Clark Papers Spotlight Three STS National Database Studies

The STS National Database has contributed to scores of research studies that advance quality and patient safety in cardiothoracic surgery. Three such studies—considered as the best submitted for the 2018 Annual Meeting—have been designated as this year’s Richard E. Clark Memorial Papers.

Richard E. Clark Memorial Paper: Congenital
Congenital: Pediatric Congenital I

Monday, January 29
1:30 p.m. – 1:45 p.m.
Room 305

Richard E. Clark Memorial Paper: General Thoracic
General Thoracic: Lung Cancer II

Tuesday, January 30
1:15 p.m. – 1:30 p.m.
Floridian Ballroom B-C

Richard E. Clark Memorial Paper: Adult Cardiac
General Session I

Monday, January 29
8:15 a.m. – 8:30 a.m.
Grand Ballroom

Instead of the Clark Papers being presented en mass, the adult cardiac paper will be presented during today’s general session, and the congenital and general thoracic papers will be featured during specialty-specific parallel sessions.

TAR Remains Gold Standard for Surgical Management of Aortic Arch Pathologies

A comparative analysis of two surgical approaches for management of aortic arch pathologies has yielded interesting and provocative results.

Total arch replacement (TAR) has been the gold standard for treatment of arch pathologies such as aneurysm, dissection, intramural hematoma, and penetrating aortic ulcer. But as endovascular technology continues to be adopted for management of thoracic aortic pathologies, hybrid arch procedures increasingly are being investigated. For hybrid arch procedures, arch vessels are debranched, and an endograft exclusion of the aortic arch is then performed.

In the Clark Paper for Adult Cardiac Surgery that will be presented today, researchers analyzed data from the STS Adult Cardiac Surgery Database to gain a national perspective on the effectiveness of TAR versus hybrid arch procedures.

“TAR is the traditional operation for arch pathologies involving the head vessels, while the hybrid arch approaches represent the newer alternative,” said Prashanth Vallabhajosyula, MD, MS, of the University of Pennsylvania. “Although several single–institution retrospective studies have demonstrated satisfactory—and sometimes superior—outcomes of hybrid arch procedures over TAR, a multicenter, large-scale comparison of the two procedures has never been done. In this investigation, we assessed the outcomes of TAR versus hybrid arch procedures performed at over 270 centers nationwide in the elective setting.”

Comparing results from the two procedures, researchers studied in-hospital/30-day mortality, stroke, paralysis, reoperation, and STS morbidity (a composite of renal failure, deep sternal infection, prolonged ventilation, reoperation for bleeding, and stroke). Patients undergoing hybrid arch procedures had a higher comorbid burden, as well as significantly higher rates of mortality, stroke, and paraplegia. Even after risk adjustment, hybrid arch procedures were associated with a significantly higher risk of stroke and mortality.

“This study emphasizes the importance of careful and meticulous investigation of hybrid arch procedures before adopting them into our routine surgical practice,” Dr. Vallabhajosyula said. “Maybe it is time that we come together as a cardiac surgical community and conduct a prospective, randomized, multicenter trial to understand the optimal surgical management of aortic arch pathologies. This issue is even more important today, as single- and dual-branch TEVAR grafts are already being investigated for treatment of arch pathologies.”

Higher-Stage Lung Cancer and Central Tumor Patients Not Receiving Proper Mediastinal Staging

Identifying key predictors of invasive mediastinal staging in stage 3 lung cancers may bridge the gap and reduce uncertainty in the quality of lung cancer care. Researchers reached the conclusion after assessing the volume and uniformity of mediastinal staging within the STS General Thoracic Surgery Database (GTSD) against previously reported rates.

According to Seth B. Krantz, MD, of NorthShore University Health System in Chicago, these predictors can help determine the best course of treatment for patients and potentially avoid unnecessary surgery.

“The guidelines for mediastinal staging are pretty clear. However, the problem is that people are not actually following the guidelines and doing it with consistency,” Dr. Krantz said. “We’ve found that for higher stage lung cancer and central tumors, people are doing the procedure at a much lower rate than expected, and patients aren’t getting more invasive staging.”

In the Clark Paper for General Thoracic Surgery that will be presented tomorrow, researchers retrospectively looked at lung cancer patients staged by computed tomography and positron emission tomography and treated with an anatomic resection without induction therapy. Researchers measured invasive staging procedures that occurred within 180 days of resection and evaluated variability in invasive mediastinal staging rates across the GTSD.

Given the significant variability they encountered, researchers questioned whether surgeons fail to follow the guidelines or whether those guidelines are flawed.

“This requires further insight. The guidelines are based on experts,” Dr. Krantz said. “We need to improve the quality gap or reevaluate the guidelines. Also, we need professionals to be systematic and consistent with the procedure.”

Dr. Krantz suggested that surgeons evaluate whether they have variability in their own practices, assess their own strict adherence to the guidelines for all patients, and present their data if they believe the guidelines are flawed.

“Inconsistency is not good enough for the patient. It’s critical to follow the guidelines,” he said.

Composite Quality Measure Improves Quality of Life for Congenital Heart Surgery Patients

As outcomes for children undergoing congenital heart surgery have improved over the past few decades, the limitations of operative mortality alone as a quality metric have increasingly become recognized. To address this, a team of investigators used data from the STS Congenital Heart Surgery Database (CHSD) to create the first composite quality measure in this area. A grant from the National Heart, Lung, and Blood Institute supported the project.

“A focus on early mortality alone ignores the 97% of patients who now survive to hospital discharge in the current era and the important morbidities they may experience,” said Sara K. Pasquali, MD, of C.S. Mott Children’s Hospital in Ann Arbor, MI.

The composite measure that the investigators developed comprises a mortality domain (operative mortality) and a morbidity domain, which includes major postoperative complications and length of stay. Mortality carries the greatest influence, or “weight,” on the overall composite measure, followed by major complications and length of stay.

When looking at performance related to the composite quality measure across the 100 hospitals included in the study (and accounting for the type and complexity of patients they treat), 75% were found to be performing as would be expected, 9% were performing worse than expected, and 16% better than expected.

“The composite measure enhances our understanding of quality and variation across hospitals beyond mortality alone,” Dr. Pasquali said.

In the future, the composite measure and its individual components will be available to hospitals participating in the CHSD in their feedback reports to support benchmarking and quality improvement activities.

The Clark Papers honor the contributions of Dr. Clark, who was a key leader behind the creation of the Database, serving as Chair of the STS Ad Hoc Committee to Develop a National Database for Thoracic Surgery.