected growing global interest in the valve’s complexity and clinical significance.”

Advancing the International Dialogue on Valve Disease

Image

By combining practical skill-building with high-level academic dialogue, the HVDF continues to raise the bar for heart valve education. The English-language conference emphasized the importance of cross-cultural collaboration in tackling complex cardiothoracic challenges and provided a space for participants to engage directly with international experts.

With its emphasis on personalized mentorship, state-of-the-art content, and a focus on clinical translation, the 2025 HVDF reinforced its position as a premier global platform for advancing the science and practice of heart valve disease treatment.