Adult Cardiac

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.

Surgeons and multidisciplinary teams from across the country gathered May 14–15 in Norcross, Georgia, for the 2026 STS Workshop on Robotic Cardiac Surgery. This intensive, two-day program combined expert lectures, case discussions, and immersive simulation to help teams launch or advance their robotic cardiac surgery programs.

Designed for all experience levels, the course focused heavily on robotic mitral valve procedures and coronary revascularization.

High-Fidelity Simulation Builds Team Confidence

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Participants spent significant time in a state-of-the-art simulation facility, gaining hands-on experience with surgical robotic platforms. Lab sessions covered critical techniques including:

• Robotic mitral valve repair and replacement
• Total endoscopic coronary artery bypass (TECAB)
• Hybrid coronary revascularization

Under expert faculty guidance, attendees practiced port placement, myocardial protection, and intraoperative troubleshooting. The environment allowed surgeons, bedside assistants, and OR staff to refine their real-time coordination.

“STS has been committed to robotic cardiac surgery for the last several years, which has been instrumental as we continue to advance the robotic cardiac surgery subspecialty through both this workshop and its integration into the Annual Meeting,” said course co-director Arnar Geirsson, MD, of NewYork-Presbyterian/Columbia University Irving Medical Center.

A Comprehensive Valve and Coronary Curriculum

Structured didactic sessions reviewed the latest evidence, patient selection criteria, and operative strategies. Faculty experts covered:

• Mitral & Tricuspid Pathways: Resection-based repair, complex pathologies (endocarditis, annular calcification), and concomitant Maze procedures
• Coronary & Aortic Pathways: LITA/BITA harvesting, robotic MIDCAB, and aortic valve replacement
• Advanced Techniques: Multivalve procedures, combined valve/CABG cases, and managing complications

Focus on Program Infrastructure

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Beyond technical mastery, the workshop emphasized the business and logistics of robotics. Sessions explored how to optimize OR setup, streamline interdisciplinary communication, and secure institutional support to build a sustainable service line.

“During this year’s workshop, the focus on teams helped bring together the interests of the faculty and allied health professionals, including surgical assistants and scrub teams, so they could learn together and build teams that advance their practice,” said course co-director Arman Arghami, MD, of Mayo Clinic.

Through its powerful mix of high-tech simulation and collaborative learning, the STS Workshop remains a premier launchpad for the future of minimally invasive cardiac surgery.

Postoperative atrial fibrillation (POAF) remains the most common complication following cardiac surgery—and a persistent challenge for clinicians seeking consistent, evidence-based management. In response, the Society of Thoracic Surgeons (STS) has released new clinical practice guidelines, now published in The Annals of Thoracic Surgery, outlining a comprehensive, surgery-specific framework for the prevention and treatment of POAF.

A Multidisciplinary, Evidence-Driven Effort

Co-led by Subhasis Chatterjee, MD, of Baylor College of Medicine, and Stefano Schena, MD, PhD, of Medical College of Wisconsin, the STS 2026 Clinical Practice Guidelines for the Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation after Cardiac Surgery were developed through a multidisciplinary effort by the STS Workforce on Evidence-Based Surgery. The group evaluated contemporary evidence to generate practical, consensus-based recommendations focused specifically on the prevention and treatment of POAF after cardiac surgery.

A Phase-Based Framework Across the Surgical Continuum

The document establishes a phase-based framework spanning the preoperative, intraoperative, and postoperative periods. Drawing from randomized and observational studies, the panel graded recommendations using standardized methods aligned with American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and STS harmonization guidelines.

A central theme of the guidelines is transparency around uncertainty and a focus on meaningful patient outcomes. “One of the goals of these guidelines was not to promote a single dominant therapy, but to provide a structured, phase-based approach that can reduce unwarranted practice variation while still allowing clinical judgment,” said Dr. Chatterjee. He emphasized that POAF should be viewed as a marker of perioperative vulnerability rather than an isolated rhythm disturbance, helping to identify patients at higher risk for complications and future atrial arrhythmias. This perspective supports targeted surveillance and follow-up rather than reflexive escalation of therapy.

The guidelines also underscore that POAF is distinct from preexisting atrial fibrillation, with different mechanisms, natural history, and management implications. Core strategies include careful rhythm monitoring, early rate or rhythm control, and individualized anticoagulation decisions. At the same time, the document acknowledges ongoing uncertainty regarding optimal anticoagulation timing and duration, arrhythmia burden, and the role of adjunctive surgical interventions.

Addressing Uncertainty and Variability in Practice

Dr. Schena noted that the guideline development process highlighted the variability in clinical practice and the limitations of available evidence. “The time spent discussing and reviewing helped us recalibrate our stance and recognize how limited the evidence truly is for many commonly used interventions,” he said. While no single strategy eliminates POAF, he emphasized that its clinical impact can be reduced through a combination of measures applied across all phases of care. He also noted that the long-term implications of POAF in patients without prior atrial fibrillation remain uncertain and must be weighed against individual patient risk factors.

Together, these guidelines provide a pragmatic framework that clinicians can apply across the surgical continuum. By emphasizing evidence-based practices, acknowledging uncertainty, and discouraging ineffective interventions, the document aims to support informed clinical decision-making and improve outcomes for patients undergoing cardiac surgery.

Read the Annals article.