Clark Papers Highlight Top STS National Database Studies

Data from the STS National Database have been part of numerous research studies over the years that have advanced quality and patient safety in cardiothoracic surgery. Three of these studies, selected as the best among the many submitted for the 2019 Annual Meeting, were designated as this year’s Richard E. Clark Memorial Papers.

The papers will be featured during specialty-specific scientific sessions on Monday and Tuesday. 

TAVR Use Increases in Higher-Risk Patients With Degenerated Bioprostheses
FDA approval of valve-in-valve transcatheter aortic valve replacement (TAVR) in 2015 raised a provocative possibility: Cardiac surgeons could stratify patients with degenerated bioprostheses by age and surgical risk, recommending younger and lower-risk patients for surgical aortic valve replacement (SAVR) and older and higher-risk patients for less invasive TAVR procedures.

Richard E. Clark Memorial

Paper: Adult Cardiac

Adult Cardiac: Aortic Valve/

Novel Technologies

Tuesday, January 29

1:00 p.m. – 1:15 p.m.

Room 29CD

A new analysis of the STS Adult Cardiac Surgery Database (ACSD) has shown that possibility became a reality very quickly. 

“The robustness of the data is arresting,” said Ankur Kalra, MD, of Case Western Reserve University School of Medicine and the Harrington Heart & Vascular Institute, both in Cleveland. “The data show a trend for a decrease in reoperative SAVR in the same year valve-in-valve TAVR was approved by the FDA. At least among surgeons and interventional cardiologists participating in the STS National Database, the new technology immediately moved into real-life clinical scenarios where sicker and older patients could suddenly be considered for the less invasive TAVR.”

Ankur Kalra, MD

Ankur Kalra, MD

Researchers focused on 4,239 patients in the ACSD who underwent isolated reoperation for degenerated aortic valve replacement from January 2012 through December 2016. The only option for replacement in 2012 to 2014 was SAVR. In 2015 and 2016, clinicians could use either SAVR or TAVR to replace a degenerated bioprosthesis.

They found that SAVR patients were older during the first period, 65.8 years, with a mean STS-predicted mortality of 4.55%. The mean age of SAVR patients declined to 64.5 years after the approval of valve-in-valve TAVR, and the mean STS-predicted mortality fell to 4.25%. There were no differences in rates for postoperative stroke, renal failure requiring dialysis, or mortality between the two periods.

“These trends reflect the availability of valve-in-valve TAVR for higher-risk patients,” Dr. Kalra said. “The new technology is safe, and it is being used in everyday practice by the heart team.”

Fontan Operation Outcomes Improve for Patients With Down Syndrome
A retrospective study using the STS Congenital Heart Surgery Database has found that although children with Down syndrome remain at higher risk for morbidity and mortality following the Fontan operation than children without Down syndrome, advancements in perioperative surgical care have improved in-hospital mortality for these children.

Richard E. Clark Memorial Paper: Congenital

Congenital: Pediatric
Congenital I

Monday, January 28

7:15 a.m. – 7:30 a.m.

Room 32

Researchers looked at patients with and without Down syndrome who underwent the Fontan operation between 2001 and 2016. Of the 12,074 patients, 81 had Down syndrome. The patients with Down syndrome had a higher in-hospital mortality rate (12.3%) than children without Down syndrome (1.6%). Patients with Down syndrome also had a longer length of hospital stay (12 days versus 9 days) and were at increased risk for complications, including delayed sternal closure, postoperative respiratory insufficiency, renal failure requiring dialysis, infection, chylothorax, cardiac failure, and cardiac arrest. 

Lauren A. Sarno, MD

Lauren A. Sarno, MD

At the same time, the in-hospital mortality rate for children with Down syndrome decreased from 21% during the first era (2001-2008) to 6% during the second era (2009-2016). 

“No one ever wants to refuse surgery to a child,” said Lauren A. Sarno, MD, of the Brody School of Medicine at East Carolina University in Greenville, NC. “If you find factors that are strong indicators of good Fontan outcomes such as minimal atrioventricular valve regurgitation, a normal pulmonary vascular system, and not a lot of other cardiac comorbidities, these patients can undergo the procedure. If we see a child who could possibly have a successful outcome, then I would recommend him/her for Fontan.” 

Early Stage Lung Cancer Survival Is Equal for Lobectomy
and Segmentectomy
An analysis of the STS General Thoracic Surgery Database (GTSD) has found that survival rates are similar for both lobectomy and segmentectomy when treating stage 1A lung cancer.

Richard E. Clark Memorial

Paper: General Thoracic

General Thoracic: Lung Cancer II

Tuesday, January 29

7:15 a.m. – 7:30 a.m.

Room 29CD

Lobectomy has long been the standard treatment for these patients. But a growing number of surgeons have urged consideration of segmentectomy in order to spare lung tissue and lower complication rates. 

“You will never get criticized for doing a lobectomy,” said Mark Onaitis, MD, of the University of California, San Diego. “But a segmentectomy preserves more lung tissue and function, which can be a benefit for patients.”

Mark Onaitis, MD

Mark Onaitis, MD

For this study, researchers linked GTSD data with Medicare data in order to evaluate long-term survival and other outcomes in 1,476 matched patients with stage 1A lung cancer who received either lobectomy or segmentectomy. There was no difference in long-term survival between the two groups.

“For more advanced cases, pretty much everyone agrees that you should perform a lobectomy,” Dr. Onaitis said. “But there has been considerable controversy regarding the most appropriate way to treat early stage disease. We now have a definitive answer, at least for STS National Database surgeons, that there is no difference in long-term survival for lobectomy versus segmentectomy.” 

Because the research was limited to the Medicare population, it is unknown whether the results are applicable to patients under the age of 65. 

Dr. Onaitis said future research will compare the costs of the two operations in this study group. 

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