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The ongoing opioid crisis has led to a marked increase in tricuspid valve endocarditis (TVE), particularly among people who inject drugs (PWID). This trend presents cardiac surgeons with complex clinical and psychosocial challenges, as patients often face overlapping issues—including infection, addiction, and social instability. These factors complicate surgical decision-making and underscore the need for comprehensive, multidisciplinary approaches to care.

To address the lack of clear surgical guidance and the unique challenges associated with TVE in PWID, the Society of Thoracic Surgeons (STS) convened a multidisciplinary panel to develop expert consensus statements focused on clinical decision-making in this high-risk population.

“Unlike left-sided endocarditis, TVE lacks definitive data to guide surgical timing and intervention strategies,” said Joshua Goldberg, MD, of Weill Cornell Medicine, who chaired the task force that produced the document. “This consensus document represents an important step forward, organizing expert recommendations into key categories that reflect the multifaceted clinical challenges encountered in managing PWID with TVE. Each group of statements addresses specific, real-world dilemmas faced by the multidisciplinary care team.”

The eight core categories outlined in the document include:

• Vegetation size
• Influence of microbial organism on surgical decisions
• Management of persistent bacteremia and timing of antibiotics
• Prosthetic valve infection
• Decisions around valve removal, repair, or replacement
• Prosthetic type selection
• Use of emerging technologies such as transcatheter debulking
• Ethical challenges of recurrent disease in the context of substance use

A Thorough, Multidisciplinary Approach to Consensus Building

The STS writing group employed a rigorous, evidence-based methodology to develop the consensus statements, incorporating a comprehensive literature review and a modified Delphi process. The evidence review was guided by PICO Framework (Patients/Population, Intervention, Comparison/Control, Outcome)-formatted questions, ensuring a structured and focused appraisal of the data. Consensus statements were established in the first round of voting, with a minimum threshold of 75% agreement required from a multidisciplinary panel that included cardiac surgeons and infectious disease specialists

Navigating Complex Decisions in Endocarditis

“First, surgeons and treatment teams must always remember that tricuspid endocarditis in the setting of injection drug use is a symptom and sign of the disease of addiction. Effective care requires addressing both the infection and the underlying pathology of addiction,” said Dr. Goldberg. “Second, published surgical indications for tricuspid valve surgery are largely extrapolated from data derived from studies on left-sided valve disease. When combined with complex psychosocial factors, the decision to operate can be enigmatic and is best approached through thoughtful, multidisciplinary evaluation.”

A Practical Framework for Attentive, Evidence-Informed Care

Ultimately, this expert consensus provides cardiac surgeons with a practical, evidence-informed framework for managing TVE in PWID. It supports individualized decision-making while promoting standardization in key areas such as vegetation assessment and the use of emerging technologies. Most importantly, it emphasizes the need for compassionate, team-based care that integrates medical, surgical, and psychosocial perspectives. The document serves not only as a clinical tool, but also as a call to action—to treat not just the infection, but the patient as a whole.

In addition to offering clinical guidance, the consensus highlights critical knowledge gaps that demand further investigation. “Because published surgical indications are largely extrapolated from studies on left-sided valve disease, the true indications and optimal timing for intervention remain unclear—particularly in the absence of uncontrolled sepsis or right heart failure,” Dr. Goldberg noted. “We also lack a clear understanding of the efficacy and utility of transcatheter therapies, which have seen a dramatic rise in use in recent years.”

Read the Annals article.

“The Society of Thoracic Surgeons applauds the House bipartisan Doctors Caucuses for their leadership in developing the Patients First Act,” said STS President Vinay Badhwar, MD. “STS has worked closely with members of the caucuses throughout this process, and we are encouraged to see several longstanding physician priorities reflected in the legislation.

In particular, we appreciate the inclusion of meaningful reforms to Medicare's budget neutrality policies and provisions based on the Access to Claims Data Act—legislation developed with strong input from STS to improve physicians' access to timely, comprehensive Medicare claims data.

These policies represent important steps toward a more stable and transparent Medicare payment system that better supports physicians and the delivery of high-quality patient care. We look forward to continuing to work with Congress to advance these reforms and strengthen the Medicare program for both patients and physicians."

This afternoon, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2027 Medicare Physician Fee Schedule (PFS) proposed rule. STS has put together a summary of key provisions affecting cardiothoracic surgery in the rule.  

Physician Payment

As required by statute starting in CY 2026, there are two separate conversion factors (CFs): one for physicians and practitioners participating in qualifying alternative payment models (or QPs) and one for those who are not (non-QPs). For CY 2027, CMS has proposed a conversion factor (CF) of $32.84 for non-QPs and $33.16 for QPs.  

While this is the second year in a row we are seeing base CF updates, as required by statute, the conversion factor for physicians will actually decrease due to the expiration of the temporary 2.5 percent increase for CY 2026, even though the formula incorporates positive base updates.

Additionally, other policies continue to diminish hospital-based proceduralists’ reimbursement. Policies such as the efficiency adjustment and reductions to practice expenses continue to threaten surgeons’ ability to practice.  Reimbursement also continues to lag inflation. STS is working with the broader physician community and members of the Republican and Democratic Doctors Caucuses to reform physician reimbursement.

Surgical Global Codes

CMS continues to question the valuation of 10- and 90-day global surgical codes. While it does not make any proposal to conduct an across-the-board revaluation at this time, CMS states that it is interested in how “CMS could 'right-size' payments for the globals over time to ensure they remain aligned with current clinical practice and resource costs, are more readily updated based on empirical data, and do not obscure differences in cost and value across settings of care.” STS has consistently pushed back against efforts to reduce payments in surgical global periods, advocating for accurate valuation of surgical services and policies that reflect the complexity, intensity, and longitudinal care provided by cardiothoracic surgeons.

Quality Payment Program (QPP)

CMS is proposing to sunset the traditional Merit-based Incentive Payment System (MIPS) reporting option in 2029 and is pushing forward with its efforts to transition all MIPS participants towards MIPS Value Pathways (MVPs), which will be reported by subspecialty.

Inpatient Only (IPO) List in Hospital Outpatient Rule

CMS also recently released the CY 2027 Hospital Outpatient Prospective Payment System (OPPS) rule. Hospitals that meet their outpatient quality reporting requirements will receive a 2027 payment increase of 2.4%.

Additionally, CMS has long maintained an Inpatient Only (IPO) list identifying services that are not payable under the OPPS because they must be performed on an inpatient basis. In last year's rulemaking, CMS finalized the elimination of the IPO list over three years, suggesting it gives physicians greater flexibility in determining the most clinically appropriate site of care.

As codes are removed from the IPO list, CMS is pricing them for reimbursement in the hospital outpatient and Ambulatory Surgical Center (ASC) settings. Removal from the list does not mean that the procedures cannot be performed in the hospital inpatient setting, only that, if safe for the patient, they may now be performed in and paid for in the outpatient or ASC setting.

CY 2027 marks the second year of this transition. Of particular interest to STS members, CMS is proposing to remove services from the respiratory, mediastinum, diaphragm, digestive, lymphatic, and endocrine clinical families, which include virtually all of the general thoracic procedures. Removal from the IPO list does not require that surgeries for Medicare patients be performed in the outpatient setting.

However, STS continues to have significant concerns that removal of CT surgery from the IPO list could impact patient safety and result in other insurers dictating where surgeries are performed without proper safeguards or clinical input.

Determining the optimal surgical approach for early-stage non-small cell lung cancer (NSCLC) has grown more complex with increasing use of sublobar resection. Recent randomized trials show comparable outcomes to lobectomy in carefully selected patients, but questions remain about real-world application.

A new expert consensus document from the Society of Thoracic Surgeons (STS), published in The Annals of Thoracic Surgery and developed by the Workforce on Evidence-Based Surgery and a panel of thoracic surgeons, provides guidance on the use of sublobar resection.

The recommendations focus on patient selection, margin requirements, and lymph node evaluation, offering a practical framework for clinical decision-making.

“These expert consensus statements are designed to provide real-world, practical recommendations,” said Onkar Khullar, MD, a thoracic surgeon at Emory University, who chaired the panel. “At the same time, we hope they place some guard rails around which patients are truly appropriate for sublobar resection, so that this technique is used appropriately, effectively, and safely.”

Bridging Evidence and Practice

The recommendations were developed through a comprehensive literature review and a modified Delphi process, requiring greater than 75% agreement for each statement. The panel reached consensus on 21 statements across seven key areas of controversy, including:

• Sublobar resection versus lobectomy
• Wedge versus segmentectomy
• Central tumor location
• High-risk histologic features
• Adequate margins
• Complex segmentectomy
• Intraoperative lymph node assessment

A major gap identified was the difference between randomized trial criteria and real-world practice, particularly in lymph node staging. In randomized trials, only patients with pathologically confirmed negative nodes were included, which is not always practical in real-world settings, where it may not be feasible to perform intraoperative frozen sections on all nodes.

To address this, the panel recommends proceeding with sublobar resection when preoperative staging is negative and nodes are not clinically suspicious, while maintaining intraoperative vigilance.

“If a surgeon becomes suspicious of a lymph node during the operation, they should perform a frozen analysis,” Dr. Khullar stated. “If that is positive, consideration should be given to converting to an anatomic resection.”

Key Recommendations

The consensus reinforces that sublobar resection—either segmentectomy or wedge resection—is an appropriate option for patients with peripheral, node-negative tumors measuring 2 cm or less, provided that adequate surgical margins and lymph node assessment can be achieved. 

“Sublobar resection should be considered in patients with peripheral, node-negative tumors less than 2 cm if, and only if, appropriate margins and lymph node evaluation can be obtained,” Dr. Khullar noted. “If those criteria cannot be met, and the patient is a candidate for lobectomy, then lobectomy remains the best option.”

The document emphasizes the importance of margin quality, recommending a minimum 10 mm margin for solid tumors and supporting intraoperative frozen section analysis to guide decision-making. It also notes that while segmentectomy is often considered a more anatomic approach, it may involve longer operative times and greater complexity, which should be weighed in older patients or those with limited pulmonary reserve.

Unresolved Questions

Despite growing evidence supporting sublobar resection, important uncertainties remain—particularly regarding high-risk tumor features such as spread through air spaces (STAS), lymphovascular invasion (LVI), and visceral pleural invasion (VPI).

“The biggest gap in current knowledge is whether sublobar resections should be performed in patients with high-risk pathology features,” Dr. Khullar explained. “First, we often cannot identify these features before surgery. Second, even if we do, it’s unclear whether sublobar resection is appropriate.”

Current consensus suggests there is insufficient evidence to recommend routine conversion to lobectomy based on these findings alone. To address this gap, new data fields have been incorporated into the STS General Thoracic Surgery Database, with the goal of generating more robust evidence in the future.

Informing Surgical Decision-Making

As sublobar resection use expands, the panel expects these recommendations to standardize care while maintaining clinical flexibility. The hope is that these statements will influence how surgeons approach case selection, margin assessment, and lymph node evaluation in everyday practice.

Although further research is needed—particularly to refine patient selection and clarify high-risk features—the consensus provides an important foundation for early-stage NSCLC care..

“As more data become available, we expect these recommendations to evolve,” Dr. Khullar added. “But for now, they offer a practical framework to ensure patients receive the most appropriate surgical treatment.”

Read the Annals article.