For Members

In recognition of Black History Month, we recently spoke with STS member and surgical leader Leah Backhus, MD, recipient of the 2023 Extraordinary Women of Cardiothoracic Surgery Award. Dr. Backhus is the Thelma and Henry Doelger Professor of Cardiovascular Surgery at Stanford University School of Medicine, specializing in thoracic oncology and minimally invasive techniques. 

Image

As we honor Black History Month, is there a historical figure or event that particularly resonates with you, and how has it shaped your perspective as a surgeon?

I have always been inspired by the story of Dr. Charles Drew. Of course, he was a medical pioneer, but his work was also far-reaching in establishing safe practices for blood donation. And yet, the time in which he lived required him to hold steadfast to his convictions of equality, ultimately leading to his resignation from the American Red Cross.

What progress have you seen in diversity and inclusion within cardiothoracic surgery, and what steps are still needed to ensure equitable opportunities?

We have made strides in terms of gender representation; however, it will take a century to achieve gender equity at the current pace. Most of these strides have been in thoracic surgery, with comparatively fewer women in cardiac, congenital, and transplant surgery. We can do better.

Regarding race/ethnic representation, we are still lagging, with some minor strides in certain areas and stagnation in others. We need better visibility and pipeline efforts to encourage those who may not picture themselves in the roles of CT surgeons they see in front of them. Representation matters.

We also need to address the elephant in the room regarding salary parity (or disparity), as outlined in both last year’s and this year’s STS Practice Surveys.  

What advice would you give to young Black students considering a career in CT surgery?

Mentorship is critical. Find a mentor. Find several. Remember that your mentor need not look like you; they just have to believe in you and be willing to support you. This is not easy, so you need a guide. Do not attempt this alone. Also, do not discredit your peer mentors and those just one level above you. They have valuable insights that are fresh and ready for the taking.

What inspired you to pursue a career in cardiothoracic surgery?

I came from a general surgery program with a long history of stimulating interest in CT surgery. In contrast to many general surgery programs today, which have lots of competing exposures and services, our exposure to CT surgery was consistent and intense. The faculty were amazing surgeons and teachers. The anatomy was incredibly interesting (I likened the chest to a “treasure chest” because there is something for everyone in there). And despite dealing with very complex patients and surgeries, the faculty were even-keeled and handled the high-stakes operations and patient care with poise.

Who has been a key mentor or role model in your professional journey, and how did they influence you? 

There are literally too many to name. One of my earliest mentors was Ross Bremner, who was the CT Surgery fellow when I was an intern. I later joined his lab after he was hired as faculty, and that exposure and experience helped hone my interest as well as my marketability as an applicant for a traditional fellowship slot.

Other senior mentors have included Bob Higgins and Doug Wood, who have taught me how to be a good and fair leader—both within one's own academic institution and on the national and international stages of CT Surgery.

I also have peer mentors: Thomas Varghese, David Cooke, and Jessica Donington, to name a few. But there are countless more!

Coarctation, a condition which comprises 4-5% of all congenital heart disease cases, is the second most common congenital heart defect  requiring neonatal intervention. Yet there is a lack of guidance regarding aspects of its management in neonates and infants, primarily due to heterogeneity in phenotype, making consensus in management challenging.

Recently, the STS Workforce on Evidenced-Based Surgery and its Task Force on Congenital Heart Surgery formed a panel of congenital cardiac surgeons, cardiologists, and intensivists to provide guidance to specialists who manage isolated coarctation in neonates and infants¹. 

Methods

The multi-disciplinary Task Force members first identified key questions related to the care of these patients using the PICO Framework (Patients/Population, Intervention, Comparison/Control, Outcome). After performing a literature search for each question, practice guidelines were developed using a modified Delphi method with a “recommendation” classification and evidence level, which were graded using Class of Recommendations (COR) and Level of Evidence (LOE) based on AAC/AHA classification system².

Results

The following recommendations reached a “consensus,” which meant that 80% of panel members voted on them, and 75% of them agreed with these statements:  

• For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications for those with prematurity, low weight, or other risk factors for surgical intervention. 
• For patients with risk factors for surgery, medical management prior to intervention is reasonable. 
• For those without associated arch hypoplasia, repair via thoracotomy is indicated. 
• For those with associated arch hypoplasia that cannot be adequately addressed via thoracotomy, repair via sternotomy is preferable. 
• For those with bovine arch anatomy, repair via sternotomy may be reasonable given the potential increased risk of recoarctation with bovine arch anatomy repaired via thoracotomy
• For those undergoing repair via sternotomy, antegrade cerebral perfusion or limited duration deep hypothermic circulatory arrest may be reasonable
• For those undergoing repair via sternotomy, extended end-to-end, arch advancement (end-to-side reconstruction with ligation of isthmus), and patch augmentation are all reasonable techniques

Conclusions

After completing the evaluation, Task Force members concluded that surgery remains the standard of care for managing isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach rather than a thoracotomy approach. Significant opportunities remain to delineate management in these patients better.

Although these statements provide guidance considering the available data, they are not intended to be prescriptive, and practitioners should apply these based on their experience, as well as within the clinical setting in which they work.

"Some of these guidelines' most valuable aspects summarize the data related to thoracotomy vs. sternotomy, which is a continued area of debate," said the study's lead author, Dr. Elizabeth Stephens, associate professor of surgery at Mayo Clinic in Rochester, Minn.  "The decision is often relatively subjective and based on the surgeon's training and/or experience."

This paper reveals the many questions that still need to be studied and answered. "The good news is that we as a specialty have moved from ensuring survival in these patients to decreased morbidities related to surgery, but the next step is studying long-term outcomes and how to improve them, namely freedom from hypertension and late reintervention," added Dr. Stephens.

Read the Annals article, which will soon be published in the upcoming September 2024 issue (Vol 118, No. 3) of The Annals of Thoracic Surgery. 

References:

1. Stephens EH, Ahmad D, Alsoufi B, Anderson BR, Ashfaq A, Bleiweis MS, Dearani JA, d’Udekem Y, Feins EN, Jacobs JP, Karamlou T, Marino BS, Najm HK, Nelson JS, St. Louis JD, Turek JW, The Society of Thoracic Surgeons Clinical Practical Guidelines on the Management of Neonates and Infants with Coarctation, The Annals of Thoracic Surgery (2024)

2. Class of Recommendation (COR) and Level of Evidence (LOE); Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 67(13), 1572–1574. https://doi.org/10.1016/j.jacc.2015.09 

Two papers recently published in The Annals of Thoracic Surgery aim to guide the management of thymoma¹ and pleural drains following pulmonary lobectomy² – thoracic conditions and treatments that lack widely accepted guidelines. Recognizing this need, the Society of Thoracic Surgeons (STS) Workforce on Evidenced-Based Surgery convened a task force to develop expert consensus documents to help alleviate this knowledge gap.

Thymoma, a rare epithelial tumor – but also the most common anterior mediastinal tumor in adult patients – is a condition thoracic surgeons will likely encounter as clinicians. However, there is a lack of evidence covering all aspects of treatment due to its relatively low incidence. Managing pleural drains following pulmonary lobectomy is standard practice, yet there are no established guidelines on this topic despite abundant published literature.

Management of thymoma

The STS Workforce on Evidence-Based Surgery, which includes general thoracic surgeons with expertise in thoracic surgical oncology, and medical and radiation oncologists with expertise in neoadjuvant and adjuvant therapies, evaluated existing literature about surgical considerations in managing thymomas, such as:

•    Imaging characteristics
•    Diagnostic tests 
•    Staging 
•    Surgical approach and technique
•    Neoadjuvant and adjuvant therapy 
•    Surgery for advanced or recurrent disease, and 
•    Postoperative surveillance

Consensus statements were drafted using the modified Delphi method. Votes for each proposed statement were tallied using a 5-point Likert scale, with the option to abstain on those not within the specific authors’ expertise. Statements with 75% of responding authors selecting “agree” or “strongly agree” were considered to have reached a consensus. 

Unlike broader guidelines encompassing various aspects of thymoma management, including medical oncology, radiology, and pathology, this paper addresses thymoma from a surgical perspective by guiding surgical interventions, especially in metastatic and recurrent diseases.

"Given the scarcity of randomized controlled trials due to the rarity of thymoma, this document is framed as an expert consensus rather than strict evidence-based clinical practice guidelines," said the study's lead author, Dr. Douglas Liou, clinical associate professor at Stanford Medicine. "Our findings rely more heavily on the combined experience and judgment of experts in the field rather than solely on data from large-scale studies." 

Read the Annals article. 

Management of pleural drains following pulmonary lobectomy

Similarly, the consensus document developed by the STS Workforce on Evidence-Based Surgery to manage pleural drains includes:

•    Choice of drain, including size, type, and number
•    Management, such as use of suction versus waterseal and criteria for removal
•    Imaging recommendations, including the use of daily and post-pull chest x-rays
•    Use of digital drainage systems, and
•    Management of prolonged air leak

Workforce members reviewed existing literature on the condition. A consensus using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached, with a total of thirteen statements that encouraged standardization and stimulated additional research in this critical area. 

“Optimal management of these drains should reduce patient discomfort, length of stay, and complications.”  said study investigator Dr. Michael Kent, associate professor of surgery at Harvard Medical School. “However, despite how commonly chest tubes are used in practice, the literature must provide more clarity on this subject. Many important questions have yet to be addressed and may require well-designed, prospective randomized trials.”

Read the Annals article. 

1. Reference: Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas, The Annals of Thoracic Surgery (2024)

2. Reference: Kent MS, Mitzman B, Diaz-Gutierrez, I, Khullar OV, Fernando H, Backus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Worrell SG, Raymond DP, Schumacher L, Hayanaga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy, The Annals of Thoracic Surgery (2024)

As key members of the multidisciplinary care team, thoracic surgeons play a pivotal role in the patient journey for resectable Non-Small Cell Lung Cancer. This patient journey map, suitable for both surgeons and patients, outlines the stages of treatment of resectable NSCLC from diagnosis and staging, to resection, referral to a medical oncologist, and surveillance. This includes consideration of biomarker testing during the diagnostic biopsy and resection stages, and the potential benefit of perioperative and adjuvant therapies.

Click the image below to view or download the full document.

Image

Additional Resources

Webinars 

• Biomarker Testing and Neoadjuvant Immunotherapy for Resectable NSCLC
• Sublobar Resection Versus Lobectomy for Early-Stage Lung Cancer: A Debate

Video 

• The Surgeon’s Role in Managing Patients with Resectable NSCLC

The House and Senate just approved a new government funding bill that provides $730 million in relief from Medicare physician payment cuts, boosting reimbursements by 1.68% starting on March 9 and lasting through the end of 2024. 
 
STS has vigorously advocated for this relief, yet the total amount is less than what many stakeholders demanded, including STS, 30 members of the U.S. Senate, and nearly 200 members of the U.S. House of Representatives. We will continue to advocate for the elimination of all payment cuts and insist on systematic reforms that eliminate this threat. This includes H.R. 2474, a bipartisan bill with broad support that would create automatic annual inflation adjustments for Medicare physician payments. Contact Congress on this important issue. 
 
Additional Details

• The relief will apply to services rendered between March 9 and Dec. 31, 2024. 
• After applying the relief, Medicare payments will remain 1.69% lower than in 2023. 
• The payment reduction relief will not apply to claims between Jan. 1 and March 8, 2024. 
• On Jan. 1, 2025, an additional reduction of at least 2.93% will occur, absent congressional action, due to the expiration of temporary relief.

If you have questions, contact advocacy@sts.org.

During this session, investigators unveiled findings from the largest multicenter study of post-arterial switch operations (ASO) that resulted in increased survival rates for adolescents and adult patients – as well as an increase in the potential for these patients to require cardiac reoperations to address arterial switch related complications that arise later in life.

At day two's presentation on “Burden of Reoperative  Cardiac Surgery among Adolescents and Adults Who Have Undergone Prior Arterial Switch Operation: Society of Thoracic Surgeons Database Analysis,” Bret Mettler, MD, from Johns Hopkins University, examined a multi-year assessment of the prevalence and types of cardiac surgical interventions in patients who previously underwent ASO using data from the STS National Database. 

“Anatomical repair of transposition of the great arteries (TGA) and related anomalies by arterial switch operation (ASO) achieves a normal anatomic and physiologic cardiac configuration,” said Dr. Mettler.  “And as survival rates have increased, so have the potential for these patients to require cardiac reoperations to address resulting ASO-related complications.”

As most reoperations involved multiple procedures, the presentation examined how a hierarchical stratification of procedure categories was established, with each eligible surgical hospitalization assigned to the single highest applicable hierarchical category.
  
Dr. Mettler's presentation also examined implications for surgical counseling, post-operative clinical surveillance, and therapeutic management. An analysis of the role of procedural prevalence, timing, categories, trends, and the growing number of reoperations was discussed.

“Over the past year, the STS has reaffirmed our mission to improve the lives of patients with cardiothoracic disease. We have revised our strategic plan and identified three top priorities: champion the value and impact of the specialty; advance the health, well-being, and inclusion of all cardiothoracic surgeons; and enhance the STS member value and educational experience.

It’s been an extraordinary year. We have been champions of the specialty and champions of each other. Thank you for the honor of being your president.”

STS President Dr. Tom MacGillivray

The Hub made its debut at STS 2024. In the Exhibit Hall, meeting participants attended the "Early Career Journey Roundtable: Trade Secrets for a Successful Career Journey," creating peer-to-peer connections while networking. 

Watch our day two wrap-up video!

Watch our day three wrap-up video!