January 28

Future Is Promising for Cancer Immunotherapy

Immunotherapy may be the key to transforming cancer from a death sentence to a chronic condition. Some progress has already been made; checkpoint blockade has changed the prognosis for 10 usually lethal tumor types, including stage IV melanoma.

Laurie H. Glimcher, MD

Laurie H. Glimcher, MD

“If we can combine data in the patient medical record, immunoprofile with tumor genomics, pathology, and imaging, we should be able to predict the optimal treatment for all of our cancer patients and treat them successfully,” said Laurie H. Glimcher, MD, President and CEO of the Dana-Farber Cancer Institute in Boston. “I think we can get there in 3 to 5 years”

Dr. Glimcher drew a guarded but hopeful picture during the Thomas B. Ferguson Lecture, Cancer Immunotherapy: The End of the Beginning. The immune system has long been a backwater in oncology research. That changed when immunotherapy produced a Nobel prize in 2018 for James P. Allison, PhD, of MD Anderson Cancer Center in Houston, and Tasuku Honjo, MD, PhD, of Kyoto University in Japan.

Their discoveries led to checkpoint inhibitors, blocking receptors that prevent T cells from attacking tumor cells. Checkpoint blockade is the most successful immunotherapy, but is successful in only 20% of patients. The next step is to expand both the robustness and duration of response as well as the types of cancers amenable to immunotherapy.

Adaptive T cell therapy, or CAR-T, inserts a chimeric antigen receptor (CAR) into T cells that have been removed from the patient. The CAR is primed to attack specific surface antigens in the patient’s own cancer. The activated T cells are expanded and reinfused into the patient. CAR-T can be very successful. It also can be highly toxic and is enormously expensive. The next steps are to develop off-the-shelf allogenic products and find other mechanisms to bind T cells to the tumor.

Bi-specific antibodies, which bind to both a T cell and a tumor cell at the same time, show good early results, Dr. Glimcher said.

Therapeutic cancer vaccines have largely failed, but work continues. Researchers at Dana-Farber and in Germany have shown positive results with a therapeutic melanoma vaccine in early clinical trials.

The tumor microenvironment (TME) is the least advanced immunotherapy. Tumors alter immune and other cell types in their immediate environment to create a protective immunosuppressive moat.

The most advanced TME research focuses on the IRE-1/XBP1 signaling pathway, the endoplasmic reticulum stress response. Disrupting the pathway drains the immunosuppressive moat, allowing the immune system to attack tumor while suppressing tumor growth.

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. 

Artificial Intelligence Touches Cardiothoracic Surgery

Artificial Intelligence (AI) already exists in medicine. AI systems can read chest radiographs faster, cheaper, and—by some accounts—at least as accurately as skilled radiologists, according to Thomas M. Krummel, MD, of Stanford University in California. With approximately 18 robotic surgical devices in development, AI is almost certainly coming to cardiothoracic surgery.

Thomas M. Krummel, MD

Thomas M. Krummel, MD

“AI is already here in a big way,” said Dr. Krummel. “Early stage medical technology may very well have intelligent components, and we will see robotic autonomy in surgery.”

Dr. Krummel explored the growth of AI in medicine during Saturday’s Tech-Con keynote address: Artificial Intelligence­—Hope, Hype or Horror for Medical Tech. The reality, he said, is that AI contains elements of all three.

The hope is that AI can augment cardiothoracic and other surgeons to improve outcomes and reduce overall costs. The hype is that AI will replace surgeons and other skilled practitioners. The horror is that AI will out-evolve and replace humans.

How AI evolves in cardiothoracic surgery depends very much on how cardiothoracic surgeons approach, develop, and accept the technology, Dr. Krummel said. The most important barrier is simply understanding what AI is and what it is not, he added.

It is not a droid, some sort of Star WarsR2-D2 or even an artificial being. AI is nothing more than a series of algorithms: very explicit instructions designed to achieve a specific end. Explicit instructions are not, however, a perfect guide in an imperfect world filled with unpredictable events, as designers of self-driving cars have discovered in the past few months.

Algorithms can follow instructions to perfection, but instructions are not enough. Instructions must be interpreted, even for something as simple as washing hair. Most shampoo bottles carry simple instructions: lather, rinse, repeat. Without some sort of check, AI would repeat the cycle endlessly and never stop shampooing.

Another barrier is the sudden emergence of AI. However, AI is nothing new. It grew out of code-breaking algorithms designed by Alan Turing and his cryptographic team during World War II. The idea of developing and applying algorithms to solve broader problems emerged from a 1956 Dartmouth project as the thesis that anything humans can imagine can be turned into an algorithm and put to use.

It took half a century for computing technology to begin to catch up with the concept of AI, creating intelligent devices that can use knowledge to learn, to reason, to make useful decisions, and prove their value. If the Volkswagen had developed at the same speed as Intel chips, today’s Beetles would run 300,000 miles on a gallon of gas at two million miles per hour and cost four cents.

“Components matter more than we can imagine,” Dr. Krummel said. “By next year, 80% of adults worldwide will be walking around with a smart phone—a super computer—in their pockets. That has a huge impact on the development and deployment of AI.”

Companies like Amazon, Netflix, and Spotify can already predict our preferences in shopping, movies, and music more precisely than most of us can, he noted. MasterCard and VISA can accurately identify potential fraud.

In 2018, IDx became the first medical device approved by the Food and Drug Administration to diagnose diabetic retinopathy. Face2Gene uses facial recognition to diagnose a growing set of hereditary conditions in children, and Suki AI already offers physicians relief from the burdens of electronic medical record (EMR) reporting using a phone-based AI app that Dr. Krummel likened to Suri for physicians.

AI is moving more deeply into medicine than most physicians realize, he added. The Veterans Administration is using Deepmind, developed by Google’s artificial intelligence lab, to predict and prevent kidney disease. IBM’s Watson missed expectations in diagnosing cancer, largely because AI requires that answers be known in order to follow rules to find them. As more is learned about cancer diagnosis, expect AI-based diagnosis to improve.

More immediately, expect practical, cost-effective AI assistance in three areas: AI-assisted robotic surgery, AI-assisted administrative and office workflow, and image interpretation. Also in development are AI-assisted surgical assessment tools that could be used by practices, hospitals, payers, and credentialing bodies to evaluate surgical competence.

“We need to keep humans in the loop with AI,” Dr. Krummel said. “We have the kind of nuanced intelligence that machines lack, at least to date. We’d better buckle up and get into the technology.”

Search Continues for Optimal Approach for Type A Aortic Dissections

The continuing evolution and improvement of procedures to repair type A aortic dissections is leaving cardiothoracic surgeons with more questions than firm answers as they plan what is typically an emergency repair. 

EACTS @ STS: Which Arch Operation Should I Do?

Decision-Making During Type A Dissection Repair

Monday

7:15 a.m. – 9:15 a.m.

Room 33

“We now have several different reconstructive options for type A dissections, and we’re trying to figure out the optimal choice on both sides of the Atlantic,” said STS Past President Joseph E. Bavaria, MD, of the Hospital of the University of Pennsylvania in Philadelphia. “European surgeons have had access to some devices we don’t have in the United States because of differences in approval processes, but the decision-making process is the same for all of us.”

Joseph E. Bavaria, MD

Joseph E. Bavaria, MD

A session organized by STS and the European Association for Cardio-Thoracic Surgery will help cardiothoracic surgeons learn the best approaches to repairing type A dissections regardless of where they practice. The session will be moderated by Dr. Bavaria and EACTS President Ruggero De Paulis, MD, of the European Hospital in Rome.

Presenters from the United States and Europe will address four key questions:

  • Where does the now-classic hemiarch procedure fit into current treatment algorithms?
  • Does the total arch procedure have a place in today’s surgical armamentarium?
  • Under what circumstances should a total arch with frozen elephant trunk be used?
  • Is it appropriate to change the index procedure at the aortic arch based on the development of branched arch thoracic endovascular aortic repair (TEVAR) grafts?

“Advancing technology has brought us to an inflection point,” Dr. Bavaria said. “We have a standard approach, and we have the real possibility that the standard isn’t good enough any longer given today’s devices and procedures. We will go through each approach, analyze where it can best be utilized, and determine whether it can be utilized in all patients or if it is more appropriate for a specific subpopulation.”

The most important question in the long term is the application of evolving TEVAR technology. Both single-branch and two-branched arch grafts currently are available in clinical trial, and newer generations of grafts are under development. Surgeons are seeing the potential for not just improving survival from type A dissection repairs, but providing definitive treatment. Whether TEVAR becomes the new index approach today or at some future point, every cardiothoracic surgeon should be aware of its potential.

“A lot of changes have happened in the last few years, and more are coming in the near future,” Dr. Bavaria said. “If treatment of type A dissections is part of your practice, this session will allow you to provide your patients with optimal care.” 

‘Shark Tank’ Takes Aim at Unmet Surgical Needs

The cardiothoracic device market has grown dramatically in recent years, but unmet needs persist. Four physician-inventors aiming to tap the burgeoning market pitched their cutting-edge devices during “Shark Tank,” part of the Tech-Con Joint Session: The Future of Cardiothoracic Surgery.

Syed T. Raza, MD, of Columbia University Medical Center in New York, opened the pitch session with a stapler to create rapid and leakproof aortic anastomoses in patients with acute Type A aortic dissections. Conventional hand-sewn anastomoses are prone to bleeding.

Dr. Raza’s solution is a round stapler that joins native vessel and graft with two rows of 30 staples. The stapler can be handheld or fitted to a robotic arm.

Grayson H. Wheatley, MD, of TriStar Centennial Medical Center in Nashville, and Daniela Molena, MD, of Memorial Sloan Kettering Cancer Center in New York, were the sharks assessing the pitches. Dr. Wheatley said that he liked the novel idea. So did the audience, with 61% voting to fund development.

Jeffrey R. Gohean, MSME, of Windmill Cardiovascular Systems in Austin, TX, pitched a two-piston toroidal pulsatile flow VAD. The gentle pulsatile flow exerts low shear force, resulting in minimal blood trauma and platelet activation, which are responsible for the high rates of adverse events seen with conventional continuous-flow VADs. Preclinical trials show acute and long-term benefits and no thrombus formation without anticoagulation therapy.

Dr. Molena praised the novel approach while 78% of the audience voted to fund the project.

Usman Ahmad, MD, of the Cleveland Clinic, pitched ThoraStim, an implantable neurostimulator for pain management following cardiac surgery. He noted that the FDA has already approved an implantable neurostimulator to manage pain following total knee arthroplasty, potentially easing approval.

The ThoraStim electrode is implanted along the intercostal nerve and protrudes slightly above the skin. Once the need for pain control has passed, the device is removed as easily as a chest tube.

Dr. Wheatley found the concept appealing, but said that human trial data are needed. The audience agreed, with 57% voting to fund the venture.

Faiz Y. Bhora, MD, of Mount Sinai Hospital in New York, pitched Tracheomend, a 3D printed artificial trachea. The printed trachea scaffold is wrapped in a biologic membrane impregnated with a “secret sauce” of homing molecules to attract epithelial and stem cells, which implant and grow to create a biologically competent trachea.

An intriguing idea, Dr. Molena suggested, but not ready for prime time. The audience agreed, with 57% voting to not fund the venture.

Re-imagining Thoracic Surgery

It was 2011 and incoming STS President Michael J. Mack, MD warned members that it was time to get on the train to treat structural heart disease or lose out. Eight years later, Tom C. Nguyen, MD, of The University of Texas Health Science Center in Houston, expanded Dr. Mack’s admonition. He said that it is time to re-envision the future of cardiothoracic surgery or lose it.

Tom C. Nguyen, MD

Tom C. Nguyen, MD

Dr. Nguyen explained that there are two ways to conceive surgery—in terms of the tools used to treat disease or in terms of the diseases surgeons treat. Most cardiothoracic surgeons, societies, and equipment manufacturers think of our subspecialty in terms of the tools we use or develop.

The reality is that tools change—and at an increasing pace. More than 300,000 transcatheter valve replacements (TAVRs) have been performed worldwide since 2002 and now outnumber surgical AVRs. He noted that he believes cardiothoracic surgeons who define their work in terms of SAVR procedures are a dying breed.  He predicts that surgeons who think of themselves as TAVR experts will be similarly displaced by the next wave of valve repair technologies.

The solution, Dr. Nguyen said, is to re-imagine cardiothoracic surgery in terms of the conditions we treat. Tools are nothing more than tools, sufficient for now and expected to be replaced by improved technologies.

Re-imaging thoracic surgery means developing a new training paradigm that focuses on the condition, not the tool, to capture the future. As a result, Dr. Nguyen called on his colleagues to look beyond specific technologies and create a new, standardized curriculum for subspecialty training. Cardiothoracic surgeons must become proactively involved in the creation, development, and implementation of new technologies as a matter of policy, practice, and survival, he said.

Plenary Session Unveils New Approaches to Familiar Problems

Expanding the pool of donors for neonatal heart transplantation and using adjuvant therapy for node-positive esophageal cancer have the potential to improve patient outcomes, according to two studies that will be presented at today’s plenary session.

Plenary Session

Monday

9:30 a.m. – 12:15 p.m.

Ballroom 20

In addition to these abstracts, a late-breaking study on platelet transfusion during the rewarming phase of cardiopulmonary bypass in neonates also will be presented. The three papers will be followed by the highly anticipated Presidential Address from Keith S. Naunheim, MD.

Research Confirms Promising Results for Adjuvant Therapy
A retrospective cohort study across nine institutions and more than 1,000 patients has found that adjuvant treatment following surgery for esophageal cancer is associated with a 24% reduction in mortality. 

Tara Semenkovich, MD

Tara Semenkovich, MD

Median survival for patients who received adjuvant therapy following resection was 2.6 years, compared to 2.3 years for patients who did not receive adjuvant therapy.

“We know the optimal treatment is neoadjuvant chemotherapy or chemoradiation therapy followed by surgical resection if you have locally or regionally advanced cancer and you are a good operative candidate,” said Tara Semenkovich, MD, MPHS, of the Washington University School of Medicine in St. Louis. “It is well established that patients who have residual positive lymph nodes following resection have a worse prognosis, but there was controversy regarding what to do about it.”

An earlier study at Washington University showed promising results for adjuvant therapy, but the cohort was only about 100 patients. A similarly small study from another institution found no benefit from adjuvant therapy. Population studies using the National Cancer Database suggested potential benefit, but the conclusion was clouded by possible selection bias. 

“Clinical guidelines right now are ambiguous, as you might expect from the lack of good data,” Dr. Semenkovich said. “This is the largest and most detailed cohort of esophageal cancer patients receiving adjuvant treatment that has ever been assembled to look specifically at this question. Our study makes a much stronger argument for providing adjuvant chemotherapy to patients who can tolerate it and can help guide clinical decision-making.”

Researchers Look to Expand Donor Pool for Neonatal Heart Transplantation
In what may be the largest consecutive case series of newborn heart transplant patients ever presented, nearly all of the neonates who received transplants to treat congenital heart defects at one institution are still alive with the same hearts that were transplanted as long as 34 years ago. 

“We wanted to show that babies who receive heart transplants do very well in the long run,” said John Mohan, MD, of Loma Linda University School of Medicine in California. “If we can find ways to enlarge the organ pool, we could increase the applicability of transplantation and make a dramatic improvement in these babies’ lives.”

The dilemma of how to treat newborns with congenital heart defects has more to do with logistics than clinical issues. Heart transplantation has long been recognized as preferable to palliative reconstructive surgery, with a 5-year survival of 80%-85% following heart transplantation compared to 58%-76% for staged palliation. But the organ pool of neonatal hearts is so small that most potential candidates are never placed on the transplantation list.

The advent of infant car seats dramatically reduced the number of newborns suffering fatal head trauma, and the decline of sudden infant death syndrome resulting from putting infants to sleep on their backs virtually eliminated the other major pool of newborn hearts that was available in the 1980s and 1990s.

But there are at least two other pools of potential donors, Dr. Mohan said. One is the 600 to 700 babies born annually in the United States with anencephaly, who inevitably die. Policies regarding the determination of brain death in these infants are not uniform, and the issue is fraught with ethical questions.

A second potential pool is donation after circulatory determination of death (DCD). Transplants using DCD organs are currently less successful than transplantation of organs retrieved following brain death.

“If we can find a way to make donation after cardiac death more usable, that would increase the pool of organ donors,” Dr. Mohan said. “We should seriously consider both these options if we want to increase the number of donor organs available for newborn heart transplantation.” 

Regional Perspectives Influence Treatment Options for Lung, Esophageal Cancers

The complex process of determining cancer stages requires accurate decision-making within the context of an interdisciplinary team. But standard general thoracic and esophageal diagnosis and treatment practices can vary due to a lack of uniformity between European and US practice guidelines.

ESTS @ STS: Controversial Issues in General Thoracic Surgery — Perspectives From Europe and North America

Monday

7:15 a.m. – 9:15 a.m.

Room 30ABCD

Mediastinal staging for clinical stage 1 non–small-cell lung cancer (NSCLC) is one example. Survival of all NSCLC patients is disappointing, with a 5-year survival of 18%. Accurate staging is crucial because it determines the choice of treatment and prognosis. 

“There’s a debate between European and North American surgeons about how extensive the staging should be,” said Michael J. Weyant, MD, of the University of Colorado in Aurora. 

Michael J. Weyant, MD

Michael J. Weyant, MD

Those differences will be highlighted during Monday morning’s collaborative session from STS and the European Society of Thoracic Surgeons. Dr. Weyant and Gilbert Massard, MD, PhD, of the Centre Hospitalier in Strasbourg, France, will co-moderate the session that will feature experts from Belgium and the United States describing and debating best practices. 

“Presenting both the European and North American perspectives will help us realize that even though we all view ourselves as modern, state-of-the-art thoracic surgery specialists, there are cultural differences that impact how lung and esophageal cancers are treated,” Dr. Weyant said. “Part of it is based on societal resources, and part of it is based on how patients in different geographic areas perceive invasive treatments for cancer.” 

Also during the session, experts from the United Kingdom and the United States will present their respective viewpoints on using mediastinal staging to select clinical stage IIIAN2 NSCLC lung cancer patients as candidates for surgery after induction therapy. Speakers also will offer insights on the role of induction therapy for select groups of patients with cT2N0 esophageal cancer. 

 “There is a continuing debate over whether those patients should get chemotherapy and radiation therapy prior to surgery,” Dr. Weyant said. 

Both the European and North American approaches to diagnosis, staging, and multimodal treatment have merit. But by exploring the geographic vantage points in treatment strategies, surgeons from both sides of the Atlantic may come away with different ways of doing things to optimize patient outcomes. 

“Surgeons might see an acceptable treatment pathway presented that they might use in a subsegment of their patients they hadn’t considered before,” Dr. Weyant said. 

Heart Team Decision-Making Adds Value

Treatment options for valve disease have grown exponentially from the days of simply choosing between tissue or mechanical valves. Now, determining the most appropriate treatment for each patient requires multidisciplinary perspectives.

Clinical Scenarios: The Heart Team

Monday

1:15 p.m. – 5:00 p.m.

Room 30ABCD

Enter the heart team, a collaborative group of clinicians who can offer a wide range of viewpoints on the benefits and risks of rapidly evolving treatment strategies, leading to optimal patient selection and improved outcomes. 

“We are entering into a new patient-centric experience that relies on the cardiac surgeon having a robust communication and interaction with cardiology colleagues,” said Vinod H. Thourani, MD, of MedStar Heart and Vascular Institute in Washington, DC, a moderator for today’s Clinical Scenarios: The Heart Team session.

Vinod H. Thourani, MD

Vinod H. Thourani, MD

Besides cardiac surgeons and interventional cardiologists, the suggested members of a heart team include cardiac anesthesiologists, intensivists, perfusionists, advanced practice providers, and cardiac imaging specialists.

The speakers in this session will draw from the latest research to identify decision-making challenges in mitral valve disease, aortic valve disease, and coronary artery disease. 

A hot discussion topic will be the recently published COAPT trial, which showed that transcatheter mitral valve approximation in combination with guideline-directed medical therapy was superior to guideline-directed medical therapy alone for patients with symptomatic heart failure with grades 3 to 4+ mitral valve regurgitation. These findings have important implications for management decisions in practice.

Speakers also will discuss transcatheter approaches to valve replacement, which have become the first-line treatment in many situations. All-cause mortality and risk of stroke are similar for transcatheter and surgical procedures, but the risks of adverse events are distinct.

In addition, the debate over whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) surgery is preferred for coronary revascularization will be highlighted. Several studies have sought to determine the factors affecting mortality and morbidity for each procedure, and recent research has indicated that the type of disease (multivessel or left main), coronary complexity, and diabetes status are important factors to consider in decision-making regarding PCI or CABG. 

Heart team discussions of specific cases related to each of these topics will help attendees gain a greater understanding of the best approaches for their own patients.

“As our patients grow in complexity, it is incumbent that we stay purposeful in our approach to managing their care,” said Dr. Thourani. 

Cardiac and Vascular Surgeons Can Learn From Each Other

More and more often, cardiac and vascular surgeons are seeing the same patients and dealing with similar challenges, making a collaborative approach essential to optimizing outcomes.

SVS @ STS: Sharing Common Ground for Cardiovascular Problems

Monday

1:15 p.m. – 3:15 p.m.

Room 31C

“Cardiac surgeons and vascular surgeons have very different training and tools in their armamentariums,” said Keith B. Allen, MD, of St. Luke’s Mid America Heart Institute in Kansas City, MO. “It’s important for both types of specialists to expand their horizons and understand what strategies the other uses.” 

Dr. Allen will co-moderate today’s session planned by STS and the Society for Vascular Surgery, which will outline common areas where surgeons should approach patient care collaboratively, considering all options at their disposal. 

Keith B. Allen, MD

Keith B. Allen, MD

One example is vascular access. The use of transcatheter procedures has increased with expanding indications for endovascular devices. The size of some of these devices adds to the challenge of vascular access. 

“The devices are getting smaller, but cardiac surgeons must be creative and think outside the box when femoral access is not available,” Dr. Allen said. “There is a continued need for alternate options for individuals with inadequate iliofemoral vessels.”

Historically, alternate options have included transapical and direct aortic approaches, but Dr. Allen noted that these choices have lost ground to minimally invasive strategies. He recommends that both cardiac and vascular surgeons have a working knowledge of less invasive approaches such as carotid, transcaval, axillary, and subclavian access.

Pulmonary embolism (PE) is another area in which the perspectives of both specialties are necessary. Acute PE is the third-leading cause of cardiovascular death in the United States, with an estimated 100,000 deaths each year. Among the challenges of PE are that it is often difficult to diagnose, clinical trial data are inadequate for evidence-based recommendations, and guidelines offer different risk stratification classifications. 

Many clinicians need a greater understanding of guidelines for management of PE, Dr. Allen noted, and many institutions have yet to establish a PE team. 

“In some institutions, care is provided in a piecemeal manner. There is no team or plan, or clinicians do not understand the distinctions among submassive, massive, and minor PE,” said Dr. Allen. “Clinicians should know how to diagnose different types of PE and understand the potential therapies—catheter-based procedures, surgery, and medical therapy. The most important point is to have a team and implement it.” 

This session will outline how to organize a PE team, triage according to type of PE, and select appropriate therapy in individual cases. 

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