News & Media

By Natalie S. Lui, MD, from Stanford University School of Medicine in California; and Sunil Singhal, MD, from the University of Pennsylvania in Philadelphia STS News, Spring 2022 — Intraoperative molecular imaging (IMI) is a promising technology with several potential applications in thoracic surgical oncology. The techniques involve an imaging agent, which is given intravenously and accumulates in the area of interest, and a fluorescence camera that detects the signal from the imaging agent intraoperatively. Imaging agents can be nontargeted or receptor targeted. The ideal imaging agent is specific enough to produce a high mean fluorescence intensity (MFI) in the area of interest but not surrounding areas, yielding a high signal to background ratio (SBR). The most commonly used nontargeted imaging agent is indocyanine green (ICG), the only FDA-approved near-infrared agent. At low doses, ICG imaging relies on vascular perfusion and has been used to define the intersegmental plane during segmentectomy, evaluate gastric conduit perfusion during esophagectomy, and identify the phrenic nerve during mediastinal mass resection. At high doses, ICG relies on the enhanced permeability and retention effect and has been used for lung tumor identification; it is called TumorGlow to emphasize its higher dose and purpose. Clinical trials of IMI using ICG in patients undergoing surgery for lung cancer have shown good fluorescence signaling in tumors but also in peritumoral inflammation, demonstrating the advantage of receptor-targeted imaging agents. Receptor targeted imaging agents are composed of a probe, which targets a receptor in tumors, conjugated to a dye, which fluoresces at a certain wavelength. For example, one IMI agent in clinical trials is OTL38 (On Target Laboratories in West Lafayette, Indiana). The probe is a folate analog, and the dye is S0456, a fluorophore in the near-infrared spectrum. The folate receptor is highly expressed in lung adenocarcinoma. This example of IMI uses the imaging agent OTL38, with the lung nodule viewed in vivo under (A) white and (B) near-infrared light, as well as (C) ex vivo on the back table. Another IMI agent being studied is panitumumab-IRDye800. The probe is panitumumab, an anti-epidermal growth factor receptor (EGFR) antibody, and the dye is IRDye800, another fluorophore in the near-infrared spectrum. EGFR is overexpressed in both lung adenocarcinoma and squamous cell carcinoma. Near-infrared dyes have been found to have greater depth of penetration compared to those in the visible spectrum. One important application of IMI is tumor localization during sublobar resections, which are performed more frequently as we diagnose earlier stage disease. IMI techniques are particularly suitable for minimally invasive surgery, because the small incisions make it difficult for surgeons to palpate nodules. In addition, fluorescence cameras are built in to the newer endoscopic and robotic cameras and are easy for surgeons to learn. There are several advantages to IMI tumor localization compared to our current methods of computed tomography (CT)-guided or bronchoscopic marker placement for lung nodules that are small, part solid, or deep to the pleural surface. IMI avoids an additional procedure before surgery and does not require radiation exposure to the patient or surgical team. The methods have been shown to be faster than intraoperative frozen section. Since IMI agents are given systemically, surgeons may be able to find synchronous lesions not identified on preoperative CT scans. Additional research is needed before IMI is standard in clinical practice. There are currently no approved IMI agents, although OTL38 is currently being studied in a randomized clinical trial of patients with lung adenocarcinoma. Development of probes that target different types of tumors, and allowing multiple probes to be used at once, would be important advancements. A current limitation is depth of penetration, and new fluorophores and fluorescence cameras are needed for reliable identification of deeper tumors. Another area of inquiry is evaluation of lymph nodes, which may be difficult to assess because they can take up the imaging agents even if not involved. IMI is an exciting new technology with many potential applications for thoracic surgical oncology. Additional trials are needed before these techniques are approved for clinical use.    

John H. Calhoon, MD STS News, Spring 2022 — These words from my mentor, Dr. J. Kent Trinkle, truly infuriated me as a young, often too mercurial, and impetuous resident and faculty member. So much needed to be changed and it seemed (to me) the only way to make it happen was by force. With much time, his words and wisdom have begun—though not fully yet—to sink in. The Challenges Ahead The cardiothoracic surgery specialty continually faces challenges, all of which are best viewed as opportunities. Most recently, our adult cardiac brethren have been confronted with guidelines for the treatment of coronary disease which simply missed the mark. Our general thoracic colleagues are repeatedly confronted by less invasive ablative techniques offered by radiology, bronchoscopy, and the like. The kiddie heart teams, and valve and aortic disciplines, also face similar emerging technologies. Fortunately, STS, through a wonderful network of volunteer surgeons and a robust staff, does its best to address these challenges daily. It has been a wonderful experience to watch as Dr. Sean Grondin deftly navigated these challenges with the STS team this past year. I’ve learned from him and so many of our leaders throughout my career. Now, with the help of Drs. Tom MacGillivray, Jenna Romano, Wilson Szeto, Vinod Thourani, and the rest of the Board of Directors, it is my honor and pleasure to take the helm of the organization for a short time. For that, I am very humbly grateful. All of us learned a great deal from Dr. Joe Sabik and continue to call on him for support and insights from his 6 years of service as STS Secretary and 5 additional years on the STS Board. I am particularly grateful to Dr. Sabik for agreeing to chair the STS Workforce on Evidence Based Surgery, as he has great knowledge and experience in this area. The Decision to Go Virtual Congratulations to Dr. John Mitchell for a successful annual meeting in January. When Omicron could not be ignored, the decision to go virtual was made, and the STS 58th Annual Meeting was developed in just 3 weeks. Dr. Grondin made a wonderful call to have a 2-day meeting, with a tight, efficient schedule that made the meeting as enjoyable and accessible as I can ever remember. This proved to be the perfect “fit” for the situation. Principles and Process behind Guidelines As this year unfolds, the challenges we face continue to evolve, but the solutions remain much the same. We will address the process by which guidelines are created. It should be by asking for the best experts available to look at the best evidence, while keeping our patients in mind. With an ever-increasing overlap in surgical treatment and medical/interventional treatment of cardiac and thoracic diseases, STS and any guideline processes need to remain focused on what is best for the patients, not for a particular technique or discipline. While STS and the American Association for Thoracic Surgery (AATS) were involved in the development of the 2021 Guideline for Coronary Artery Revascularization, the organizations withdrew their support due to concerns about the interpretation of scientific evidence and challenges related to the guideline development process. The process for writing what we believe were failed coronary disease “guidelines” (I still consider them recommendations) is being examined by STS and our AATS colleagues. We also have the unanimous, unsolicited support from the European Association for Cardio-Thoracic Surgery (EACTS) and other global cardiac surgical societies. The principles by which guidelines should be created are: using best evidence, removing bias from their interpretation, and fielding solid expert teams. Many of the global surgical societies are aligned on this coronary disease guideline opportunity and we should all collaborate to address it. There is a great faith that we can get this right with time. We must. What Is Happening at STS STS is doing some impactful things. CEO Elaine Weiss has begun to enhance the STS team. She has added Charlie Simpson as Senior Vice President of Marketing and Communications. He joins Bill Seward and Grahame Rush in the senior leadership team. Elaine also has begun to implement some of the organizational changes provided from a special Presidential task force that was started by Dr. Grondin. Led by Drs. Richard Prager and Doug Mathisen, the Task Force on Governance has offered operable suggestions and a modified organizational chart to make the Society more efficient and productive. As we are hopefully emerging from COVID for the last time, the ability of and need for STS to refocus on key services for us—the surgeon members—has never been greater. Over the next few months, we will be looking hard at the STS National Database to continue its evolution. It should be easier to enter data, more malleable to our needs, and in my humble opinion, it must begin to capture longer term data. It is the long-term data that differentiate surgical treatment from all others. We must figure out how to highlight that. A productive educational retreat was held last summer, and there are many initiatives that we can begin to stage and address. Likewise, the STS advocacy arm remains crucial to the specialty, so we will continue to leverage our data and voice in Washington, DC. Similarly, the opportunity for collaboration on a global scale is present. We are excited about the EACTS annual meeting in Milan this October and look forward to partnering with EACTS on other international meetings as well. One of my late heroes, Dr. Alfonso Chiscano always signed his notes with “More to come.” So in his honor, “More to come.” In Memoriam The cardiothoracic surgery community recently lost one its revered leaders: Dr. Marian Zembala. This internationally renowned cardiac surgeon—a past president of EACTS and former Health Minister of Poland—was known for his humility and passion. He will be greatly missed. 

Mosca Leads CT Surgery at NYU Langone Ralph S. Mosca, MD, is the chair of the Department of Cardiothoracic Surgery at NYU Langone Health in New York. In addition to this new role, he will continue to serve as chief of the Division of Pediatric and Adult Congenital Cardiac Surgery and director of the Congenital Heart Center at NYU Langone, as well as professor at the NYU Grossman School of Medicine. Dr. Mosca has been an STS member since 1995. Takayama Promoted at Columbia University Hiroo Takayama, MD, PhD, has been named chief of the Adult Cardiac Surgery Section at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City. He also will continue as co-director of the Columbia Aortic Center and the Hypertrophic Cardiomyopathy Center, director of the Cardiovascular Institute, and professor of surgery at Columbia University Medical Center. Dr. Takayama has been an STS member since 2012. Ouzounian Appointed Division Head in Toronto Maral Ouzounian, MD, PhD, is the new head of the Division of Cardiovascular Surgery in the Sprott Department of Surgery and the Peter Munk Cardiac Centre at University Health Network (UHN), both in Toronto, ON, Canada. She also is an associate professor of surgery in the Department of Surgery at the University of Toronto and the Peter Munk Cardiac Centre Chair in Advanced Cardiac Therapeutics at UHN. Dr. Ouzounian has been an STS member since 2017. Moon Moves to Texas Marc R. Moon, MD, has been named chief of the Division of Cardiothoracic Surgery at Baylor College of Medicine in Houston, Texas, chief of the Adult Cardiac Surgery Section at Baylor St. Luke’s Medical Center, and chief of adult cardiac surgery at the Texas Heart Institute. Previously, he served as chief of cardiac surgery, director of the Center for Diseases of the Thoracic Aorta, and co-director of the Heart and Vascular Center at the Washington University School of Medicine in St. Louis, Missouri. Dr. Moon has been an STS member since 2001. Lazzaro Guides Thoracic Surgery in South Jersey Richard S. Lazzaro, MD, will serve in the newly created role of southern region chief of thoracic surgery for RWJBarnabas Health in Monmouth County, New Jersey. Before accepting this position, he was the director of thoracic robotic surgery and associate professor of cardiothoracic surgery at Northwell Health in New York City. Dr. Lazzaro has been an STS member since 2007. Fraser Directs New Cardiovascular Institute Charles D. Fraser Jr., MD, has been named the inaugural executive director of the new Institute for Cardiovascular Health, a collaboration between Ascension Texas and The University of Texas at Austin, which includes the Dell Medical School. He will continue his roles as professor of pediatrics and surgery and founding chief of pediatric and congenital heart surgery at the Texas Center for Pediatric and Congenital Heart Disease at Dell Children's Medical Center in Austin. Dr. Fraser has been an STS member since 1997. Samy Is Promoted to Albany Chief Sanjay A. Samy, MD, has been named the Alley Sheridan Chair in Cardiothoracic Surgery and chief of the Division of Cardiothoracic Surgery at Albany Medical Center in New York. With the institution for more than 5 years, he also will continue his role as professor of surgery. Dr. Samy has been an STS member since 2009. Fiedler Joins UCSF Amy G. Fiedler, MD, has joined the Department of Surgery at the University of California San Francisco (UCSF) as a cardiac surgeon and assistant professor of clinical surgery. She also will serve as director of global cardiac surgery within the UCSF Center for Health Equity in Surgery and Anesthesia. Dr. Fiedler previously was an assistant professor at the University of Wisconsin School of Medicine and Public Health in Madison. She has been an STS member since 2021. Wakeam Is Co-Director of Michigan Transplants Elliot Wakeam, MD, has been appointed transplant program surgical co-director at the University of Michigan in Ann Arbor. He also is assistant professor in the Section of Thoracic Surgery at Michigan Medicine. Dr. Wakeam has been an STS member since 2021. Karamichalis Earns PhD John M. Karamichalis, MD, PhD, recently earned his higher doctorate research degree from the University of Oxford, Medical Sciences Division in England. He is an assistant professor and attending pediatric cardiac surgeon at Columbia University Medical Center in New York, New York. In addition, Dr. Karamichalis is the associate program director of the Columbia Cardiothoracic Surgery Integrated Training Program. He has been an STS member since 2006.

STS News, Spring 2022 — Several important Bylaws changes were approved, and STS officers and directors were elected or reelected during the virtual Annual Membership (Business) Meeting on Sunday, January 30. The meeting was held in conjunction with STS 2022, the Society’s 58th Annual Meeting. Two Bylaws changes were to the makeup of the Board of Directors. The Society’s membership voted to remove the Editor of The Annals of Thoracic Surgery from the Board. In addition, the number of International Directors was increased from two to three. This change will allow for greater diversity and a wider variety of perspectives on the Board. Leading the Board and the Society for 2022-2023 is John H. Calhoon, MD, from San Antonio, Texas, who was elected STS President. Thomas E. MacGillivray, MD, from Houston, Texas, was elected First Vice President, and Jennifer C. Romano, MD, MS, from Ann Arbor, Michigan, was elected Second Vice President. The following also were elected or reelected: Secretary Wilson Y. Szeto, MD, Philadelphia, Pennsylvania Treasurer Vinod H. Thourani, MD, Atlanta, Georgia International Directors Alessandro Brunelli, MD, Leeds, United Kingdom Alan D.L. Sihoe, MBBChir, MA(Cantab), FRCSEd(CTh), Hong Kong Directors-at-Large Leah M. Backhus, MD, MPH, Stanford, California Anthony L. Estrera, MD, Houston, Texas Ara A. Vaporciyan, MD, Houston, Texas John D. Mitchell, MD, Aurora, Colorado Historian Keith S. Naunheim, MD, St. Louis, Missouri Changes to the Society's governance structure also were approved at other recent meetings. Several workforces were assigned to different councils to better align the emphases and missions of the affected groups, and some workforce names were changed. In addition, to help with the development of future STS leaders, vice chairs were appointed for most workforces and two of the council operating boards.  Learn more about the Society’s governance structure at sts.org/governance.

STS News, Spring 2022 — With a current pipeline showing steady gains of female trainees, the cardiothoracic surgery workforce may be on the verge of changing. This is according to research that examined data from the active membership directories of four cardiothoracic surgery societies: STS, the American Association for Thoracic Surgery (AATS), the European Association for Cardio-Thoracic Surgery (EACTS), and the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS). The comprehensive analysis—which offered a snapshot of the global cardiothoracic surgery workforce—was presented during the Society’s Annual Meeting in January. “What is unique about this work is the breadth of our capture,” said study author Barbara C.S. Hamilton, MD, MAS, from the University of California San Francisco (UCSF). “Understanding our global workforce is challenging, and survey data are inherently biased. Our data acquisition was novel, with our research using membership data that did not require any additional input from members. We attempted to obtain a more global and less biased representation of our workforce.” Dr. Hamilton and colleagues queried the organizations’ membership directories. A total of 12,053 profiles were included in the study. The researchers found that the membership is overwhelmingly male (93%). As far as female members, EACTS has the highest proportion (9%), and ASCVTS has the lowest (3%). STS membership is 6% female. The Shift Although the current workforce still is predominantly male, more female representation awaits in the trainee population, according to Dr. Hamilton. The researchers found that 25% of EACTS trainees were female (trainee data were not available for STS, AATS, or ASCVTS). In addition, data from the Association of American Medical Colleges (AAMC) show that the proportion of female cardiothoracic surgery trainees has grown—from 15% in 2007, to 19% in 2011, and 26% in 2020. “Thankfully there seems to be a larger proportion of female trainees in cardiothoracic surgery than the proportion of practicing female surgeons, which gives hope that we are beginning to change and progress,” said Dr. Hamilton. Importantly, the representation of women in the active cardiothoracic surgery workforce also has consistently increased, from 4% in 2007 to 8% in 2020, according to AAMC data. However, cardiothoracic surgery remains one of the most unevenly gender-distributed specialties. “We have come a long way since the original STS membership survey in 1976, when a question on sex was not even included,” the researchers stated in the study article. ‘Long Way to Go with Diversity’ One of the first women to pursue a career in cardiothoracic surgery was Nina Starr Braunwald, MD. Dr. Braunwald achieved many other female firsts as well: She was the first woman to perform open heart surgery; the first woman to be certified by the American Board of Thoracic Surgery; and the first woman to be elected to AATS. But more than 60 years after she entered the specialty, men still dominate the world of cardiothoracic surgery. This is despite the fact that women now outnumber men in US medical school enrollment—in 2019, for the first time, the majority of medical students were women (50.5%), according to the AAMC. “We are in danger of being unable to evolve and grow as a specialty if we do not aggressively support and promote young and female surgeons,” Dr. Hamilton said. “We must work harder to not just attract but also retain, support, and increase the visibility of female and other underrepresented trainees and surgeons for our specialty to find longevity and sustainability.” Among the four organizations—STS, AATS, EACTS, and ASCVTS—there are 788 female members. Interestingly, within this group, most practice academic medicine (60%), but only 5% are full professors. “With such a dearth of female representation in the upper echelons of cardiothoracic surgery academia, it can be hard for young and especially female trainees to believe this is a specialty in which they can achieve success,” said Dr. Hamilton. In addition, Dr. Hamilton explained that cardiothoracic surgery has a “long way to go with diversity, both in terms of age and sex.” Her team’s research showed that the median age within the specialty is 63 years, and 64% of members are in the later stages of their careers. “We are very unbalanced in terms of who makes up our surgical practice, and we are overwhelmingly male and old,” said Dr. Hamilton. “We work in a fantastic field that medical students, both male and female, find exciting and unique, but we lose many of these candidates, especially women, along the way.” Why? Other research has shown that the perceived barriers for female trainees considering a career in cardiothoracic surgery include implicit and explicit bias, lifestyle factors, and lack of mentorship and role models. A study from Maria S. Altieri, MD, MS, et al. determined that cardiothoracic surgery was perceived as the least receptive specialty for women. Further, 57% of cardiothoracic surgeon respondents would advise only men to pursue a career in the specialty. Cardiothoracic surgery holds a serious responsibility to change this narrative and create action on both individual and leadership levels, and additional research focusing on the disparities in cardiothoracic surgery is a must, Dr. Hamilton emphasized. “We have made small strides in some areas, but plentiful opportunities exist for continued growth and development. It is crucial that we wake up to these issues,” she said. Coauthor Tom C. Nguyen, MD, from UCSF, added, “This is the first and largest global snapshot of our cardiothoracic surgery workforce. Understanding who we are is incredibly important as we shape the future of where we are going.”