2018 STS Meeting Bulletin

Embracing Failures Serves as a Catalyst to Success

Drawing from both the profession and the sport that he loves, 2017-2018 STS President Richard L. Prager, MD encouraged attendees of his Presidential Address on Monday to “see their realities” and to “make seeing and knowledge continuous with each other.”

Richard L. Prager, MD highlighted the importance of performance measurement.

“Professional innovation is our responsibility, and recognizing we are a creative specialty, I would offer that we—as surgeons—and our professional societies must be the leaders in accountability and transparency. To do so, we must embrace and advance performance measurement and analytics, performance feedback, and performance improvement,” he said.

Dr. Prager’s work with quality improvement initiatives is his professional equivalent of a grand slam, according to Keith S. Naunheim, MD, who introduced Dr. Prager. It was therefore fitting that the focus of Dr. Prager’s address was the vital role of performance measurement and feedback in achieving success.

Dr. Prager took attendees on a journey of quality improvement initiatives in cardiovascular surgery, highlighting the STS National Database and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, the latter of which he now directs.

As one example of the power of the Quality Collaborative in improving outcomes, Dr. Prager described an initiative to increase use of the internal mammary artery in coronary bypass surgery. The success was the result of identifying rates of use at various sites, offering educational sessions, creating an exclusion form for operating surgeons who chose not to use the internal mammary artery, and providing feedback.

Subsequent Quality Collaborative initiatives were successful in reducing ventilator time, decreasing unnecessary blood transfusions, and identifying when the critical or sentinel thought process or care process occurred leading to a patient’s death.

“Cardiac and thoracic surgeons have a unique opportunity with the data we have from our registries in the United States and worldwide to explore our outcomes and comparative performances, and—with understanding and feedback, discussion, and resetting of approaches and goals—create improvements, knowledge, and benefit for patients and our national health care systems,” he said.

Dr. Prager then reinforced the integral role of performance analysis and feedback for success in the sport he loves: tennis. Through short video clips of interviews with players and coaches, attendees heard how performance measurement, performance feedback style and timing, and personal qualities lead to improvement and success.

Dr. Prager captured the essence of the interviews by noting that cardiothoracic surgeons must embrace their failures, as that is the path to greatness, and should always think about getting better—not winning, but getting better—in order to be successful.

“The commitment of [tennis] players is unwavering and the recognition that performance feedback is essential is understood by every player at every level. Perhaps we can learn from their commitment and approaches,” said Dr. Prager.

He added, “Accepting performance feedback and looking at our outcomes is as much about our character as our talent or ability as surgeons, and as our future tennis stars recognize, there always are ways to improve.

“For all of us, while this may seem to be an aspirational narrative, the mastery of the approach, whether it is a hospital network, an individual hospital, or an individual surgeon, our professional innovation, our seeing, will create success,” he said.

 

Keith S. Naunheim Elected 2018-2019 STS President

Saint Louis University surgeon will focus on health care delivery and reimbursement

Cardiothoracic surgeon Keith S. Naunheim, MD, from the Saint Louis University (SLU) Medical Center, was elected by the STS membership yesterday evening as the Society’s 2018-2019 President.

Keith S. Naunheim, MD

“It means the world that my fellow surgeons think highly enough of me to elect me as STS President,” said Dr. Naunheim, the Vallee L. Melba Willman Professor and Chief of Cardiothoracic Surgery at SLU. “I am flattered and gratified by their confidence, and I will work diligently to move the Society along the right path.”

The path to cardiothoracic surgery was not necessarily a straightforward and obvious one for Dr. Naunheim. With a knack for memorizing numbers and formulas, he was attracted to the discipline of physics and was convinced that a career as a physicist made sense. But after struggling through an advanced physics course during his freshman year at The Johns Hopkins University, he was given what his professor termed a “gift B” on the condition that he seek a more promising career choice. In reminiscing about his fondness for sciences in high school, Dr. Naunheim quickly realized that medicine might be a better choice. An interest in the world of medicine had been inspired by two part-time science instructors in his hometown high school in Saint Louis, Missouri. Ironically, those two teachers had day jobs as the chief of cardiology and the dean of the medical school at Saint Louis University—the institution where Dr. Naunheim has spent the last 33 years.

After graduating cum laude from Johns Hopkins, Dr. Naunheim was accepted to The University of Chicago School of Medicine, where he trained under Robert L. Replogle, MD, who would later become an STS President, and two other nationally recognized cardiothoracic surgeons, David B. Skinner, MD and Tom R. DeMeester, MD. Following a general surgery internship and residency, as well as a fellowship in cardiothoracic surgery at The University of Chicago, Dr. Naunheim returned to his hometown in 1985 and joined the faculty at SLU, where he remains today.

An STS member since 1988, Dr. Naunheim has served on numerous committees and workforces; most recently, he was the Society’s Secretary and First Vice President. Dr. Naunheim also has chaired the Workforce on Nomenclature and Coding, the Council on Health Policy and Relationships, and the Workforce on Media Relations and Communications. In addition, he has held leadership positions in other cardiothoracic surgery organizations, including president of both the Southern Thoracic Surgical Association and the Saint Louis Thoracic Surgical Society.

As STS President, Dr. Naunheim said he will be committed to expanding the Society’s role in advancing health care policy issues that are important to cardiothoracic surgery. “The Society is already front and center with regard to quality improvement and clinical care, but I would like for us to take a step further and help determine policy decisions on a national level,” said Dr. Naunheim. “My hope is that Washington will pay closer attention to what we have to say about health care delivery and reimbursement methodology. We deserve to be heard, and with active participation, we’re going to make a real difference.”

Dr. Naunheim’s agenda as STS President also includes continuing the diversity and inclusion initiative started by his predecessor, Richard L. Prager, MD. “I think that now is the time to turn more of our resources and attention to the issue of diversity and the ethnic, racial, and gender discrepancies within our specialty,” said Dr. Naunheim. “We need to put forth efforts and resources to broaden our ranks. The more varied our membership, the more diverse the perspectives on training, research, and operative techniques will be. Such diversity can only make us stronger.”

With interests in lung cancer, esophageal disease, and health policy, as well as in coding and reimbursement issues, Dr. Naunheim has authored or co-authored more than 270 peer-reviewed journal articles, abstracts, and book chapters. He also has participated in approximately 300 presentations on these topics.

“One of the proudest moments of my career is being elected as STS President,” said Dr. Naunheim. “I look forward to working directly with the members because this is their Society. They are the ones who we represent and the people who, day after day, make cardiothoracic surgery the remarkable specialty that it is.”

Dr. Naunheim’s personal life is as busy as his professional one. He very reluctantly admits to being an amateur magician and has been an early morning runner for more than 25 years. Together with his wife of 39 years, Rosanne Naunheim, MD, they enjoy skeet shooting, traveling, antique hunting, and caring for their two oversized Leonberger dogs. They have four children and three grandchildren.

 

Three Honored for Remarkable Dedication to STS

Distinguished Service Award recognizes commitment to the Society and the specialty

Distinguished Service Awards were presented to Drs. Cameron D. Wright, Francis C. Nichols III, and Marshall L. Jacobs.

STS honored three respected and extraordinary contributors with its 2018 Distinguished Service Award, presented yesterday evening at the Annual Membership (Business) Meeting.

“Marshall Jacobs, Cameron Wright, and Francis Nichols are on the frontline, giving back in ways that help other surgeons, help our specialty, and—in the end—help our patients. These three surgeons deserve to be recognized as exceptional individuals,” said 2017-2018 STS President Richard L. Prager, MD.

 

Marshall L. Jacobs, MD
Baltimore, Maryland

Marshall L. Jacobs, MD

An STS member since 1991, Dr. Jacobs has served the organization in many capacities, including as Chair of the STS Workforce on Congenital Heart Surgery and his current role on the Workforce on National Databases—particularly as Chair of its Congenital Heart Surgery Database Task Force. He also has served on the Committee for Congenital Heart Surgery Initiatives and the Workforce on Evidence Based Surgery.

Dr. Jacobs has been a cardiothoracic surgeon and clinical investigator for 30 years, with special emphasis on congenital heart disease, pediatric heart transplantation, and pediatric cardiac critical care. In addition to his clinical career, he is the author of more than 250 peer-reviewed publications.

A graduate of Yale College and Harvard Medical School, Dr. Jacobs trained in general and cardiothoracic surgery at Massachusetts General Hospital (MGH), where he also was a fellow in cardiovascular research. He currently holds the positions of Professor of Surgery at The Johns Hopkins School of Medicine and Director of Pediatric Cardiac Surgery Outcomes Research at The Johns Hopkins Hospital.

“Dr. Jacobs’s tireless efforts in the complex world of congenital heart surgery and his expertise in helping to build a database around it make him very deserving of this award,” said Dr. Prager. “With his thoughtful and keen intellect, he recognizes the challenges and diagnostic complexities in the congenital world. Dr. Jacobs has been phenomenal.”

 

Cameron D. Wright, MD
Boston, Massachusetts

Cameron D. Wright, MD

An STS member since 1991, Dr. Wright currently is an STS Director-at-Large and serves on the Meetings and Education Council Operating Board. He previously chaired the American Board of Thoracic Surgery in addition to serving on several STS governance bodies, including the Council on Health Policy and Relationships, the Quality, Research, and Patient Safety Council Operating Board, the Workforce on National Databases (chairing its General Thoracic Surgery Database Task Force for many years), and the Workforce on Coding and Reimbursement.

Dr. Wright graduated with honors from the University of Michigan and the University of Michigan Medical School. He completed his internship and residency at MGH and became board certified in both surgery and thoracic surgery. With a special interest in quality and patient safety in surgery, Dr. Wright chairs the MGH Department of Surgery Quality Assurance. He also is Associate Chief of the Division of Thoracic Surgery and an Associate Program Director at MGH, as well as a Professor of Surgery at Harvard. Dr. Wright serves as a colonel in the Medical Corps of the US Army Reserve and completed three tours of duty in Iraq and Afghanistan.

“Dr. Wright is a clinical leader in general thoracic surgery, as well as a recognized and thoughtful commentator in the world of general thoracic surgery,” said Dr. Prager. “His ability to provide instrumental guidance in coding and reimbursement has been most helpful, and he is universally viewed as a thoughtful discussant on complicated issues.”

 

Francis C. Nichols III, MD
Rochester, Minnesota

Francis C. Nichols III, MD

Dr. Nichols—an STS member since 1993—is currently the Chair of the STS Workforce on Coding and Reimbursement, while also serving on the Health Policy and Relationships Council Operating Board. His previous STS experience includes service on the Workforce on Patient Safety.

After graduating with honors from the University of Virginia School of Medicine, Dr. Nichols completed a residency at the Mayo Clinic. With more than 30 years of diverse thoracic and vascular surgery experience, he currently holds the positions of Chair of Thoracic Surgery at the Mayo Clinic and Professor of Surgery at the Mayo Clinic College of Medicine.

“Dr. Nichols works behind the scenes of our specialty via STS, effecting change in coding and reimbursement,” said Dr. Prager. “His dedication, commitment, and desire to help have been unheralded—until now. This award signifies how important his efforts are to all of us in cardiac and thoracic surgery.”

The Distinguished Service Award, established in 1969, recognizes individuals who have made significant and far-reaching contributions to STS.

New Officers, Directors Elected

In addition to electing Keith S. Naunheim, MD as the Society’s new President, STS members elected several new officers and directors yesterday evening.

Robert S.D. Higgins, MD, MSHA was elected First Vice President, and Joseph A. Dearani, MD was elected Second Vice President. Joseph F. Sabik III, MD was reelected Secretary, and Thomas E. MacGillivray, MD was reelected Treasurer.

Kevin D. Accola, MD, Vinod H. Thourani, MD, and Ara A. Vaporciyan, MD also were elected or reelected as Directors-at-Large.

Ferguson Lecture Highlights Health Care Reform

Thomas B. Ferguson Lecture

Tuesday, January 30
9:00 a.m. – 10:00 a.m.
Grand Ballroom

Not one, but two speakers have been chosen for the Thomas B. Ferguson Lecture, which will be presented on Tuesday morning.

John Z. Ayanian, MD, MPP

John Z. Ayanian, MD, MPP will deliver “Health Care Reform: Why It’s Still Needed and Where It’s Headed.” He is the Director of the Institute for Healthcare Policy and Innovation at the University of Michigan.

Karen Joynt Maddox, MD, MPH

Karen Joynt Maddox, MD, MPH will present “The Future of Payment Reform in Medicare.” She is a practicing cardiologist at Washington University in St. Louis who has served as a health policy advisor for the Department of Health and Human Services.

Following the two presentations, there will be a panel discussion on health care reform with Keith S. Naunheim, MD, Richard L. Prager, MD, David M. Shahian, MD, and Alan M. Speir, MD.

The Ferguson Lecture was established in 2002 and recognizes Thomas B. Ferguson, MD, one of the few individuals to serve as President of both STS and AATS.

Critical Care Pioneer to Give Lillehei Lecture

The 2018 C. Walton Lillehei lecturer will be Robert H. Bartlett, MD, a ground-breaking and internationally recognized medical researcher, surgeon, and professor. He will give a talk on “The History and Evolution of ECMO.”

C. Walton Lillehei Lecture

Tuesday, January 30
11:00 a.m. – 12:00 p.m.
Grand Ballroom

Robert H. Bartlett, MD

Dr. Bartlett is best known for developing this lifesaving heart-lung technology. When Dr. Bartlett and his team first started using ECMO, the mortality rate for infants with lung failure was 90%; eventually, the survival rate became 90%. Primarily used in the beginning for babies in critical condition, ECMO is now the dominant short-term life support mechanical technology worldwide.

“The concept of using mechanical devices to keep people with no heart or lung function alive is new in the last 50 years,” explained Dr. Bartlett. “No one believed you could do that, and now we do it routinely.”

The Lillehei lecture honors C. Walton Lillehei, MD, one of the world’s preeminent cardiac surgeons who was considered to be the “father of open heart surgery.”    

Debate Continues on Key Issues for Treating Bicuspid Aortic Valves

As the treatment of bicuspid aortic valve (BAV) disease evolves, the cardiothoracic surgery community remains split on key issues, such as remodeling versus reimplantation for BAV associated with aortic insufficiency and root aneurysm, as well as the indication for resection in BAV aortopathy.

EACTS @ STS: Bicuspid Aortic Valve Repair With Aortic Valve Insufficiency and Proximal Aortic Aneurysm Repair

Tuesday, January 30
1:00 p.m. – 3:00 p.m.
Floridian Ballroom D

These are some of the topics to be discussed during today’s EACTS @ STS session, which will be moderated by leaders of both societies: STS Past President Joseph E. Bavaria, MD and European Association for Cardio-Thoracic Surgery Vice-President Ruggero De Paulis, MD.

Joseph E. Bavaria, MD

BAV is the most common congenital heart defect, with a prevalence of 1% to 2% in the general population. “The prevalence of BAV makes it important for cardiothoracic surgeons to know about advances in surgical repair and reconstruction,” Dr. Bavaria said. “We borrowed from the mitral valve history, where we now strive to repair most insufficient mitral valves. So the question before us is whether we can apply the same logic to the aortic valve.”

The session is a “meeting ground” of North American and European schools of thought on root aneurysm, said Dr. Bavaria, and a debate will focus on reimplantation versus remodeling for BAV aortic insufficiency with root aneurysm. Each of these approaches has its advantages and disadvantages, but the differences between the two have narrowed over time because of advances in techniques. The debate will help to clarify the clinical scenarios in which each approach is best.

Another ongoing debate among cardiothoracic surgeons relates to the resection diameters in BAV aortopathy. North American and European guidelines differ in their recommendations for cutoff diameters, and practice varies. Speakers will address factors in decision making regarding resection.

“World-renowned experts will take a deep dive into sophisticated content on decision making, as well as surgical techniques. Presentations will be very nuanced, with clinical pearls that attendees can apply to practice,” said Dr. Bavaria.

Detailed descriptions of aortic root and leaflet anatomy will be presented, along with a discussion of the geometry of repairs in relation to commissural angles and the proper annular dimensions—points that are important to the successful execution of the procedure. Also discussed will be different decision strategies according to various Sievers classifications, factors that contribute to poor and good outcomes, and the mid-term and long-term determinants of failure.

 

Survey Reveals Key Traits Sought in Mentors

Mentorship in cardiothoracic surgical training has an important influence on personal development, career selection, advancement, and productivity. Despite its importance, mentorship has remained uncharacterized, and its specific role among residents has not previously been assessed adequately. 

Cardiothoracic Surgical Education

Tuesday, January 30
3:30 p.m. – 4:30 p.m.
Rooms 220-221

In a session this afternoon, Elizabeth H. Stephens, MD, PhD, of New York Presbyterian Hospital, will share results from questions related to mentorship in the 2017 Thoracic Surgery Directors Association/Thoracic Surgery Residents Association In-Training Exam Survey. The survey asked about characteristics that residents want in their mentors and the current gaps residents are experiencing in mentorship.

Virtually all residents (91%) responded that they valued mentorship and considered it crucial to success. They reported that most of their mentors were mid-career and focused on both clinical practice and research.

“This group of mentors had certain perceived benefits, such as leadership, inclusion in research, and advice regarding research,” said Dr. Stephens. “Mentors at different career stages and clinical or research focus bring different strengths.”

The survey also revealed that residents highly valued mentorship that could guide their career paths in areas such as obtaining interviews and networking. However, of those residents who currently had mentors, nearly a quarter said they lacked mentorship in these areas.

Dr. Stephens said the results indicated a number of differences between what residents were seeking in mentors and the impact of the mentor. “The role of mentorship, including traits sought and its impact, changes throughout training and also varies with gender and program type,” she said.

With regard to gender, more female residents than male residents valued mentors who could serve as role models and help with networking. Women also reported that their mentors were less effective than they desired in teaching technical skills and clinical ability. “It’s unclear if these findings are related to the different traits valued by women or to mentors being less effective in imparting specific knowledge and training to women,” said Dr. Stephens. 

Can Social Media Bridge the Mentorship Gap?

“Women in surgery often report a lack of mentorship as a significant obstacle to career progression and job satisfaction and also value same-sex mentors as sharing a sense of history and understanding of both personal and professional career paths,” said Mara B. Antonoff, MD, of The University of Texas MD Anderson Cancer Center in Houston, another presenter.

Unfortunately, same-sex mentors for women are lacking in surgery—especially in cardiothoracic surgery, where women represent only about 5% of practicing cardiothoracic surgeons.

Dr. Antonoff and her coauthors hypothesized that social media is a useful supplement to physician and trainee interactions, particularly for women in cardiothoracic surgery who may lack access to same-sex mentors at their own institutions. In a separate survey, the researchers asked trainees in various surgical specialties about the role of social media in enhancing mentorship.

The results showed that approachability, ability to match by field of interest, availability, and sharing of information about daily life made prospective mentors on social media more attractive to all surgical trainees. Compared with trainees in other surgical specialties, cardiothoracic surgery trainees were more likely to say that they valued the role of same-sex mentorship in their career path but lacked exposure to same-sex mentors at their own institutions. In addition, cardiothoracic surgery trainees were more likely than other surgical trainees to use social media for building a network of same-sex mentors. They also were more likely to seek advice from same-sex mentors on work-related topics such as survival, politics, conflicts, and career planning.

“Social media brings a new dimension to networking, allowing for interactions that may be asynchronous and geographically remote,” said Dr. Antonoff. “Social media serves as a valuable tool to enhance networking and mentorship of cardiothoracic surgeons, particularly for women.”

Recognizing the importance of mentorship for the next generation of cardiothoracic surgeons, the STS Workforce on Career Development is creating a platform to connect early career mentees with mentors. Workforce members also are planning a Twitter chat this spring; visit sts.org/career-development for more details on upcoming chats.

 

European and North American Strategies Differ for Controversial Procedures

Level 1 evidence is often missing in cardiothoracic surgical practice, due to a lack of controlled trials. As a result, standard treatment and management may vary between continents.

ESTS @ STS: Controversial Issues in General Thoracic Surgery

Tuesday, January 30
3:30 p.m. – 5:30 p.m.
Room 316

Those differences will be explored in this afternoon’s collaborative session from STS and the European Society of Thoracic Surgeons (ESTS).

Session moderators Janet P. Edwards, MD, of the University of Calgary in Canada, and ESTS President Kostas Papagiannopoulous, MD, of St. James University Hospital in Leeds, United Kingdom, will lead the comparative discussion on a variety of controversial issues in general thoracic surgery, including the surgical management of lung metastases, multimodal approaches to the treatment of malignant pleural mesothelioma, surgical management of small cell lung cancer, and approaches to treatment of primary chest wall malignancies.

“We selected hot topics that are considered controversial in Europe and North America and chose expert speakers who can give their take on what’s currently happening in each area,” Dr. Edwards said. “Our session will compile the evidence in these domains to help practicing surgeons make the best possible treatment decisions for their patients.”

The speakers will address whether it’s appropriate to operate on lung metastases and whether it actually prolongs survival. Survival after resection of lung metastases likely varies based on many factors, including tumor type. Speakers will provide advice on when metastectomy is advisable, Dr. Edwards said. As for malignant pleural mesothelioma, surgeons will discuss options for multimodal therapy, as well as the availability of clinical trials.

Discussion of limited-stage small cell lung cancer is expected to address which cases should be managed with surgical resection. Finally, surgeons will explore complex reconstruction following a chest wall tumor. Chest wall tumors are relatively uncommon, and some patients may benefit from multimodal therapy.

Considering existing differences in current practice, as well as possible recommendations for change, may convince general thoracic surgeons to rethink treatment in these domains, Dr. Edwards said.

 

Options for Aortic Valve Replacement Vary in Younger Patients

Aortic valve replacement is one of the most common open heart procedures performed by cardiothoracic surgeons. Although the choice of approach is fairly standard for patients older than 70 years, the best approach for younger patients is less clear.

Adult Cardiac: Aortic Valve/Novel Technologies

Tuesday, January 30
3:30 p.m. – 5:30 p.m.
Floridian Ballroom D

American and European guidelines on valvular heart disease recommend mechanical prostheses for patients younger than 60 years, but the use of bioprosthetic valves has substantially increased, and some studies have shown that mid- to long-term survival rates are similar for both types of valves.

Ibrahim Sultan, MD

A three-way debate during this afternoon’s Adult Cardiac: Aortic Valve/Novel Technologies session will shed light on this issue. Three cardiothoracic surgeons will discuss the case of a 50-year-old patient with severe symptomatic aortic insufficiency and a non-aneurysmal bicuspid aortic valve, with each surgeon presenting a different approach: isolated valve repair, mechanical aortic valve replacement, and bioprosthetic aortic valve replacement.

“Prosthetic valve choice is important to our patients because the kind of valve chosen acts as a surrogate for life expectancy and need for reoperative heart surgery,” said Ibrahim Sultan, MD, of the University of Pittsburgh, a moderator of the session and a speaker in the debate.

Decision making is complex because of the risk/benefit ratios for each approach. “Aortic valve repair is an excellent choice in young patients with aortic insufficiency and sinus of Valsalva (SOV) aneurysms,” said Dr. Sultan. “However, in the absence of SOV aneurysm, isolated aortic valve repair may not be as durable. Patients may require reoperation at 10 years or less.”

With regard to valve replacement, mechanical aortic valve replacements may outlast a patient’s life, but require anticoagulation and are associated with bleeding risks. In contrast, bioprosthetic aortic valves do not require therapeutic anticoagulation, but carry greater risk for structural valve deterioration, with reoperation or transcatheter aortic valve replacement being needed at an average of 13 years.

Dr. Sultan encouraged attendees to come with questions and help stimulate discussion about each of the viewpoints.

“We want attendees to go home with a better understanding of the most appropriate option based on the specific advantages and disadvantages of each approach, the clinical characteristics of the patient, and the patient’s preferences,” he added.

 

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