January 26/27, 2016

Presenters Meet the Media in STS Press Conferences

The Society will host three press conferences on Tuesday highlighting some of the exciting research being presented at the STS 52nd Annual Meeting. The press conferences will take place in Room 223 at 10:00 a.m.

Race Is Associated With Reduced Overall Survival Following Esophagectomy for Esophageal Cancer Only Among Patients From Lower Socioeconomic Backgrounds
Speaker: Loretta Erhunmwunsee, MD, City of Hope, Duarte, Calif.

Cost Analysis of a Physician Assistant Home Visit Program to Reduce Readmissions Following Cardiac Surgery
Speaker: John P. Nabagiez, MD, Staten Island University Hospital, North Shore-LIJ Health System, N.Y.

Operative Risk for Major Lung Resection Increases at Extremes of Body Mass Index: Analysis of the STS General Thoracic Surgery Database
Speaker: Trevor Williams, MD, The University of Chicago, Ill.

Researcher Examines Impact of Valve Type on Mortality in Women

Hughes

Joy Hughes, MD

Surgeons often have friends who ask for medical advice. When two female friends asked Joy Hughes, MD about whether they should replace their bioprosthetic valves with the same valve type or a mechanical valve, she went well beyond sharing her opinion.

The fourth-year resident in general surgery and critical care fellow at the Mayo Clinic in Rochester, Minn., and her colleagues conducted a retrospective analysis and found that valve type did not influence survival. The researchers looked at 606 women aged 13-45 years (mean = 33 years) who underwent cardiac valve replacement between January 1967 and December 2012.

Dr. Hughes will present her research on long-term survival and valve durability after bioprosthetic and mechanical valve replacement in young women at 2:15 p.m. Tuesday during the Adult Cardiac Session: Mitral Valve in Room 120D from 1:00 p.m. to 3:00 p.m.

“I had several conversations with these friends and also female patients who were approaching the time when they needed to have their valves replaced,” Dr. Hughes said. “When women are in their 30s and looking to have children, it is a complicated issue. A tissue valve pretty much guarantees reoperation, and a mechanical valve requires anticoagulation therapy.

“Although there have been many successful and uneventful pregnancies for women on anticoagulation, pregnant women with mechanical valves have an increased risk of hemorrhage, complications in childbirth, and potentially could be teratogenic. Those are issues we cannot change, but we can reassure patients.”

The researchers concluded that initial selection of a bioprosthesis did not increase late mortality, and survival of patients with bioprosthetic valves replaced with mechanical valves was excellent.

Ninety-five patients had complex congenital heart disease; nine patients had prior valve replacements at other institutions. Of the 318 patients who underwent aortic valve replacement, 97 were bioprosthetic and 221 were mechanical. Of the 261 patients who underwent mitral valve replacement, 55 were bioprosthetic and 206 were mechanical. Follow-up averaged 15 years. Survival for all patients at 10, 20, and 30 years was 81%, 66%, and 41%, respectively. Reoperation at 10, 20, and 30 years for all valves was 8%, 43%, and 56%.

“We weren’t sure what we were going to find, but the results were reassuring,” Dr. Hughes said. “For a woman, this can be about what she is comfortable with, rather than whether she has to accept a mortality risk on top of other issues in choosing one valve over the other.”

Probability of reoperation increased in younger patients, valve replacement after year 2000, and with bioprosthetic valves. There were 65 patients who initially underwent valve replacement with bioprosthesis and subsequently had mechanical valves implanted during reoperation (82%), and their survival was 94%, 91%, 76%, and 68% at 5, 10, 15, and 20 years, respectively.

“This confirms that young patients who choose a tissue valve are going to need a reoperation,” Dr. Hughes said. “The procedures have advanced to the point that mortality risk doesn’t necessarily increase, which is a great credit to cardiac surgeons and health care teams who have worked to improve cardiac surgery outcomes.”

STS/CATS/CSCS Offers Primer on Internet, Social Media, 3D Printing

STS-CATS-2_350

Monday’s STS/CATS/CSCS session gave attendees a new perspective on how the internet, social media, and 3D technology can impact cardiothoracic surgical practice.

Presenters at the STS/CATS/CSCS session on Monday took attendees beyond their comfort zones, giving them a glimpse of how they can improve their internet presence, benefit from the use of social media, and use 3D printing applications in cardiothoracic surgery. The program was a collaboration among STS, the Canadian Association of Thoracic Surgeons, and the Canadian Society of Cardiac Surgeons.

The rapid increase of individuals looking to the internet for their health care needs has subsequently altered the doctor-patient relationship, said Christopher W. Seder, MD, Assistant Professor of Surgery in the Department of Cardiovascular and Thoracic Surgery at Rush University Medical Center in Chicago, who discussed how to build a winning website.

Beyond his presence on the Rush website, he and his colleagues worked with an outside company to create a website for their practice, www.midwestesophagus.com.

“It’s important to optimize your internet presence. To do that, you need to do four things: get people to your website, emotionally connect with them, logically justify that connection in their mind, and convert that to an office visit,” Dr. Seder said.

He provided several tips for achieving search engine optimization, including the use of high-quality, original content, high-quality back links for users to link to your website, and social media to increase those back links. Because the duration of website visits are short lived, he said it’s vital that websites are inviting and well designed, but surgeons should resist the urge to overly self-promote and rather provide useful information, including avenues for connecting with their offices.

Mara B. Antonoff, MD shared her insights about the advantages social media can bring to cardiothoracic surgeons, describing Twitter as a fruitful environment for her professional networking, which she said gives her endless potential interactions with patients, caregivers, advocacy groups, and societal organizations.

“I use Twitter to communicate with others about my primary academic interests, including lung cancer and medical education. I have formed collaborations, learned an inordinate amount, participated in important dialog with others, and shared my own resources with a wide audience,” said Dr. Antonoff, Assistant Professor in the Department of Thoracic and Cardiovascular Surgery at The University of Texas MD Anderson Cancer Center in Houston.

Dr. Antonoff also discussed the preliminary 6-month experience of the Thoracic Surgery Social Media Network (TSSMN), an organization that she helped create. TSSMN participants are charged with promoting Twitter discussions relevant to the content of The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery, using the hashtag #TSSMN.

Mackenzie Quantz, MD has embraced the world of 3D printing, producing a number of models, including an aortic root and mitral valve, on his 3D printer, which is about the size of two paper shredders.

“The use of 3D surgical simulators helps train residents to be more proficient outside of the operating room in a stress-free environment, at their own pace, and under mentorship, which enhances the learning experience,” said Dr. Quantz, Associate Professor of Surgery and a Consultant in Cardiac Surgery at the University of Western Ontario in London, Canada.

“You can make your own simulators, fine-tune them, and create special one-offs for any type of situation, and you can do it very quickly for a low cost,” Dr. Quantz said. “I control the entire process, which makes it extremely user friendly and flexible.”

The co-moderators of the STS/CATS/CSCS program were Sean C. Grondin, MD, MPH, Clinical Professor of Surgery in the Section of Thoracic Surgery at the University of Calgary, Alberta, Canada, and Colin Schieman, MD, Assistant Professor of Surgery and Director of the Thoracic Residency Program at McMaster University, St. Joseph’s Healthcare in Hamilton, Ontario, Canada.

Session Preps Surgeons on Advanced Therapies for End-Stage Heart Disease

The field of treating advanced-stage heart failure is rapidly evolving, and several expert speakers will introduce the latest recommendations in mechanical circulatory support, heart transplantation, and alternative treatment strategies during a half-day of education Tuesday.

Francis D. Pagani, MD, co-moderator of the 1:00 p.m. to 5:30 p.m. session in Room 128AB, said with the advent of ENDURANCE, ROADMAP, and other left ventricular assist device (LVAD) clinical trial results, along with newer devices planned for clinical evaluation, it is important to update surgeons about the implications for patient outcomes.

Michael A. Acker, MD, Philadelphia, will discuss whether ENDURANCE and ROADMAP have changed the practice of LVAD therapy in the United States. In ROADMAP, trial investigators evaluated the effects of treatment with the HeartMate II LVAD to standard medical therapy. ENDURANCE, for which Dr. Pagani is a co-principal investigator, compared the HeartWare HVAD against the HeartMate II LVAD.

“Although both the HeartMate II and HeartWare HVAD are efficacious in terms of keeping patients alive without a heart failure, they have different adverse event profiles. It’s important for surgeons to understand those differences,” said Dr. Pagani, the Otto Gago, MD Professor of Cardiac Surgery, Surgical Director of Adult Heart Transplantation, and Director of the Center for Circulatory Support at the University of Michigan in Ann Arbor.

Daniel J. Goldstein, MD, Bronx, N.Y., will discuss new LVAD trials and technology, including whether these new LVADs have been associated with better patient outcomes. In particular, he will discuss the recently completed HeartMate 3 trial in Europe.

Three speakers will help surgeons understand where the field is at in terms of new devices. Carmelo A. Milano, MD, Durham, N.C., will present on developing a rational approach to treatment of shock with extracorporeal mechanical circulatory support and extracorporeal membrane oxygenation. Nicholas G. Smedira, MD, Cleveland, will describe high-risk alternative strategies in the era of STS National Database reporting. Jay D. Pal, MD, Seattle, will talk about non-sternotomy approaches to VAD implantation.

After a panel discussion and two abstract presentations, four speakers will tackle important topics. Gonzalo V. Gonzalez-Stawinski, MD, Dallas, will discuss solutions for the unique challenges of LVAD therapy or transplant for adult congenital heart disease. Eric J. Velazquez, MD, Durham, N.C., will update attendees on the STICH trial, including whether the approach to ischemic heart disease should be altered because of trial results. Stephanie L. Mick, MD, Cleveland, will look at percutaneous options for structural heart disease in the setting of severe left ventricle dysfunction, as these patients are not optimal surgical candidates. The last speaker, Donald D. Glower, MD, Durham, N.C., will give a talk on the evolution of surgical management of functional mitral insufficiency, including recent trial results.

Surgeon Shares Tips for Treatment of Thoracic Outlet Syndrome

In the SVS @ STS session, Michael P. Fischbein, MD, PhD, Stanford, Calif., spoke about conservative management of acute type B dissections.

Cardiothoracic and vascular surgeons came together to share their insights on several of their overlapping interests during the Monday afternoon SVS @ STS session.

“STS and the Society for Vascular Surgery have held collaborative programs at each other’s annual meetings for the last 4 years. The collaborations bring state-of-the-art, evidence-based practice together from two different worlds,” said co-moderator A. Michael Borkon, MD, Co-Director of the Mid-America Heart Institute and Chair of the Department of Cardiovascular Surgery at Saint Luke’s Health System in Kansas City, Mo.

Presenters from both societies shared their perspectives on three areas: conservative management and stent grafting of acute type B dissections, open treatment and endovascular repair of thoracic aortic aneurysms, and cardiothoracic and vascular surgery approaches to arterial/venous thoracic outlet syndrome.

John A. Kern, MD said that treating thoracic outlet syndrome is so rewarding that he has continued caring for these challenging patients for nearly 20 years.

“The more experience you gain, the better you get at figuring out who is going to benefit from surgery and who is not,” said Dr. Kern, Professor of Surgery, Chief of the Division of Cardiothoracic Surgery, and Surgical Director of the Cardiac Transplant and Circulatory Device Program at the University of Virginia Health System in Charlottesville.

For Dr. Kern, the days of seeing patients living with arterial thoracic outlet resulting in subclavian artery aneurysms and distal embolization are for the most part gone, as these patients are now being referred earlier. He finds patients with venous thoracic outlet to be extraordinarily challenging because they tend to be young athletes who are pitchers, swimmers, and tennis players intent on continuing their athletic careers.

“Sometimes this diagnosis can be missed, but it should not be; if it is, the results can be devastating,” he said. “The treatment for venous thoracic outlet is really quite straightforward.

“I lyse the clot and operate sooner rather than later. In order to decompress and reconstruct the vein, an infraclavicular incision is best. This allows you to remove the subclavius muscle and costoclavicular ligament, as well as the medial aspect of the first rib, and totally mobilize the subclavian vein. You need to free up the entire vein as it goes under the clavicle, under the manubrium, and into the mediastinum. Sometimes these patients may need extensive reconstruction, necessitating a partial upper sternotomy. There are a lot of different ways to reconstruct the vein after it’s decompressed. These details learned along the way help enhance the chances of a good outcome.”

Intended to be thought provoking and give attendees the opportunity to learn from members of both specialties, the session also featured Julie A. Freischlag, MD, Sacramento, Calif., who shared her approach as a vascular surgeon to arterial/venous thoracic outlet syndrome.

SCA @ STS Addresses Evaluation, Management of Circulatory Shock

Jay G. Shake, MD

On the heels of last year’s successful SCA @ STS session, planners from the Society of Cardiovascular Anesthesiologists and STS have created a compelling new program centering on perioperative evaluation and management of circulatory shock.

“Anesthesiologists and surgeons work together in the operating room, so both groups experience shock perioperatively,” said Jay G. Shake, MD, Jackson, Miss. Dr. Shake, Aaron M. Cheng, MD, Seattle, and Jerrold H. Levy, MD, Durham, N.C., are co-moderators of the session, which will be from 3:30 p.m. to 5:30 p.m. Tuesday in Room 126ABC.

Leaders in their fields will discuss how to identify shock in challenging postoperative cardiac patients, perioperative hemodynamic monitoring, and pharmacologic management and mechanical support for shock.

When patients present with acute circulatory failure, their surgeons are left with several questions: “When should we make the decision that we need mechanical support?, Which is the right support?, Are there any cost considerations?, and Do we have data to support some of this?,” Dr. Shake posed. “Sometimes, it isn’t crystal clear. I think these talks will make for a stimulating discussion.”

Dr. Levy will look at shock in difficult patients.

“I think Dr. Levy will give a good review and also discuss the areas that challenge us, such as patient management of individuals with left ventricular assist devices, mechanical support, and low ejection fraction,” said Dr. Shake, Associate Professor, Director of the Cardiovascular Intensive Care Unit, Director of Adult Extracorporeal Membrane Oxygenation, and Co-Director of the Wallace Conerly Critical Care Hospital at the University of Mississippi Medical Center in Jackson.

With new technologies for perioperative hemodynamic monitoring now available, Robert Sladen, MD, New York, will compare options for surgeons, such as noninvasive cardiac output devices, as well as conventional options.

“Everyone is trying to come at this from different angles,” said Dr. Shake, “but what are our choices, and are there data to support one technology over another?”

In his talk on proven strategies for pharmacologic management of shock, Peter von Homeyer, MD, Seattle, will dig into recent prospective trials and share evidence for choosing pharmacological agents to treat circulatory failure.

The last speaker, Ashish Shah, MD, Nashville, Tenn., will identify indications, options, and outcomes for using mechanical circulatory support devices in these patients.

Symposium Examines Impact of Human Error on Cardiothoracic Surgeons

James Fan, M.D. a Cardiothoracic Surgery Physician at Stanford Hospital and Clinics on Tuesday, November 24, 2014. ( Photo by Norbert von der Groeben )

James Fan, MD

Health care providers involved in a medical error or adverse event are often considered “second victims.” They perceive themselves as being personally responsible for the unexpected outcomes and having failed their patients, causing them to further question their medical knowledge and clinical abilities.

This year’s Patient Safety Symposium will delve into When Bad Things Happen to Good CT Surgeons—Human Error and the Impact on You, the “Second Victim” from 1:00 p.m. to 3:00 p.m. Tuesday in Room 127ABC.

“We do not know the proportion of health care professionals who are affected by the second victim phenomenon, the long-term impact on their careers, or how these events contribute to work-related stress,” said moderator James I. Fann, MD, Professor of Cardiothoracic Surgery at Stanford University in Palo Alto, Calif.

For Dr. Fann, a human factors approach within the framework of patient safety acknowledges that medical errors can result from a combination of individual and work system factors. Thus, it’s important for clinicians who are second victims to understand the need and develop an infrastructure for a support program.

“For instance, some have advocated for a dedicated team that would support providers during the early stages of emotional stress, facilitate recovery from the events, and enhance career satisfaction,” Dr. Fann said.

The first presenter, James Jaggers, MD, Aurora, Colo., will discuss the impact of an adverse event on the provider.

“As much as we’d like to think that this is all a team effort, the reality is that surgeons have a substantial amount of burden placed upon them,” Dr. Fann said.

Co-author of “When Bad Things Happen to Good Surgeons: Reactions to Adverse Events,” published in the February 2012 issue of Surgical Clinics of North America, Carol-Anne Moulton, MD, PhD, Toronto, will describe the various stages a provider goes through, including stresses that may lead to burnout and how to overcome the trauma of an adverse event.

Anesthesiologist and attorney Timothy McDonald, MD, JD, Chicago, will help attendees understand the importance of disclosure and legal issues after an adverse event, including the perspective of hospitals and clinicians.

The afternoon will conclude with a panel discussion.

Ethics Debate Tackles the Case of a Postoperative Advance Directive

When patients or their caretakers want to limit the use of life-sustaining technologies after major operations, those limitations may present a challenge for surgeons.

Robert M. Sade, MD

“Some surgeons feel it’s up to the patient to decide how much technology they are willing to accept, while others feel it’s their professional responsibility to do what’s best for the patient, so they are unwilling to accept limitations in advance,” said Robert M. Sade, MD, Distinguished University Professor and Professor of Surgery at the Medical University of South Carolina in Charleston.

Dr. Sade is the facilitator of this year’s Ethics Debate: An Advance Directive Limits Postoperative Care—Should Surgeons Accept Limits on Care? from 12:00 p.m. to 1:00 p.m.
Tuesday in Room 229AB. Constantine Mavroudis, MD and Jeffrey G. Gaca, MD will debate the case of an 80-year-old man with an aortic dissection and associated risk factors. He needs an urgent operation, and it’s likely he will require long-term support with a ventilator and kidney dialysis. His wife is his health care agent, and she has imposed a limit of no more than 1 week of life support after the operation, and then all supportive measures must be discontinued.

Constantine Mavroudis, MD

“I would do the operation and respect the patient’s autonomy and the advanced directives. The possibility of a successful surgery may be low, but it is still real. However, during the postoperative period, I would try to persuade the wife using ethically acceptable means to change her posture and accept further care,” said Dr. Mavroudis, Professor of Surgery at Johns Hopkins University School of Medicine and Site Director of Johns Hopkins Children’s Heart Surgery at the Florida Hospital for Children in Orlando.

Agreeing with Dr. Mavroudis that the patient coming off extubation within a week was slim, Dr. Gaca added that this life-threatening situation dictated urgent surgery, and 1 week was a strict time limit.

Gaca

Jeffrey G. Gaca, MD

“Patients who want ‘everything done’ oftentimes are not aware of what everything involves. Everything can be tough, painful, and almost cruel and unusual punishment. We have to help patients and their families clarify what their wishes are,” said Dr. Gaca, Associate Professor of Surgery at Duke University in Durham, N.C.

He added that a period of time after the surgery, he would talk with the wife about discontinuing care if needed. “I don’t think we should place limits on this person’s care before going into the operation, but at some point, there is always a limit on care,” Dr. Gaca said.

The Ethics Debate requires a ticket to attend. If you haven’t yet purchased a ticket, you may do so at Registration on the lower level of the convention center.

Robert A. Guyton Honored for Leadership, Service to Cardiothoracic Surgery

Robert A. Guyton, MD

Robert A. Guyton, MD is the recipient of the STS 2016 Distinguished Service Award, presented Monday evening at the Annual Membership (Business) Meeting.

“This award recognizes Dr. Guyton’s tremendous contributions not only to STS but also to the entire specialty of cardiothoracic surgery,” said 2015-2016 STS President Mark S. Allen, MD. “Through his work with the American College of Cardiology (ACC), he has earned tremendous respect among our cardiology colleagues and has influenced all aspects of cardiac care.”

An STS member since 1986, Dr. Guyton has served the organization in many capacities, including 2003-2004 President and 1997-2002 Treasurer. He participated on the Operating Boards of the Council on Health Policy and Relationships and the Council on Education and Member Services. Dr. Guyton also chaired the Information Technology and Information Technology Liaison Committees, the Workforce on Media Relations and Communications, and the Nominating Committee.

“Dr. Guyton always maintains the highest standards of professional excellence and is a strong, dynamic leader,” said Dr. Allen.

During his time as STS President, the Society opened a dedicated office in Washington, DC. This was at a time when the medical profession was faced with sky-high professional liability insurance premiums while simultaneously threatened with a substantial cut in Medicare reimbursement. Dr. Guyton championed the Society’s participation in Doctors for Medical Liability Reform, a coalition formed to raise awareness about the need to reform the medical liability system. He also initiated a series of STS activities aimed at elevating the level of expert witness testimony in medical malpractice litigation.

Dr. Guyton graduated from the University of Mississippi and Harvard Medical School; he then completed an internship, residencies in general surgery and cardiothoracic surgery, and a clinical fellowship in surgery at Massachusetts General Hospital in Boston.

He joined Emory University in Atlanta in 1980, where he currently is the Distinguished Charles Ross Hatcher Jr. Professor of Surgery, Chief of the Division of Cardiothoracic Surgery, and Director of the Emory Cardiothoracic Surgery Residency Training Program.

Throughout the years, Dr. Guyton has been involved in the creation and refinement of several cardiothoracic surgery techniques, including transcatheter aortic valve replacement. His commitment to patient care has led to strong collaborations with other physicians, especially cardiologists. He currently serves as ACC Treasurer and previously served a term as a member of the ACC Board of Trustees.

“Other STS members should learn how Dr. Guyton has been able to accomplish many goals with our cardiology colleagues with tactful and appropriate interactions. They should also seek to learn his methods of developing and implementing a plan with harmony and cooperation,” noted Dr. Allen.

Dr. Guyton was recognized for his commitment to resident education and mentorship through a 2009 Socrates Award from the Thoracic Surgery Residents Association. He also was a member of the Board of Directors for the Thoracic Surgery Foundation for Research and Education.

A son of an internationally renowned physician and medical textbook author and brother to nine siblings, all of them physicians, Dr. Guyton currently resides in Atlanta with his wife, Beth.

The Distinguished Service Award, established in 1969, recognizes individuals who have made significant and far-reaching contributions to STS and the specialty.

Joseph Bavaria Elected STS President

Joseph E. Bavaria, MD

Internationally recognized cardiothoracic surgeon Joseph E. Bavaria, MD was elected by the STS membership yesterday evening as the Society’s 2016-2017 President.

“I am honored to follow in the footsteps of some of the greatest cardiothoracic surgeons who have led our specialty and look forward to my tenure as STS President,” said Dr. Bavaria, the Brooke Roberts-William Measey Professor in Surgery and Director of the Thoracic Aortic Surgery Program at the University of Pennsylvania. “I hope to spend my year as President focusing on expanding the STS National Database to include more cardiothoracic surgery procedures; I also plan to execute educational opportunities globally.”

Raised in Cincinnati, Ohio, Dr. Bavaria spent many of his adolescent years living abroad, moving across Europe with his family. He started high school at the American School in Paris, France, before returning to the United States to complete his high school education.

Dr. Bavaria received a Bachelor of Science degree in chemical engineering from Tulane University in New Orleans, where he later earned his medical degree and participated in the Honors Chemical Engineering Exchange Program at the University of Edinburgh in Scotland.

“Having spent a portion of my life abroad has helped me keep a more global focus,” said Dr. Bavaria. “Because of this, one of my goals during my presidency is to increase STS presence internationally and increase our cooperation with other organizations like the American College of Cardiology, American College of Surgeons, and the European Association for Cardio-Thoracic Surgery.”

Dr. Bavaria completed his surgical internship and residency at the Hospital of the University of Pennsylvania in Philadelphia. He served for a year as Chief Resident of Surgery before completing additional residencies in thoracic and cardiovascular surgery at the Hospital of the University of Pennsylvania and Children’s Hospital of Philadelphia.

An STS member since 1996, Dr. Bavaria most recently served as the organization’s First Vice President. He also participated on the Operating Board of the Society’s Council on Health Policy and Relationships. Previously, he served as Chair of the STS Workforce on New Technology.

“STS is a broad-based membership society open to all cardiothoracic surgeons, and we welcome anyone who wants to join us in helping shape the future of our specialty,” said Dr. Bavaria. “I want to encourage all of my colleagues to get involved with the Society and become an advocate for our specialty at all levels.”   

Dr. Bavaria lives with his wife, Kim, in Philadelphia. The couple has two children, Edward and Melanie. Dr. Bavaria enjoys playing golf and is an avid Philadelphia sports fan.

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