January 23

New Data Released on Heater-Cooler Device Infections

heater

A session on infections caused by bacteria in heater-cooler devices drew a large crowd Sunday.

Annual Meeting attendees crowded into a packed 7:00 a.m. session yesterday to hear about newly revealed research regarding a critical patient safety issue.

Over the last few years, a growing number of serious infections have been linked to bacteria forming in heater-cooler devices (HCDs) used in cardiac surgery operating rooms. In these cases, aerosolized bacteria, predominantly nontuberculous mycobacterium (NTM) from the HCDs, contaminated the operative field. Emerging evidence regarding the incidence and challenges of detecting the infections has triggered alarms at the US Food and Drug Administration and regulatory agencies in Europe.

The latest update on the threat of NTM was presented Sunday by cardiothoracic surgeons and experts in perfusion and infectious diseases during a special session, “Heater-Cooler-Induced Infections: Practices, Protocols, and Mitigation Strategies.”

“We are just beginning to scratch the surface, even though this research has been going on for more than 2 years,” said Keith B. Allen, MD, of St. Luke’s Mid American Heart Institute and the University of Missouri–Kansas City, the lead author of an abstract focusing on the problem. He has worked with other experts at the request of the FDA, which organized a special conference last summer to address the problem.

The infections associated with HCDs have a latency period of up to 72 months, with a mean time of 17 months from surgery to onset of symptoms, said Neil Fishman, MD, an infectious disease expert at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

The incidence of infections has been tracked in the Medical Device Report database, which collects reports from manufacturers, importers, and user facilities, as well as physicians, patients, and consumers. The database has 339 reports related to HCDs between January 2010 and August 2016. The surgical procedure involving HCDs was identified in 94 reports, and 50% of them involved device implants, such as left ventricular assist devices, prosthetic valves/rings, and vascular grafts.

NTM was the most frequent organism cited in the reports, and Mycobacterium chimaera was the predominate isolate. Detection is challenging because it takes 2–8 weeks to grow on mycobacterial media, Dr. Fishman said. Identifying the species requires sequencing that is performed at only a “handful of labs” in the US.

“This is a device problem, not a surgical problem,” he added.

The infections are linked to HCDs from five different manufacturers that are used in the US and around the world, with 89% linked to one manufacturer, Dr. Allen said, emphasizing that all of the manufacturers are working with regulatory agencies to resolve the problem.

The FDA recommends that all institutions adhere to manufacturer instructions for HCDs, use only sterile or filtered water in the devices, direct HCD exhaust away from the surgical field, and remove units with signs of contamination.

The FDA and the Centers for Disease Control recommend that some HCDs manufactured before September 2014 be transitioned out of service and that patients exposed to the devices since January 1, 2012, be notified in writing about the risk of infection.

The risk of infection increases with length of exposure to NTM, which is aerosolized from the HCDs. Clinical presentations of infection include fatigue, fever, sweating, dyspnea, weight loss, and cough. Because surgical wound infections are involved, treatment includes removal of the involved device and multiple-drug therapy, Dr. Fishman said.

“We don’t know how long to treat these infections. At the least, most people are treating for 9 months, but some people are extending therapy to a year or 18 months,” he said. “The outcomes are not great. In general, the overall mortality is greater than 50%. That is attributed almost certainly to the delayed diagnosis.”

Miguel Sousa Uva, MD, PhD, President of the European Association for Cardio-Thoracic Surgery, commented on the European experience with these infections, which were reported overseas before being identified in the US.

Larry L. Shears, MD, of Wellspan Health in York, Pa., first experienced NTM infections in June 2015 at after consulting with infectious disease specialists at Penn State Health Milton S. Hershey Medical Center in Hershey, Pa.

Kenneth G. Shann, CCP, LP, Director of Perfusion Services at Massachusetts General Hospital in Boston, offered recommendations on properly caring for HCDs. He suggested that a checklist be used to clean devices, that cleanings be documented, and that the serial numbers of HCDs used in procedures be recorded.

STS President Joseph E. Bavaria, MD noted that the Society has issued a statement about HCDs, as well as provided advisories from the CDC and FDA, on its website at
sts.org/heater-cooler.

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Devices Draw Mixed Reviews in Tech-Con’s Shark Tank

Shanda H. Blackmon, MD, MPH explains the benefits of using the Blackmon-Mayo Buttressing Anastomotic Device to Shark Tank judges Saturday.

Shanda H. Blackmon, MD, MPH explains the benefits of using the Blackmon-Mayo Buttressing Anastomotic Device to Shark Tank judges Saturday.

Inventors tend to be optimists, perceiving their ideas as game-changers when the reality often is far different. Three physician-inventors of medical devices got a dose of reality Saturday by diving into STS/AATS Tech-Con’s Shark Tank, where peers judged their developments.

For two device developers, the news was good, while the third may be headed back to the drawing board, based on the comments of two judges and attendee polling results during “Shark Tank—Rapid-Fire Elevator Pitches of Revolutionary Thinking.” The “sharks” judging the devices were Patrick M. McCarthy, MD, of Chicago, and Rick Anderson, of PTV Healthcare Capital in Austin, Tex.

First up in pitching a development was Shanda H. Blackmon, MD, MPH, of the Mayo Clinic in Rochester, Minn., who presented the Blackmon-Mayo Buttressing Anastomotic Device, designed to prevent anastomotic leaks. It is used during an esophagectomy, after the stomach is pulled into the chest.

The device is a mandrel that is introduced through the mouth and goes down the esophagus, exiting the distal portion of esophagus. Inside the device is a self-expanding stent or mesh. The mandrel has LED lights that improve visibility and is moved into four positions where the stomach and esophagus are attached to the stent or mesh using T-fasteners.

“This allows coverage with overlap of the two structures you are joining, rather than creating an end-to-end anastomosis, so if there is a small leak, it is covered by an internal buttress,” Dr. Blackmon said.

In a texting poll, 43% of the audience said they were interested in investing, 33% said they would “possibly invest,” but would not be early investors, and 24% were not interested in investing. Dr. McCarthy called the device “novel” and said he was a possible investor, while Anderson said he was all in.

The second device pitched was the FlexDex, which translates a surgeon’s hand motion to a laparoscopic instrument tip during taxing minimally invasive surgery, such as a foregut procedure. It is a relatively inexpensive option to robotic surgery, said James D. Geiger, MD, of the University of Michigan in Ann Arbor, who is on the device development team.

FlexDex has a three-axis cuff gimbal that attaches to a surgeon’s wrist, isolating the hand from the arm. The device’s Virtual Center™ allows hand and wrist motions to precisely control the articulation of the instrument’s jaw.

“It is low-cost, simple, and easy to use, with a short learning curve,” Dr. Geiger said.

Both judges were interested in investing, and 73% of the audience agreed. Of the remaining attendees, 14% were possibly interested in investing, and 13% were not interested.

The final device presented was an expandable device for creating an easier, quicker, and more efficient anastomosis in aortic prosthetic substitution, presented by Stefano Nazari, MD, of Fondazione Alexis Carrel in Milan, Italy. Both judges and 41% of the audience were not interested in investing in the device. Also, 36% were interested, but not as early investors, and 23% were all in.

The session also featured two debates on the role that new technology plays in cardiothoracic surgery. A surgeon and a radiation oncologist debated whether thoracic surgeons need to do more than just operate as a treatment for early stage lung cancer, or if they should be involved at all in non-surgical treatment. The second debate explored whether new technology was the birth or the death of cardiac surgery.

Also during the session, John C. Laschinger, MD, a cardiothoracic surgeon who is a Medical Officer in the Food and Drug Administration’s Division of Cardiovascular Devices, discussed the agency’s device review process, while Dr. McCarthy reviewed missteps made by developers during the FDA’s review of the MitraClip device.

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Chamberlain Papers Offer Latest High-Impact Research

J. Maxwell Chamberlain Memorial Papers

Monday

7:15 a.m. – 8:15 a.m.

Grand Ballroom

Strategies distinguishing coronary artery bypass grafting (CABG) from percutaneous coronary intervention (PCI) in blocked arteries, optimal timing for stage-2 palliation after the Norwood operation in neonates, and long-term outcomes for elderly lung cancer patients are the topics of the three most important scientific abstracts accepted to the 2017 Annual Meeting program.

The J. Maxwell Chamberlain Memorial Papers honor Dr. Chamberlain, who has been called “the most important influence in the formation of The Society of Thoracic Surgeons.” The Chamberlain Papers will be presented this morning as part of General Session I.

Rethinking CABG Strategies

Surgeons have long delayed CABG in patients with mild to moderate stenosis. Long-term data suggest that grafting patients with moderately stenosed coronary arteries provides long-term protection from myocardial ischemia.

Joseph F. Sabik III, MD

Joseph F. Sabik III, MD

“Studies in percutaneous interventions showed that if you stented an artery that had moderate stenosis, it was harmful. You had better outcomes if you waited until stenosis became severe,” said Joseph F. Sabik III, MD, co-author of the Chamberlain Paper for Adult Cardiac Surgery, “Natural History of Moderate Coronary Artery Stenosis After Surgical Revascularization.”   

Although many people assumed the same was true of bypass surgery, Dr. Sabik said he and his colleagues found that CABG and PCI require different revascularization strategies.

“We now know that there is value in bypassing a moderately stenosed artery because the graft is going to stay open 90% of the time. As stenosis in the native artery progresses, the graft remains patent and protects the patient,” said Dr. Sabik, from University Hospitals Cleveland Medical Center.

The study authors analyzed retrospective data on 55,567 patients with moderate stenosis (50%–69% angiographic blockage) who underwent primary isolated CABG between 1972 and 2011 at the Cleveland Clinic, Dr. Sabik’s previous institution. The study compared 1-, 5-, 10-, and 15-year outcomes for patients who were not grafted, were grafted with an internal thoracic artery (ITA), or were grafted with a saphenous vein (SV).

As expected, native vessel stenosis progressed from moderate to severe in most patients. Stenosis progression was lowest in nongrafted patients, highest in SV-grafted patients, and intermediate in ITA-grafted patients. At 1, 5, 10, and 15 years, 8%, 9%, 11%, and 15% of ITA grafts were occluded compared to 13%, 32%, 46%, and 56% of SV grafts. At those same time points, ITA grafts conferred 29%, 47%, 59%, and 61% protection from myocardial ischemia compared to nongrafted arteries.

“As disease progressed in the native vessel, the ITA graft remained open and became protective,” Dr. Sabik said. “If you bypass a moderately stenosed vessel with an ITA, you help patients live longer.”

New Timing for Stage-2 Palliation After Norwood

James M. Meza, MD

James M. Meza, MD

Clinicians may need to reconsider current protocols for stage-2 palliation following a Norwood operation in neonates with critical left ventricular outflow tract obstruction (LVOTO). Some existing protocols call for stage-2 palliation as quickly as possible following an initial Norwood operation, especially in high-risk infants. New data suggest an optimal window for stage-2 palliation for low- to average-risk infants.

“Performing the second stage operation after 3 months in low- or average-risk infants appears to maximize survival,” said James M. Meza, MD, of the Hospital for Sick Children in Toronto. “Clinicians should adopt protocols or modify existing protocols for low- and average-risk patients to ensure that the operations take place within the optimal window for the second stage. And for higher-risk patients, many may end up failing single ventricle palliation. Survival was especially poor in high-risk patients who underwent the second stage quickly after the Norwood. Earlier consideration for heart transplantation may be what maximizes their long-term survival, with the caveat that there is a limited supply of hearts available for neonates.”

Dr. Meza will present “The Optimal Timing of Stage-2 Palliation After the Norwood Operation: A Multi-Institutional Analysis From the Congenital Heart Surgeons’ Society” as the Chamberlain Paper for Congenital Heart Surgery. Researchers analyzed outcomes for 534 neonates with LVOTO from 20 institutions. Most patients (71%) had stage-2 palliation surgery at a mean age of 5.4 months; 22% of patients died after Norwood, and the remainder underwent either biventricular repair or heart transplantation.

After stage-2 palliation, 10% died, 66% underwent Fontan, and the remainder were either awaiting Fontan or underwent heart transplantation.

The most important risk factor for death after Norwood was low birth weight. The risk-adjusted 4-year survival after Norwood was 72%. In low-risk infants, survival was compromised only by stage-2 palliation earlier than 3 months. Survival in high-risk infants was severely compromised, especially when undergoing stage-2 palliation earlier than 6 months of age.

Data Linkage Helps Analyze Long-Term Lung Cancer Survival

Mark Onaitis, MD

Mark Onaitis, MD

The Chamberlain Paper for General Thoracic Surgery presents the first long-term survival analysis of elderly patients undergoing lung cancer surgery. The new analysis is the first from data linked between the STS General Thoracic Surgery Database (GTSD) and Medicare data.

“Until now, the GTSD has been limited to analyzing 30-day outcomes, which meant we could only address short-term surgical questions,” said lead author Mark Onaitis, MD, of the University of California, San Diego. “Clearly, age and stage are the strongest predictors of survival, but because we now have such a large database, we can see how medical and surgical factors also contribute to long-term survival. We will be able to better hone in on individualizing treatments for patients in order to maximize long-term survival.”

The paper, “Prediction of Long-Term Survival Following Lung Cancer Surgery for Elderly Patients in The Society of Thoracic Surgeons General Thoracic Surgery Database,” linked the GTSD to Medicare data for lung cancer resections from 2002 to 2013, creating a database of 29,899 lung cancer resection patients. Wedge resection, segmentectomy, bilobectomy, and pneumonectomy were associated with increased risk of mortality compared to lobectomy. Smoking and low body mass index increased risk, while the thoracoscopic approach was associated with improved long-term survival compared to thoracotomy.

Dr. Onaitis said key areas for future study are oncologic outcomes from limited resections, survival following sublobar resection versus lobectomy, and survival after minimally invasive versus open procedures.

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ACC @ STS Tackles Complex Clinical Scenarios

ACC @ STS

Monday

1:15 p.m. – 5:15 p.m.

Room 330AB

Cardiac surgery has entered a new era, with cardiologists and surgeons facing more complex cases. To manage these patients, it has become vital for specialists to interact, collaborate, and perform as one heart team.

Members of the American College of Cardiology and STS will examine difficult clinical scenarios facing heart teams, with a focus on aortic stenosis, atrial fibrillation, coronary artery disease (CAD), and mitral regurgitation.

Vinod H. Thourani, MD

Vinod H. Thourani, MD

“These topics embody the majority of cardiac care that practicing surgeons provide on a daily basis,” said co-moderator Vinod H. Thourani, MD, adding that each section of the session will include a patient case, data to back up decision making, and a panel discussion.

A highlight of the aortic stenosis section will be lessons learned from the STS/ACC TVT RegistryTM, which was created by surgeons and cardiologists. Among the data that will be shared will be volume trends for surgical and transcatheter aortic valve replacement (TAVR) in the United States.

“TAVR has been approved for extreme-, high-, and now medium-risk patients, but low-risk patients represent 80% of aortic valve surgical volume,” said Dr. Thourani, of Emory University in Atlanta.

With a growing population of atrial fibrillation patients, session planners seek to give attendees a better understanding of the medical, interventional, and surgical options.

“It remains alarming to me that so many patients present to our operating rooms with atrial fibrillation, yet we have no surgical therapeutic interventions. We have to be asking ourselves as a surgical community why this is the case,” Dr. Thourani said. Presenters will look at which patients are optimal candidates for transcatheter management, how to decide between biatrial and left atrial-only surgical ablation surgery, and how to perform biatrial ablation.

The content of the CAD section was developed in response to the innovation of percutaneous coronary interventions in hybrid revascularization, which are pushing the envelope for the management of CAD.

“This section will highlight the most recent technologies that interventional cardiologists and surgeons are performing to help physicians make decisions about the best options for care,” Dr. Thourani said. It also will include which patients with multivessel disease are best treated percutaneously and options for non-sternotomy multivessel coronary artery bypass grafting.

During the mitral regurgitation section, speakers will share insights about the ACC/American Heart Association Valve Guidelines, management of a patient with functional mitral regurgitation, and an update on transcatheter mitral valve devices. Dr. Thourani also will describe his worst transcatheter mitral valve case and how he handled it.

“Our goal in this section is to provide a standard of care defined by our societies and to uphold our surgical heritage with the management of mitral valve regurgitation,” Dr. Thourani said. “We’ll also highlight new technologies that can expand the armamentarium of tools for treating mitral valve disease.”

Dr. Thourani’s co-moderators are Niv Ad, MD, of Cardiac Vascular and Thoracic Surgery Associates in Falls Church, Va., Jodie Hurwitz, MD, of the North Texas Heart Center in Dallas, Roxana Mehran, MD, of Mount Sinai School of Medicine in New York, Patrick T. O’Gara, MD, of Brigham and Women’s Hospital in Boston, and Joseph F. Sabik III, MD, of University Hospitals Cleveland Medical Center.

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Important STS National Database Research Featured as Clark Papers

Richard E. Clark Memorial Papers

Monday

8:15 a.m. – 9:00 a.m.

Grand Ballroom

Since its inception in 1989, the STS National Database has played an essential role in generating research on quality improvement and patient safety. Three of the latest practice-changing studies—one each from the Adult Cardiac Surgery Database (ACSD), the Congenital Heart Surgery Database (CHSD), and the General Thoracic Surgery Database (GTSD)—will be presented as the 2017 Richard E. Clark Memorial Papers.

Surgical Ablation for Atrial Fibrillation Concomitant to Mitral Operations Reduces Mortality

J. Scott Rankin, MD

J. Scott Rankin, MD

The Clark Paper for Adult Cardiac Surgery suggests that performing surgical ablation (SA) to treat atrial fibrillation (AFib) at the time of mitral valve repair or replacement (MVRR) may have a protective effect on mortality.

Adding SA during MVRR is known to improve late sinus rhythm. However, clinicians have been unsure of the operative mortality impact of performing the two procedures concomitantly. Early studies indicated little effect on mortality, while more recent studies suggest a reduction in operative mortality.

Researchers investigated the ACSD for MVRR patents between July 2011 and June 2014. Including tricuspid repair and coronary artery bypass grafting generated a cohort of 88,765 patients.

Risk-adjusted odds ratios for mortality were compared at the time of surgery whether or not SA was performed. Group 1, with no preop AFib and no SA, was the comparator for other groups. Group 2 had no immediate preop AFib but had SA. Group 3 had AFib but no SA. Group 4 had AFib plus SA.

Lead author J. Scott Rankin, MD, of West Virginia University in Morgantown, will present “Mortality Is Reduced When Surgical Ablation for Atrial Fibrillation Is Performed Concomitantly With Mitral Operations.”

Patients in group 3 who had AFib but who did not receive SA had an odds ratio of 1.16 for mortality, or a 16% increase in relative risk of mortality compared with group 1 patients with no preop AFib or SA. But patients in group 4 who had AFib plus SA had a mortality similar to group 1 patients.

“At the time of mitral operations, the addition of SA to treat AFib can be performed without increased risk of mortality and may even be protective,” Dr. Rankin said. “The data suggest an early mortality benefit for SA and imply that further increase in SA application may be appropriate.”

Preoperative Risk Factors in Early Shunt Failure

Nhue Do, MD

Nhue Do, MD

A new analysis of congenital heart surgery data was performed to determine the incidence of early shunt failure and identify specific patient groups that may be at increased risk of functional failure of a systemic-to-pulmonary artery shunt or a ventricle-to-pulmonary artery shunt.

Early failure of systemic-to-pulmonary shunts is a potentially catastrophic complication in infants. But evidence to identify preoperative risk factors has been lacking, with most studies focusing on prevention of failure using pharmacologic or other therapies but having small sample sizes or being underpowered.

Researchers queried the CHSD to find 9,172 infants aged 1 year or younger who underwent shunt construction as the primary source of pulmonary blood flow from 2010 to 2015 at 118 centers. The cohort included both systemic-to-pulmonary artery and right ventricle-to-pulmonary shunts. The study found in-hospital early shunt failure occurred in 674 infants (7.4%) overall and that patients with early in-hospital shunt failure had significantly higher operative mortality and major morbidity and longer postoperative lengths of stay.

Lead author Nhue Do, MD, of Johns Hopkins School of Medicine in Baltimore, will present the Clark Paper for Congenital Heart Disease, “Early Shunt Failure, Prevalence, Risk Factors, and Outcomes: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database.”

Many of the identified in-hospital risk factors were intuitively expected, Dr. Do said, such as low body weight at the time of shunt creation and the presence of a preoperative hypercoagulable state. Neither use or nonuse of cardiopulmonary bypass during shunt creation was associated with an increased risk of early shunt failure. And there was no increased risk of early shunt failure in single ventricle patients, including those with hypoplastic left heart syndrome.

“The data suggest that the Norwood operation with a right ventricle-to-pulmonary artery shunt was somewhat protective against early shunt failure,” Dr. Do said. “There has been debate over whether to do a right ventricle-to-pulmonary artery shunt versus a modified Blalock-Thomas-Taussig shunt because of the need for a ventriculotomy, but we found it to be associated with decreased risk of early shunt failure.”

The study confirmed that in-hospital shunt failure is both common and associated with high mortality. Results also highlight higher-risk patients and cohorts that may benefit from increased surveillance, enhanced anti-thrombotic prophylaxis, or other strategies to minimize the risk of shunt failure.

New Quality Measure for Esophageal Cancer Surgery

Andrew C. Cheng, MD

Andrew C. Cheng, MD

Investigators have developed a composite quality measure for esophagectomy for esophageal cancer using data from the GTSD.

The researchers queried the GTSD for esophagectomies performed at 167 participating centers between 2012 and 2014 to ascertain risk-adjusted operative mortality (at discharge and at 30 days post-surgery) and risk-adjusted major complications.

Participants whose 95% Bayesian credible intervals (CrI) overlapped the STS mean composite score were considered two-star participants, while those whose 95% CrI were entirely below or above the STS mean were classified as one- or three-star sites, respectively. Discharge mortality and lengths of stay were used to benchmark GTSD participants against the National Inpatient Sample 2012 cohort.

Andrew C. Chang, MD, of the University of Michigan in Ann Arbor, will present the Clark Paper for General Thoracic Surgery, “The Society of Thoracic Surgeons Composite Score for Evaluating Program Performance in Esophagectomy for Esophageal Cancer.”

Operative mortality—a combination of discharge and 30-day mortality—was 3.1%, and the major complication rate was 33.1%. Of the 167 participants, only 70 reported an average yearly operative volume of five or more esophagectomies during the study period.

Of these 70 participants, four (5.7%) were three-star, 64 (91.4%) were two-star, and two (2.9%) were one-star. The remaining 97 (58.1%) participants did not have sufficient operative volume to score reliably.

“The pressing concern is that a significant majority of participants don’t do enough esophageal cancer operations to get valid measures,” Dr. Chang said. “We also find that there are programs that have lower volumes and very good results. This measure still needs to be validated, but it demonstrates that we can measure quality in esophagectomies.”

The next step, he added, is to consider how widely the measure can be used. It would be difficult to apply a quality measure knowing that more than half of GTSD participants would not qualify due to low volume.

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STS National Database Helps Improve Outcomes

Redefining Practice Through Quality and Evidence: What’s New

Monday

1:15 p.m. – 5:15 p.m.

Room 351DEF

For more than 25 years, the STS National Database has provided a foundation for cardiothoracic surgeons to improve patient outcomes by collecting data to assess procedures and develop guidelines for evidence-based practice. The breadth of evidence in the Database continues to grow, and a Monday afternoon session will address the latest Database initiatives in clinical practice guideline development, risk modeling, public reporting, and quality measurement and improvement.

“The goal is to showcase the scholarship and quality of data that are available in the STS National Database,” said session co-moderator Vinay Badhwar, MD, of West Virginia University in Morgantown.

Vinay Badwhar, MD

Vinay Badhwar, MD

Seven research abstracts will focus on topics that include Medicaid expansion, links between outcomes of bypass grafting and valve surgery, lung resection, Staphylococcus aureus prevention strategies, and preventing wound infections.

“The invited presentations are from leaders of the STS Workforce of National Databases, other related STS workforces, and STS task forces,” said session co-moderator Jeffrey P. Jacobs, MD, Chair of the STS Workforce on National Databases. “This combination of abstracts and invited lectures will allow attendees to grasp what is state of the art in quality improvement for cardiothoracic surgery.”

A highlight will be the review of new quality insights in general thoracic surgery and how this effort has helped launch the opportunity to publicly report outcomes from the General Thoracic Surgery Database for the first time, said Dr. Badhwar, Chair of the STS Task Force on Public Reporting.

Another highlight will be the review of the new STS Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation, released online in December in The Annals of Thoracic Surgery.

“The guidelines support the safety and efficacy of adding surgical ablation to a cardiac operation for the treatment of atrial fibrillation,” Dr. Badhwar said.

The STS Quality Measurement Task Force recently developed two mitral valve surgery composite measures and a surgeon-level composite measure. David M. Shahian, MD, Chair of the Task Force, will review those measures.

Jeffrey P. Jacobs, MD

Jeffrey P. Jacobs, MD

Dr. Jacobs, Professor of Surgery and Pediatrics at Johns Hopkins University in St. Petersburg, Fla., will review other STS measures that have been endorsed by the National Quality Forum.

“I will discuss specific aspects of several measures of performance that relate to cardiac and thoracic surgery, including survival after pediatric heart surgery and one of our newest measures related to individual cardiac surgeon performance,” said Dr. Jacobs, Chief of the Division of Cardiovascular Surgery at Johns Hopkins All Children’s Heart Institute.

Dr. Badhwar said, “This session is extremely important for learning how quality measurement is progressing and how to apply these developments in one’s clinical practice, particularly given the ever-increasing influence that quality has on practice.”

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Using Data to Improve Patient Care

STS/CATS/CSCS

Monday

11:30 a.m. – 12:30 p.m.

Room 351DEF

More than ever, cardiothoracic surgeons may feel as if they are under a microscope with increasing scrutiny of their performance from professional societies, patients, and employers. Today’s session from STS, the Canadian Association of Thoracic Surgeons, and the Canadian Society of Cardiac Surgeons will focus on bringing real-life quality improvement methods to cardiothoracic surgeons, their divisions, and the specialty.

Andrew J. Seely, MD, PhD, of the University of Ottawa in Ontario, Canada, will share how surgeons within the same group can help each other improve their performance. Dr. Seely developed a robust grading system—the Ottawa TM&M—and an in-house data collection tool designed specifically for data-driven quality improvement. He then adopted a novel concept, looking at the “positive deviants.” This method focuses on positive outliers and positive performers, rather than negative performers, said session co-moderator Colin Schieman, MD.

Colin Schieman, MD

Colin Schieman, MD

This focus on the high performers, rather than the low performers, is a change from how we typically think of morbidity data review, and it helps drive more open discussion and team-based improvement, said Dr. Schieman, of the University of Calgary in Alberta, Canada. Dr. Seely will show how this method, widely adopted by Canadian centers, objectively allows for implementing a quality improvement system.

“Most surgeons are uncomfortable with data collection,” Dr. Schieman said. “I was always worried about who would handle the data. What’s the intention going to be? How public would it be? Would there be any control for the complexity of the cases?”

With positive deviance, the data collection is anonymous with a focus on “like individuals in a group who are particularly good at certain areas,” Dr. Schieman said. “It’s a different way of framing the conversation.”

Susan D. Moffatt-Bruce, MD, PhD, MBA, of The University of Texas MD Anderson Cancer Center in Houston, will discuss how data derived from cardiothoracic surgery quality improvement efforts can lead to changes in care on a national scale.

“Her work is important because the whole process is about improving patient care,” Dr. Schieman said. “She’ll bring the discussion back to the patient and how to enhance patient safety. Instead of identifying where the problems are, she will close the loop, going from data generation, to review, optimizing the patient experience, and creating a mechanism for improving patient safety.”

STS Past President David A. Fullerton, MD, of the University of Colorado Anschutz Medical Campus, will then take the next step by looking at how public reporting of quality metrics can affect and improve cardiothoracic surgical practices.

“The data collected from hospitals, health administrators, regions, and societies provide powerful tools for surgeons to improve their performance, garner more resources for their institutions, and elevate the standard for all surgeons,” Dr. Schieman said. “Participation in our national databases is a major plus. Those who use the data can reflect on their own practices, but also on their own hospitals, cities, and regions to see where there are potential areas for improvement. This goes beyond individual surgeon performance.”

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Surgery Recommendations Vary by Race, Study Shows

Redefining Practice Through Quality and Evidence: What’s New

Monday

1:15 p.m. – 5:15 p.m.

Room 351DEF

Surgeons are more likely to recommend lung resection for black cancer patients than white cancer patients, according to a study that will be presented this afternoon.

The study showed that “patient race significantly influenced risk estimation and surgical recommendations. How these findings influence shared decision making and their association with treatment disparities require further investigation,” said Mark K. Ferguson, MD, of The University of Chicago, who is the lead author of “Patient Race Influences Risk Assessment and Recommendations for Lung Resection.”

For the study, surgeons read a clinical vignette and then viewed a video interview with either a black or white patient-actor. The participating surgeons recommended that 88% of black patients have lung surgery versus 75% of white patients. The patients were matched by age, body mass index, gait speed, and strength.

The 117 participating surgeons included 51 practicing surgeons and 66 trainees; 86 were white and 31 were in other self-identified racial categories; 96 were men and 21 were women.

“The literature suggests that black patients are less likely to be recommended to have surgery than white patients,” Dr. Ferguson said. “We found the opposite of that. I can’t explain why recommendations for surgery in other studies are less for blacks than for whites.”

The study, one in a series examining the use of video in making treatment recommendations, also suggests that videos influenced surgery recommendations more than the race-neutral clinical vignettes did. Because of the limited number of participating surgeons, more research is needed.

“I wouldn’t say that I could draw clear-cut conclusions from this. It seemed that the physicians—and this is both physicians of color and white physicians—had similar tendencies in terms of how they responded to the videos. Male and female physicians had some like tendencies in terms of how they responded to the videos,” Dr. Ferguson said. “It suggests that maybe physicians don’t see black patients in the same way they see white patients.”

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AFib Differences Between Women, Men

Adult Cardiac: Arrhythmia

Monday

11:30 a.m. – 12:30 p.m.

Room 310ABC

New-onset atrial fibrillation (AFib) after coronary artery bypass grafting (CABG) surgery has decreased in recent years, but an abstract being presented today has found that incidence has decreased more among women than men.

The differences between women and men in incidence and duration of AFib post-CABG were examined in a study of data from the STS National Database. The data were augmented with continuous in-­hospital electrocardiography/telemetry monitoring.

“We were very careful about making sure we captured every single episode of AFib and its details,” said lead author Giovanni Filardo, PhD, MPH, of Baylor Scott & White Health in Dallas. “We investigated the epidemiology of post-CABG AFib and gender differences in terms of incidence, timing, type, and duration of each single AFib episode, and the changing trends over time.”

The abstract, “Sex Differences in the Epidemiology of New-Onset Post-Coronary Artery Bypass Grafting Atrial Fibrillation: A Large, Multicenter Study,” found that from 2002 to 2010, adjusted new-onset AFib in women decreased from 36% to 24%, while in men it decreased from 42% to 31%. Following adjustment for STS-recognized risk factors, women had significantly lower risk for post-­CABG AFib, as well as shorter durations of first and longest AFib episodes and total time in AFib.

“Women are doing significantly better, and that is very important,” Dr. Filardo said. “We are working on understanding why. Our next paper will be on assessing whether certain prevention and management strategies lead to better prevention and/or long-term survival.”

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SVS @ STS: Examining the Potential of Cell Therapy

SVS @ STS: Sharing Common Ground for Cardiovascular Problems

Monday

1:30 p.m. – 3:30 p.m.

Room 350DEF

The use of cell therapy for treating critical limb ischemia, refractory angina, and heart failure is just one of the links between cardiac and vascular surgery that will be reviewed Monday during an annual session planned by STS and the Society for Vascular Surgery.

“In years past, we have learned a lot by listening to each other and not practicing in vacuums. Vascular surgeons bring interesting insights to problems we treat and vice versa,” said cardiac and vascular surgeon Keith B. Allen, MD, co-moderator of the session with vascular surgeon Jason T. Lee, MD, of the Stanford University School of Medicine in Palo Alto, Calif.

Cell therapy is an obvious area for the two groups to have a meeting of the minds. Studies released in the past 18 months have shown vascular surgeons its potential to treat critical limb ischemia. At the same time, cardiac surgeons have learned more about using cell therapy to manage heart failure and refractory angina.

“Here we are with two disciplines treating three areas and using the same compounds. We thought this would be a nice way to cross-pollinate,” said Dr. Allen, of St. Luke’s Mid American Heart Institute and the University of Missouri–Kansas City.

The first two presentations will look at areas where both specialties often work. A cardiac surgeon will offer management options for arch pathology, and a vascular surgeon will share tips on management of the left subclavian artery during aortic endovascular repair.

“They will talk about different approaches to managing the left subclavian artery because those often involve a bypass,” Dr. Allen said. “Vascular surgeons don’t do the big operations for the arch, but it is important for them to hear how cardiac surgeons manage that. Cardiac surgeons should hear about how to manage the head vessels or brachiocephalic vessels, particularly the left subclavian.”

Two talks will review cell therapies for “no option” patients—those with critical limb ischemia and those with medically refractory angina.

“Some are proprietary, some are autologous, and some are factor-derived,” Dr. Allen said of therapies for critical limb ischemia. “The speaker will summarize the ups and downs of these therapies, which are in different stages of clinical trials.”

For patients with medically refractory angina, many therapies involve the same grouping of cells, whether they are taken from a patient’s hip, have been expanded and cultured, or have been filtered, Dr. Allen said.

The last talk, on end-stage congestive heart failure, will go beyond angiogenesis to address the use of cell therapy or stem cells in enhancing and improving heart function, he said.

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