Clinical Decision-Making

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.

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.”

STS 2023 DAY 1 — Watch surgeons and intensivists square off about who’s in charge in the ICU as STS hosts a friendly debate bringing two top specialists together to help attendees develop the best care models for their institutions.  On Saturday, January 21 at 9:45 a.m. PT, a multidisciplinary panel will present the CT Ethics Forum, “For the Post-operative Patient in the ICU, Who Is in Charge and Who Is the Consultant? Surgeon or Intensivist?” As reimbursement changed for surgeons outside the OR, and as surgeons’ time for ICU care became unpredictable, intensivists began to enter the post-operative ICU arena. 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, will advocate for surgeon-directed management. Martin Zammert, MD, a surgical critical care physician who heads the cardiothoracic unit at Lahey Hospital & Medical Center in Burlington, Massachusetts, will make the case for intensivist-directed management. Both physicians will seize their best chance to persuade attendees about the merits of their specialty informing decision-making in a critical care setting. From their perspectives, a spectrum of opportunities will emerge for attendees to create the best care model at their institutions within available resources. “The bottom line is that the best model is a well-managed, protocol-driven team with clear lines of communication and shared responsibility. The caveats are challenging and involve deep respect and trust among the caregivers,” says debate moderator Joseph Zwischenberger, MD, a cardiothoracic surgeon at University of Kentucky HealthCare in Lexington. “Titles, egos, zealous trainees, and nursing bias can foil the best laid plans.” Dr. Zwischenberger adds that this ideal state is a delicate balance, reached by well-trained intensivists, surgeons and nurses, robust protocols, and buy-in from all concerned.

Tomorrow morning at STS 2023, surgeons will introduce the first-ever STS risk model that will help adults living with congenital heart disease better understand their risk of dying from a cardiac operation. “Patients who have repaired congenital conditions often need ongoing care throughout their lifetime,” said presenter Jennifer S. Nelson, MD, MS, from Nemours Children’s Health in Orlando, Florida. “Sometimes this care is for the congenital condition, but they can also develop acquired heart disease problems later in life, just like anyone else.” These patients may have different factors contributing to their mortality risk than the general adult cardiac patient population. But until now, the extent of risk from those factors hasn’t been comprehensively evaluated. While the STS Congenital Heart Surgery Database contains a trove of information about congenital surgery outcomes—and the STS Adult Cardiac Surgery Database captures nearly every adult heart surgery in the US—the former doesn’t capture adult risk factors such as hypertension and liver disease, and the latter doesn’t provide the fine details of congenital surgeries. So the extent to which risks overlap as a child “graduates” from a congenital registry to an adult registry has been difficult to mine. “With this project, we’ve been able to incorporate additional relevant preoperative risk factors with the types of procedures patients are having, to evaluate what seems to influence their risk for operative mortality,” Dr. Nelson said. To form the adult congenital heart disease (ACHD) model, Dr. Nelson’s team added 47 new variables, for procedures and diagnoses, to existing STS adult risk model variables. They were able to calibrate the model within demographic, procedural, and diagnosis subgroups, achieving excellent discrimination for operative mortality. The team also sought to make future data curation as easy for Database participants as possible, introducing a new adult congenital data collection module that will create an automatic destination in the congenital database for any patient aged 18 or older.   “Moving forward, we will be obtaining much more relevant information pertaining to adults with congenital heart disease,” said Dr. Nelson. “We’ll get the best of both worlds—details of congenital heart conditions and prior operations, and we’ll be able to understand more about hemodynamics and the impact of traditional cardiovascular risk factors on cardiac surgery outcomes for adults.” “It is not going to be a simple task to introduce a new data collection module,” Dr. Nelson continued. “But it’s really worth the investment of time and energy and we owe it to our patients. We’ve done a great job taking care of infants and children with congenital heart disease, we’ve helped them grow up. Now that they’re adults, they deserve the best ongoing care from us.”

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.