Adult Cardiac

On day two of the 62nd Annual Meeting in New Orleans, co-lead authors Subhasis Chatterjee, MD, of Baylor College of Medicine, and Stefano Schena, MD, PhD, of the Medical College of Wisconsin, presented a summary of The Society of Thoracic Surgeons’ (STS) 2026 Clinical Practice Guidelines for the Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation after Cardiac Surgery. Their presentation highlighted a comprehensive, surgery-specific framework designed to address new-onset postoperative atrial fibrillation (POAF), the most common complication following cardiac surgery.

To develop the guidelines, the STS Workforce on Evidence-Based Surgery convened a multidisciplinary panel to review contemporary evidence and generate practical, consensus-based recommendations focused specifically on POAF after cardiac surgery. Using a phase-based approach that spans the preoperative, intraoperative, and postoperative periods, the group synthesized data from randomized and observational studies and graded recommendations using standardized methods based on AATS/EACTS/ESTS/STS harmonization guidelines¹.

The final document includes a total of 15 recommendations: eight on preventive strategies, three on intraoperative adjunctive procedures, and four on postoperative management. Key guidance includes two Class I recommendations addressing perioperative oral amiodarone and rhythm cardioversion for hemodynamically unstable POAF. Two Class IIa recommendations supporting posterior pericardiotomy and perioperative beta-blockers. Eight Class IIb recommendations reflected areas of uncertainty and limited data. Three Class III recommendations addressed therapies without demonstrated benefit.

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A central theme of the guidelines is transparency around uncertainty and an emphasis on meaningful patient outcomes. “One of the goals of these guidelines was not to promote a single dominant therapy,” said Dr. Chatterjee, “but to provide a structured, phase-based approach that can reduce unwarranted practice variation while still allowing clinical judgment.” He emphasized that POAF should be viewed as a marker of perioperative vulnerability rather than an isolated rhythm disturbance, identifying 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 document also underscores 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, while acknowledging persistent uncertainty around optimal anticoagulation timing and duration, arrhythmia burden, and the role of adjunctive surgical interventions.

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Dr. Schena highlighted how the guideline development process itself reshaped the panel’s collective thinking. “When we started this project, all nine members had their own way to address atrial fibrillation occurring de novo after cardiac surgery,” he said. “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 noted that while no single strategy eliminates POAF, its clinical impact can be significantly reduced through a combination of measures applied across the preoperative, intraoperative, and postoperative phases of care. He also emphasized 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, the guidelines provide a pragmatic framework that clinicians can operationalize across the surgical continuum. By emphasizing evidence-based practices, openly acknowledging uncertainty, and discouraging ineffective interventions, the document aims to support thoughtful clinical decision-making and improve outcomes for patients undergoing cardiac surgery.

1: Milojevic, M., Freemantle, N., Hayanga, J. A., Kelly, R. F., Myers, P. O., Petersen, R. H., ... & Bakaeen, F. G. (2025). Harmonizing guidelines and other clinical practice documents: A joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS). The Journal of thoracic and cardiovascular surgery, 169(1), 170-185.

As the population undergoing mitral valve surgery continues to age, the choice between repair and replacement has taken on new urgency. At the "Masters of the Mitral Valve" session on Thursday, Jan. 29 at 10:10 a.m., Dr. Allen Razavi of Cedars-Sinai Medical Center will address this issue in the Is Degenerative Mitral Valve Repair Superior to Replacement in Patients Aged >65 Years? presentation.

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Drawing from a large national cohort within the Society of Thoracic Surgeons Adult Cardiac Surgery Database linked with Medicare data, Dr. Razavi and his team compared long-term outcomes for patients aged 65 and older who underwent mitral valve repair with those who received mitral valve replacement. Their objective was to evaluate differences in survival, major complications, and the need for future mitral valve interventions across treatment strategies.

The study found that mitral repair was associated with significantly improved long-term survival compared with replacement, with benefits persisting across much of the older age spectrum. Patients who underwent repair also experienced lower rates of heart failure readmission, stroke, and major bleeding. While overall reintervention rates were similar between groups, repair patients tended to require earlier surgical reintervention, whereas replacement patients were more likely to undergo late transcatheter procedures.

Dr. Razavi will present findings showing how evolving treatment options and advances in repair techniques prompted the team to reassess outcomes in this population. The growth of transcatheter mitral therapies and improvements in surgical durability have heightened the need to revisit traditional assumptions about when repair should be favored over replacement.

The Richard E. Clark Memorial Paper on day one of STS 2026, Optimal Management for Moderate Aortic Stenosis at the Time of Coronary Artery Bypass Grafting, will be featured during the “Optimizing AVR: Aiming for Perfection” session on Thursday, Jan. 29, at 11:00 a.m. In this presentation, Pey-Jen Yu, MD, of Northwell Health, will explore how best to manage moderate aortic stenosis (AS) in patients undergoing coronary artery bypass grafting (CABG), a question that has grown increasingly important as transcatheter approaches continue to reshape treatment pathways.

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Drawing from a large cohort in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD), linked with national inpatient records, Dr. Yu and colleagues compared outcomes for patients who had isolated CABG versus those who received CABG combined with aortic valve replacement (AVR). The goal was to understand both the immediate risks and the longer-term implications of addressing—or deferring—valve intervention in patients with moderate AS.

The study found that patients undergoing CABG alone experienced slightly lower operative risk, but they were more likely to require later aortic valve intervention and were at increased risk for readmission related to heart failure. Meanwhile, those who underwent concomitant AVR faced a higher initial risk but significantly lower likelihood of needing future valve procedures. Importantly, mid-term survival was similar between the two groups.

In her presentation, Dr. Yu will highlight how the rapid expansion of transcatheter valve therapies served as a key motivation for this work, prompting the team to revisit longstanding assumptions about when to intervene on a moderately stenotic valve during open-heart surgery.
 

New findings slated for presentation at the 2026 Society of Thoracic Surgeons (STS) Annual Meeting suggests that aortic hemiarch reconstruction provides outcomes comparable to more complex extended arch reconstruction in patients over age 65 with acute type A aortic dissection (ATAAD). John Spratt, MD, clinical assistant professor of thoracic and cardiovascular surgery at University of Florida Health, will present Extended Arch Reconstruction for Acute Type A Dissection Does Not Impact Long-Term Survival or Reoperation in Patients Over Age 65: An STS-CMS Longitudinal Analysis during Sunday’s 11:15 a.m. adult cardiac session, “Tips & Tricks to Get Through Any Dissection.”

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The study used a risk-adjusted analysis of patients from the STS Adult Cardiac Surgery Database, which includes millions of adult cardiac surgery records. Patients underwent surgery at U.S. hospitals over several years, with most receiving aortic hemiarch reconstruction and the remainder undergoing extended arch reconstruction. Researchers evaluated postoperative mortality, stroke, and the need for reintervention for aortic disease and found no significant differences in these outcomes among patients ages 65 and older.

Extended arch reconstruction is a more complex operation that includes replacement of the aortic valve and repair of the ascending aorta, aortic arch, and the major arteries branching from the arch. Hemiarch reconstruction, by comparison, involves replacement of the aortic valve and repair of the ascending aorta and the underside of the aortic arch. Because aortic dissections most commonly affect older adults and require emergency surgery, surgeons must weigh the benefits of a more extensive repair against increased operative time, longer heart-lung bypass duration, and greater neurologic risk—factors that older patients often tolerate less well than younger individuals.  

“You have to balance what a patient may need on paper, compared with what their overall risk profile is,” says Dr. Spratt. “The majority of patients age 65 and older will be fine with hemiarch reconstruction and have the same outcomes as they would with a higher-risk procedure.”