Limited Populations, Lost Patient Follow-Up Impact TAVR versus SAVR Data

Three pivotal trials—Evolut, PARTNER 3, and PARTNER 2A—have shown that transcatheter aortic valve replacement (TAVR) was noninferior to surgical AVR (SAVR) in terms of mortality and stroke among low-risk patients with symptomatic severe aortic stenosis. But speakers at Sunday’s session on the evolving impact of TAVR said that many questions about TAVR and SAVR remain unanswered.

Michael J. Reardon, MD, from Houston Methodist Hospital in Texas, emphasized that TAVR may be preferred over surgery for low-risk patients, but only in the population tested in the Evolut trial. The mean ages for Evolut and PARTNER 3 were similar (74 years and 73 years, respectively), while the PARTNER 2A population had a mean age of 82 years.

“We did not test enough young people,” said Dr. Reardon. Physicians must emphasize to younger patients that the results of these trials should not be applied to them, he added.

Another issue is the number of patients who were excluded and those who withdrew from the studies. Dr. Reardon highlighted two key exclusion criteria for Evolut: bicuspid aortic valve (verified by imaging) and coronary artery disease. PARTNER 3 had these same exclusion criteria. Excluding patients with these clinical features created “knowledge gaps,” said Dr. Reardon.

He said that his “biggest regret” about Evolut is not knowing why 260 of 1,728 patients (14.8%) were screened out at the national level. He said that it would have been better to allow these patients to stay in the study and have their data collected in a registry.

Vinod H. Thourani, MD, from Piedmont Heart Institute in Atlanta, reported the 5-year outcomes for the PARTNER 2A trial. He noted that a disproportionate number of SAVR patients withdrew from the study. At the end of 5 years, 91% of patients in the TAVR group and 81% in the surgery arm completed follow-up. “I consider this a limitation of the study,” said Dr. Thourani.

In reporting data from PARTNER 3, Gilbert Tang, MD, from the Mount Sinai Health System in New York, compared the findings of all three studies, saying the data indicate that surgery is better in terms of new left bundle branch block, mild pulmonary vascular resistance, and valve gradients; SAVR and TAVR are similar in terms of the need for new pacemakers, vascular complications, moderate-to-severe pulmonary vascular resistance, and coronary obstruction; and TAVR is better in terms of mortality, stroke, rehospitalization, acute kidney injury, severe bleeding, new-onset atrial fibrillation, 30-day quality of life, and length of stay (hospital and ICU).

Nick Freemantle, PhD, a biostatistician from University College London, discussed flaws in the methodology of the trials. For example, he said that the non-inferiority boundary on the primary endpoint of 6% includes many clinically important values for major morbidity and mortality. He also pointed to biases related to as-treated (per-protocol) analysis and inadequately concealed randomization.

In light of these issues, he stated, “TAVR may or may not be a safe and effective alternative to SAVR.”








Yancy Makes Impassioned Plea for Diversity and Inclusion

In a thought-provoking and inspiring talk at Sunday afternoon’s opening session, Clyde W. Yancy, MD, emphasized the need for diversity and inclusion within the medical profession as a way to improve health outcomes.

Dr. Yancy, vice dean for diversity and inclusion and chief of the Division of Cardiology at Northwestern University’s Feinberg School of Medicine in Chicago, delivered the inaugural Vivien T. Thomas Lecture, established to honor a man who helped usher in a new era in cardiothoracic surgery during a polarizing time in the United States.

Thomas was a black laboratory supervisor who worked with famed physician Alfred Blalock, MD, at Vanderbilt University in the 1940s. When Johns Hopkins recruited Dr. Blalock, he refused to move unless Thomas accompanied him as a “package deal.” Despite Thomas’s integral role in Blalock’s pioneering work in shock, vascular, and cardiac surgery, he was hired and paid as a janitor and was not allowed to use the main entrance to Johns Hopkins. He was not mentioned as a coauthor in scientific publications and was not included in group photos of trained physicians. Thomas’s life was beset by discrimination, segregation, and bias, said Dr. Yancy. “But was it?” he asked.

Before answering that question, Dr. Yancy explored the current state of diversity and inclusion in the United States. The demographics of the country are changing, and there is no longer a majority population. “This is an excellent opportunity to make an argument for inclusion,” he said.

He noted that the absence of a diverse workforce in medicine contributes in part to disparate disease outcomes, pointing to the low percentage of transcatheter aortic valve replacement procedures performed in black patients as an example. “When we make decisions, we bring certain templates of thoughts to the table,” he said.

Dr. Yancy also explained the influence of implicit bias—which he described as a tendency or inclination that results in judgment without question. “Implicit bias shapes our decisions and modifies our professional interactions,” said Dr. Yancy. “We all must be willing to think unconventionally and check our assumptions at the door.”

Bias can be overcome with awareness, allyship, and sponsorship. Dr. Yancy noted that everyone can be an ally. “Allyship is a lifelong process of building relationships based on trust, consistency, and accountability with marginalized individuals and/or groups of people. It is an opportunity to grow and learn about ourselves while building confidence in others,” he said.

Sponsorship is the core attribute of allyship. Whereas a mentor can advise and provide perspective on another’s role, career, and situation, a sponsor is the person who can make someone’s potential career a reality, said Dr. Yancy. “A sponsor believes in you. Sponsors offer serious seniority, power, and influence.”

Dr. Yancy came full circle at the end of his lecture by answering the question he posed earlier about Vivien Thomas. Rather than telling a story about segregation, discrimination, and bias, said Dr. Yancy, Thomas’s story “is about diversity and inclusion; it is about allyship; it is about sponsorship.”




Q&A with STS President Robert S.D. Higgins

Robert S.D. Higgins, MD, MSHA

Robert S.D. Higgins, MD, MSHA

In the past year, STS President Robert S.D. Higgins, MD, MSHA, has led tireless efforts to enhance and expand the Society’s activities in many important areas. As his presidential term comes to a close Monday evening, he looks back at the achievements, challenges, and lessons learned—and shares a preview of his Presidential Address, which he will deliver Monday morning at 11:15 in Great Hall A.

Q: What are you most proud of accomplishing during your year as STS President?

Dr. Higgins: We have been fortunate with the great support of the volunteer leadership and STS staff to craft a vision for the future of the Society. I’m proud that we’ve been able to enhance the STS National Database, create educational opportunities for young cardiothoracic surgeons, address concerns about physician reimbursement, and work together with our colleagues in Europe and across the country. Our specialty has an impact on some of the most deadly and challenging medical conditions in the Western world—namely, atherosclerotic heart disease and lung cancer. And if we keep our eye on the prize, we will continue to be influential in those diseases, help patients, and benefit society. Honoring our past while also creating a sustainable future has been a source of pride for me this past year.

Q: You’ve been very involved with the recent enhancements to the STS National Database. Why is this such an important endeavor?

Dr. Higgins: We know that our Database has been the gold standard for clinical registries over the past 30 years. And yet, we needed to modernize and improve it to meet the demands and needs of our membership. It’s pretty clear, though, that with the pressures in the market, we need to stand together as a specialty with one data-driven, cohesive voice to address the concerns that people have about quality and patient safety. If we divide our voice, we lose traction and impact.

Dr. Higgins (right), pictured here with European Association for Cardio-Thoracic Surgery Secretary General Domenico Pagano, MD, FRCS(C-Th), FESC, said that establishing stronger relationships with colleagues throughout the world has been a key achievement in his year as STS President.

Dr. Higgins (right), pictured here with European Association for Cardio-Thoracic Surgery Secretary General Domenico Pagano, MD, FRCS(C-Th), FESC, said that establishing stronger relationships with colleagues throughout the world has been a key achievement in his year as STS President.

Q: What challenges has the specialty encountered during your term?

Dr. Higgins: In addition to modernizing the Database, we again have been trying to build a platform of collaboration across our specialty between our European, Asian, and African colleagues. There’s a recognition that many people in our society are not able to benefit from heart and lung surgery, and there are significant disparities in care. Recognizing those disparities and working to fix them is an important aspect of what we should be doing, because it really is about the patient in the final analysis.

We’ve also dealt with challenges related to public reporting of surgical outcomes, and some of our congenital colleagues have felt that they’re under the microscope. We’ve been working hard to address their concerns, and we’re proud and happy that Joe Dearani, who’s a world-renowned pediatric and congenital heart surgeon, is coming in as President. We’ve also created a task force of leaders from around the country to advise us, and hopefully, that group will improve our ability to provide feedback for patients and families alike and share best practices. I think it’s a really positive time for action, and our leadership has stepped up.

Q: How do you want to be remembered in your role as President?

Dr. Higgins: I’m hopeful that people will remember me as someone who listened first, who acted strategically and wisely, and who paved the way for others who have not historically been considered for leadership roles—who showed women and people of color that they have a future in our organization. That would be a cool legacy to leave behind for future generations.

Q: Drawing on your experience as President, what advice would you give to the next generation of STS leaders?

Dr. Higgins: I’ve learned a lot as a leader, and I hope that I can pass along some of these lessons to those who will come after me. To our trainees, I would say that they not only have to work hard and have talent, but also have passion, persistence, and grit to accomplish their goals. It’s also important to diversify your skillset to adapt to the changing future.

We also have to change our perspective in terms of mentorship and sponsorship. We need to reach out to women and others who have been underrepresented in our specialty and bring them into the fold. 

Q: You’ll give your Presidential Address on Monday morning. What can attendees expect to hear?

Dr. Higgins: As I thought about my year, I thought about the lifesaving benefits of cardiac and lung cancer surgery over the past 75 years. We are continuing to grow, develop, and save lives—millions of lives—and we respect and admire that. That requires progressive leadership and learning from the past to adapt our leadership for the next generation. This generation has different expectations, and we need to be aware of that.

We also have to keep our eyes on what’s really important in our lives. Not so much the day-to-day grind, but rather, developing successful strategies to not only be satisfied in our work, but happy in our work. In my address, I’ll refer to some of the tenets that we have as an organization—inclusion, diversity, teamwork, collaboration, and quality. All of those things need to come together to make you feel happy in the field of cardiothoracic surgery. 

I’ll offer some advice for people to think about, like looking for humor in life, being a teacher or a leader, learning to cultivate compassion, working in your community, and using coaching when necessary. Those things will make what we do even that much more gratifying. That’s the message I’ll be trying to get across.

One of the great quotes that I’m going to use in my talk—and there are many of them—says that life isn’t about waiting for the storm to pass. It’s about learning to dance in the rain. And I think that’s been one of the things I have emphasized this past year. 

Clark Papers Reveal New Insights on Diaphragm Paralysis, LVRS, Infective Endocarditis

STS National Database data are used for numerous important medical research studies each year that improve cardiothoracic surgical outcomes and enhance the quality of patient care. Three of these studies, selected from among the many submitted for the 2020 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. 

Charles D. Fraser, MD

Charles D. Fraser, MD

Diaphragm Paralysis Leads to Worse Outcomes for Pediatric Patients Following Heart Surgery
A study using data from the STS Congenital Heart Surgery Database showed that pediatric patients who experience diaphragm paralysis after heart surgery have worse outcomes than patients without paralysis. 

“Our study is the largest multicenter investigation of diaphragm paralysis after pediatric cardiac surgery and of how this complication is associated with postoperative morbidity and mortality,” said Charles D. Fraser, MD, from The Johns Hopkins Hospital in Baltimore. “Furthermore, ours is the first study to highlight significant center-level variability regarding the practice of diaphragm plication.”

Overall, 2,214 of 191,463 patients (1.2%) in the study experienced diaphragm paralysis: 945 of 43,102 neonates (2.2%), 828 of 67,739 infants (1.2%), and 441 of 80,622 children (0.5%). 

Prior single-center studies found that the incidence of diaphragm paralysis after congenital cardiac surgery ranged from 0.3% to 12.8% and was associated with increased respiratory complications, prolonged ventilation, lung infections, prolonged length of stay, and mortality. 

“As such, we sought to investigate the true incidence of this complication, as well as the variability in plication practices and the impact plication has on outcomes,” said Dr. Fraser.

Richard E. Clark Memorial Paper: Congenital
Pediatric Congenital I

7:00 a.m. – 9:00 a.m.
Room 217

Some studies have suggested that delayed diagnosis and delayed plication are associated with higher rates of lung infections, prolonged ICU length of stay, and mortality, particularly in neonates and infants. However, previous data were limited by small sample sizes and single-center experiences. 

In this study, plication was not associated with decreased mortality, morbidity, or shorter hospital stays, and in many categories, it actually was associated with worse outcomes.

Richard E. Clark Memorial Paper: General Thoracic
General Thoracic:
Lung Transplantation

1:15 p.m. – 3:15 p.m.
Room 215

Dr. Fraser said the authors were surprised by the significant center-level variability in the use of plication, suggesting that the management of diaphragm paralysis remains a target for quality improvement.

“The next steps likely would include a prospective multicenter study to corroborate these data and better delineate the utility of diaphragm plication,” he said. 

Rates of Lung Volume Reduction Surgery Increase while Mortality Rates Decrease
A large, national study using data from the STS General Thoracic Surgery Database found that utilization of lung volume reduction surgery (LVRS) has increased and become safer with lower mortality rates, even at lower-volume hospitals. However, there is regional variation in LVRS use that does not match national prevalence rates of chronic obstructive pulmonary disease. 

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

7:00 a.m. – 9:00 a.m.
Room 211

“Traditionally, Medicare only reimbursed LVRS at three types of hospitals: National Emphysema Treatment Trial participants, transplant centers, and centers certified in LVRS by The Joint Commission,” said Zaid M. Abdelsattar, MD, MS, from the Mayo Clinic in Rochester, Minnesota. “This policy may be responsible for the regional variation in LVRS utilization.” 

Zaid M. Abdelsattar, MD, MS

Zaid M. Abdelsattar, MD, MS

Interestingly, all centers performing LVRS in this study had similar risk- and reliability-adjusted outcome rates.

“There might be an unintended access disparity, created in part by current reimbursement policy, without much added benefit in
the contemporary era,” Dr. Abdelsattar said.

The study also highlighted the importance of careful patient selection in deciding who undergoes LVRS. “The most consistent risk factor for adverse outcomes is the functional status of the patient,” he added. 

Increased Prevalence of Infective Endocarditis Tied to Illicit Drug Use
Another study—this one using data from the STS Adult Cardiac Surgery Database—showed that one-third of valve operations for infective endocarditis (IE) performed in the US are due to illicit drug use (IDU), pointing to a severe manifestation of the opioid epidemic.

Arnar Geirsson, MD

Arnar Geirsson, MD

Researchers examined nearly 35,000 cases from 1,000 cardiac surgery centers spanning 7 years. Cases were stratified into groups with IDU (11,756) and without (23,149). 

“The proportion of valve surgery performed for drug-use-associated endocarditis has increased dramatically, and we observed significant regional variation in the burden of these types of cases, which correlated to opioid epidemic hotspots,” said Arnar Geirsson, MD, from the Yale School of Medicine in New Haven, Connecticut.

Although all cardiac surgery centers have experienced an increase in volume of these cases, the regional variability is quite striking, he added. For example, in some centers within the Appalachian corridor, more than 60% of valve cases performed for endocarditis were drug related.

“The epidemiology of endocarditis is really changing due to the opioid epidemic, and surgeons can play a leading role in managing these patients,” Dr. Geirsson said.

The sheer burden of the cases and the fact that, after risk adjustment, the short-term outcomes—including survival—are worse in patients with drug-use-associated endocarditis are major points of concern.

“The findings of this study hopefully will give surgeons a strong argument to push for and lead multidisciplinary team approaches to these complex cases,” said Dr. Geirsson. “Understanding the burden, as well as the risk, of these cases will provide an opportunity to improve patient safety.” 

A multidisciplinary team would include cardiac surgery, infectious disease, cardiology, psychiatry, addiction medicine, and social work, he added.

STS Advances Use of Artificial Intelligence, Machine Learning in CT Surgery

David M. Shahian, MD

David M. Shahian, MD

The Society is a recognized leader in quality measurement and public reporting of surgical outcomes. Now, STS is taking a leading role in the use of artificial intelligence (AI) and machine learning (ML) to further improve patient care and outcomes in cardiothoracic surgery. 

“STS is ideally positioned for this leadership role because of our long history in traditional statistical modeling approaches, the ongoing collaborations of many STS surgeon investigators with academic AI/ML departments, and our most unique asset—the premier clinical data outcomes registry in health care: the STS National Database,” said David M. Shahian, MD, from Harvard Medical School and Massachusetts General Hospital in Boston. “Modern AI/ML approaches are ‘data hungry,’ and within the Database, we have not only the most (8 million records), but also the highest-quality, audited, and validated clinical data available.” 

In the coming year, the STS National Database will be further enhanced by supplemental data that include sociodemographic indicators, long-term survival, and reoperation information. Collectively, Dr. Shahian said, it will form an unparalleled source of data from millions of cardiothoracic surgical patients that can be used for AI and ML studies.

The role and future direction of AI/ML is the focus of Tuesday’s session, Machine Learning in Prediction of Cardiothoracic Surgery Outcomes, moderated by Dr. Shahian and Joseph A. Dearani, MD, from Mayo Clinic in Rochester, Minnesota. 

Machine Learning in Prediction of Cardiothoracic Surgery Outcomes

7:00 a.m. – 9:00 a.m.
Room 224

Dr. Shahian explained that many aspects of supervised AI and ML (such as binary classification of a patient’s outcome) are similar to those of conventional modeling, including the selection of a population cohort and identification of potential risk factors. Just as in traditional statistical modeling techniques, it’s important to develop independent training and validation sets and to validate model performance both in the original population from which the models were developed, as well as in new populations; this avoids model overfitting and assures their generalizability.  

“Arguably, the biggest difference between traditional and AI/ML modeling techniques is that the former pre-specify the form of the anticipated relationships between input (e.g., risk factors) and output (e.g., outcomes) variables, which often are assumed to be rather simple (e.g., additive),” Dr. Shahian said. “Conversely, the algorithms in AI/ML learn iteratively from the data to which they are exposed, and they are mathematically much more complex. They may involve complex nonlinear relationships and patterns that are not apparent with traditional approaches.” AI/ML also may identify additional risk factors or combinations of factors that were previously unrecognized. Finally, unsupervised AI/ML algorithms may detect associations or groupings, sometimes called clusters, that otherwise would not have been evident.

With the availability of cloud-based data storage and ever-increasing computer processing speeds, the potential applications of AI/ML continue to expand, Dr. Shahian said. However, he noted that claims about the superiority of this technology for certain tasks—such as predicting patient outcomes based on preoperative data—have been premature and sometimes wildly exaggerated. Accordingly, STS has formed a working group of surgeons and AI/ML experts from numerous academic centers to coordinate these investigative efforts in a strategic, thoughtful manner.

Dr. Shahian said he began exploring AI and ML more than 2 decades ago with colleagues from the Massachusetts Institute of Technology in an attempt to improve the prediction of coronary artery bypass grafting outcomes using a multilayer perceptron neural network. Incorporating data from the STS National Database, it was among the earliest studies utilizing AI and ML in health care. He expects Tuesday’s session to demonstrate how far AI and ML have advanced since those early studies, but also how much opportunity there is for continuing investigation.

“We hope that this session stimulates all STS members to delve deeper into AI and ML techniques and think about possible applications in our specialty,” he said. 

ISCHEMIA, Surgical Experience Trials Refine Current Practice

Ibrahim Sultan, MD

Ibrahim Sultan, MD

Two hot topics will be discussed and debated at an adult cardiac session on Monday afternoon—the ISCHEMIA trial and the impact of surgical experience on mortality rates following reoperative cardiac surgery. 

“The session puts these trials into perspective, which is critical,” said Ibrahim Sultan, MD, from the University of Pittsburgh Medical Center in Pennsylvania. “We can be overwhelmed by the amount of information coming our way. This session focuses on what is relevant and important to us as surgeons.”

The ISCHEMIA trial compared outcomes for patients with stable ischemic heart disease who received optimal medical therapy and lifestyle interventions versus optimal medical therapy plus angiography and revascularization by percutaneous intervention or coronary artery bypass grafting (CABG) surgery. Nearly 5,200 patients with confirmed stable ischemic heart disease were randomized and followed for 3.3 years. 

Patients who received optimal medical therapy plus lifestyle interventions had more spontaneous myocardial infarctions (MIs), while patients who received percutaneous intervention or CABG had more procedural MIs. The overall composite outcome of cardiovascular death, MI, hospitalization for unstable angina, heart failure, or resuscitation from cardiac arrest were similar between the two groups. 

Adult Cardiac: Ischemic

1:15 p.m. – 3:15 p.m.
Room 211

“ISCHEMIA confirmed what some of the prior work has shown for patients with stable angina—that the noninvasive approach does not increase mortality in the medium term,” said Dr. Sultan, who is a member of the STS Workforce on Annual Meeting Program Task Force and helped plan the Adult Cardiac: Ischemic session.

“These results are not likely to change anything major for surgeons,” Dr. Sultan continued. “What it may change is the number of invasive coronary angiograms that are done for patients with stable disease. If these patients continue to have significant disease and progress, they will continue to be referred for surgery. It is important to realize that CABG is still beneficial for patients who present with acute coronary syndrome such as a non-ST segment elevation myocardial infarction.” 

The session also will feature scientific abstracts on bilateral versus single internal mammary artery grafts for CABG, the optimal configuration for bypass of the left anterior descending artery during bilateral internal thoracic artery grafting, total arterial off-pump multivessel revascularization, and the impact of surgical experience on operative mortality following reoperative cardiac surgery.

Marc R. Moon, MD, from the Washington University School of Medicine in St. Louis, and his colleagues found that standardized mortality ratios are higher early in a surgeon’s career, but also that surgical outcomes decline during the later years of a surgeon’s working life.

“Our data suggest that there is a learning curve during the initial years of practice and a degree of skill attrition with very senior surgeons,” Dr. Moon said. 

To offer additional perspectives on the topic, two surgeons will debate whether age matters when performing cardiac surgery. Audience members also will be encouraged to share their opinions.

“We all should be asking for assistance as needed and making sure that those who are assisting us are at a high level–the senior resident as opposed to a junior intern or even a colleague for selected cases,” Dr. Moon said. “That is true at both ends of our individual career spectrums.” 

Technology and Common Sense Are Key to Avoiding Practice Extinction

Tom C. Nguyen, MD

Tom C. Nguyen, MD

What’s the secret to keeping your practice alive and well? Embrace new technology, new skills, and even social media—that’s the prescription for success and avoiding practice extinction, according to Tom C. Nguyen, MD, from The University of Texas at Houston. 

“It’s like a game of chess. To win, a practice must think not only one to two steps ahead, but three to four steps ahead,” Dr. Nguyen said. “We must look to the future, be receptive to new technologies, be involved with innovation, and work in a multidisciplinary and collaborative fashion.” 

Dr. Nguyen will moderate Tuesday’s session, “Avoiding Practice Extinction: Staying Relevant with New Technologies and Techniques,” with Lana Y. Schumacher, MD, from Massachusetts General Hospital in Boston. The session will describe a framework for keeping practices sustainable now and in the future and will offer tips that physicians can apply immediately upon returning home. 

Technology will be a key focus of the session, and speakers will guide attendees toward adopting the newest tools and techniques, including transcatheter aortic valve replacement (TAVR), electromagnetic navigational bronchoscopy, and robotics.

Avoiding Practice Extinction: Staying Relevant with New Technologies and Techniques

7:00 a.m. – 9:00 a.m.
Room 208

It’s an exciting time for cardiothoracic surgery, Dr. Nguyen said, thanks to recent “disruptive advancements” in catheter-based technologies and minimally invasive techniques. TAVR and MitraClip procedures are now critical treatments for structural heart disease.  

“Most surgeons currently do not have the skillset to proficiently perform these procedures. If they do not learn them, they will become extinct,” he said. “Nearly 35% of what we do as cardiac surgeons is in the structural heart space. If we don’t learn transcatheter and minimally invasive skills, we’ll lose this share.”

Presentations will cover how to start transcatheter valve and robotic thoracic programs, better collaborate with cardiologists, fit training on new technologies into your schedule, and take advantage of support tools from specialty societies. Representatives from STS, the American Board of Thoracic Surgery, and the Accreditation Council for Graduate Medical Education will provide unique perspectives on reviving practices headed toward extinction.

“How do surgeons learn to adopt new technology?” Dr. Nguyen asked. “The train has left the station. Can surgeons still get a ticket for the ride?”

Learning to use social media also is critical to avoiding practice extinction. “Most patients will use the internet to research or find their physician. In medicine, we tend to disregard the power of the internet and social media, but it’s clearly there,” Dr. Nguyen said.

Ultimately, the secret to a healthy practice now and in the future requires cutting-edge thinking and a little common sense.

“Think outside the box, embrace new technology, learn to be proficient at transcatheter and minimally invasive procedures, and attend not only the STS educational courses, but also cardiology meetings,” Dr. Nguyen advised. 

Surgeon Burnout May Jeopardize Patient Safety

Michal Hubka, MD

Michal Hubka, MD

Personal and professional responsibilities that are overly demanding can have a major impact on burnout and job satisfaction for cardiothoracic surgeons—and this can have significant patient safety consequences. 

“Surgeons who are at high risk of burnout may depersonalize their colleagues and patients, which then impairs the safety of their care,” said Michal Hubka, MD, from Virginia Mason Medical Center in Seattle, who will moderate Tuesday’s Patient Safety Symposium on burnout in the specialty. “If you don’t perceive others as human beings and are just going through the motions, that’s a real problem.”

The session will outline causes of workplace burnout and offer practical solutions for addressing the variety of factors involved, with a focus on counseling, coaching, and mentorship. 

“The speakers will discuss resources and strategies to solve this problem on many levels, from the individual to the systematic,” said co-moderator Dawn S. Hui, MD, from The University of Texas Health Science Center at San Antonio. 

Beyond Burnout: What You Should Know and Do Going Forward

1:00 p.m. – 3:00 p.m.
Room 208

Dr. Hubka will present the results of an STS survey on physician wellness in cardiothoracic surgery. The key discoveries include:

  • Job satisfaction was higher among surgeons with only one support staff member versus those surgeons with more than one support staff member. 
  • Better financial compensation and improved personal and organizational alignment were drivers of job satisfaction, but did not influence burnout rates.
  • Job dissatisfaction and burnout scores peaked in the group practicing for 11-15 years and tracked until 20 years in practice, when burnout scores decreased and job dissatisfaction scores increased.
  • Of surgeons who participated in the survey, 34% reported that they don’t perceive their colleagues as resilient or possessing the appropriate emotional tools to deal with stress; 17% of respondents said this of themselves. 

“One of the biggest threats to a lasting career is a lack of personal resilience and coping skills. How are we going to deal with it?” asked Dr. Hubka.

Attendees should note that this 2-hour session fulfills the Patient Safety requirement of the American Board of Thoracic Surgery’s 5-year and 10-year Milestones for Maintenance of Certification. 

Fetal Cardiac Intervention Represents a New Era in Congenital Heart Disease

Anita J. Moon-Grady, MD

Anita J. Moon-Grady, MD

A few decades ago, congenital heart defects weren’t diagnosed until after babies were born. Then, fetal echocardiography allowed for early diagnosis and preparation. More recently, fetal cardiologists have successfully intervened in structural cardiac disease before birth. 

“Just 10 years ago, there was a lot of eyerolling about fetal intervention. It was considered impossible or even unethical,” said Carl L. Backer, MD, from Ann & Robert H. Lurie Children’s Hospital in Chicago. “But today, we’re realizing that fetal cardiologists are changing the natural history of congenital heart disease.”

At a Tuesday session moderated by Dr. Backer, two expert fetal cardiologists will present recent innovations, dramatic case studies, and practical information that every congenital heart surgeon needs to know.

“When a surgeon is consulted on a patient with a fetal diagnosis of aortic stenosis or another structural abnormality, it’s important to consider more than Norwood/Fontan. Fetal intervention is not a cure, but it opens up more options,” said Anita J. Moon-Grady, MD, from the University of California at San Francisco.

Meet the Experts:
Current State of Fetal Cardiac Intervention

11:00 a.m. – 12:00 p.m.
Room 217

The most common fetal procedure is balloon aortic valvuloplasty for severe aortic stenosis. The goal is to prevent the development of hypoplastic left heart syndrome (HLHS). Other fetal techniques include balloon pulmonary valvuloplasty and atrial septoplasty or stent placement. 

Only a handful of medical centers in the US perform fetal cardiac interventions. In Europe and South America, the procedures are more common because Norwood reconstruction is not available. A recent report from the International Fetal Cardiac Intervention Registry concluded that regionalization of treatment is the best path forward. 

“Fetal intervention procedures should not be attempted at every congenital heart surgery center,” said Dr. Backer. 

Parents who travel to regional centers for fetal interventions do so at great risk and expense. After the babies are born, they deserve appropriate follow-up care, so it’s especially important that local surgeons are prepared to evaluate and manage each newborn’s unique condition. 

“Fetal intervention is only the start of a treatment algorithm for the child. Postnatal care is very important for the ultimate outcome. Standard care is not enough. We have to rethink the paradigm,” said Dr. Moon-Grady. 

Wayne Tworetzky, MD, from Boston Children’s Hospital, will describe surgical strategies for babies who have undergone fetal interventions. Many neonates require additional balloon treatments, Ross surgeries, or other procedures to help them develop biventricular circulation. 

“What you see at birth is part of a continuum. The patient’s left ventricular function can get better over time. The disease may still be evolving,” said Dr. Moon-Grady.

These babies represent a new era in congenital heart disease, requiring that surgeons throughout the world learn what to expect when they arrive. And with each passing year, new fetal techniques and technologies are being developed to help these tiny patients survive. 

“Dr. Moon-Grady will enlighten us about a micro-pacemaker trial for fetal heart block, plus an IRB-approved laser treatment for HLHS with intact atrial septum,” said Dr. Backer. “It’s going to be a fascinating session with opportunity for a lively discussion.” 

Cardiothoracic Surgery Slow to Adopt Robotic Technology, But Times May Be Changing

Robotic-assisted surgery has grown in popularity among many US surgeons. In fact, urologists and gynecologists use robots for a majority of their procedures. So why are thoracic surgeons still performing traditional open surgery 50% of the time?

Thomas K. Varghese, MD, MS

Thomas K. Varghese, MD, MS

Is it because they believe open surgery is best for their patients? Or are they unable to gain access to the equipment?

“Thoracic surgeons have been late adopters of robotic technology, but industry leaders are getting on board. I think we’re going to make up for lost time,” said Thomas K. Varghese, MD, MS, from the University of Utah School of Medicine in Salt Lake City, who will moderate Tuesday’s panel session featuring four proponents of robotic surgery.

The session will explore innovative techniques, best practices, patient benefits, financial considerations, and training for robotic surgery.

“Today, most cardiothoracic training programs teach all three operating platforms: open thoracic surgery, video-assisted thoracic surgery (VATS), and robotic-assisted thoracic surgery. Trainees who have a complete foundation are considered the best candidates for quality centers,” said Dr. Varghese, who said he believes that almost every high-volume center in the US should have at least one robotic-assisted surgery system in place. 

“We will discuss how to compete with urologists and gynecologists for access and how to negotiate with the C-suite for extra equipment,” he added.

Building a Thoracic Robotics Program

11:00 a.m. – 12:00 p.m.
Room 225

Dr. Varghese said he is perplexed by the lack of support for robotics among some of his colleagues. In his mind, the benefits over open surgery are clear: smaller incisions, no rib-spreading, less pain, shorter hospital stays, and quicker recovery. Robotics simply is the next generation of minimally invasive surgery.

“The robotic incisions are even smaller than VATS. The robotic arms allow wrist-like movements that are far more precise than VATS instruments. And the high-definition, 3D monitors make it much easier to move around arteries, veins, and critical structures,” he said.

Of course, robotic surgery is not right for every patient, nor every surgeon. Naysayers point to a lack of hard evidence about outcomes. “It’s a justified criticism,” said Dr. Varghese. “We need a randomized clinical trial that proves robots are better than VATS.”

Another complaint from hospital administrators is the price tag. Some believe costs will drop when competitive systems enter the marketplace. Many argue that while the initial expenditure is high, the return on investment can be considerable over time.

Both advocates and critics will learn new information about the future of robotics at this session. “We look forward to a robust, open conversation,” said Dr. Varghese. “That’s good for our field and good for our patients.”

Stephanie G. Worrell, MD, from the University Hospitals Cleveland Medical Center in Ohio, will present “Robotics and My First 100 Days in Practice.”

Dr. Worrell added that the session will serve as a great networking opportunity. “I hope to encourage junior faculty about the resources available to help them embark on a thoracic robotics program,” she said.