STS 2023 Daily Bulletin: January 21, 2023

Tomorrow at STS 2023: A study of more than 100,000 patients reveals that, for patients with blockages in multiple arteries, those who opt for coronary artery bypass grafting (CABG) are less likely to die from their condition, less likely to need additional surgery, and less likely to have a heart attack than patients who choose to undergo a stent procedure. “The findings of our study were very convincing,” said J. Hunter Mehaffey MD, MSc, from the Department of Cardiovascular and Thoracic Surgery at West Virginia University. “The singular message to the public is that the optimal treatment for multivessel coronary artery disease—to improve not only long-term survival but also lower your risk of complications—is coronary artery bypass surgery.” The results from the study, “Contemporary Artery Bypass Grafting versus Multivessel Percutaneous Coronary Intervention in 100,000 Matched Medicare Beneficiaries,” will be presented at 9:05 a.m. PT on Sunday, January 22, during STS 2023. The background and rationale for this research project started with the publication of the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization, Dr. Mehaffey explained. “The cardiac surgery world was really shocked, because the guidelines downgraded the indications for CABG from a class 1 recommendation to a class 2B.” “Much of this decision to downgrade was based on the guideline committee’s goals to focus on the most recent data, to ensure that they were capturing contemporary stent technology, so they only evaluated studies published within the past 5 years,” continued Dr. Mehaffey. “Therefore, these guidelines relied heavily on the recently publicized ISCHEMIA trial, which looked at medical therapy in coronary artery disease, comparing an initial invasive approach versus a conservative approach to patients who had stable coronary artery disease.” The problem that arises when using ISCHEMIA to compare CABG to stenting is that the majority of patients in the ISCHEMIA trial were not representative of patients undergoing CABG in the US. Therefore, the study didn’t fully represent the comparative benefits for patients who had multiple blockages in their coronary arteries.   Dr. Mehaffey’s team sought to conduct a large contemporary analysis that more fully represented this population, comparing patients undergoing bypass surgery with those undergoing stenting. They, too, wanted to ensure that the study included only the most contemporary technology, so their longitudinal analysis captured outcomes over a 3-year period, 2018 to 2020. “We used one of the largest and most inclusive databases of patients hospitalized in the US, including all patients over the age of 65 on Medicare,” Dr. Mehaffey explained. “We performed a very robust statistical analysis including propensity score balancing to help ensure that the groups of patients who underwent stenting versus those who underwent bypass surgery were well matched and well balanced in order to compare their outcomes.” The population included more than 100,000 patients with multivessel coronary disease, with 51,000 patients undergoing CABG and 52,000 undergoing stenting. Analysis was performed by a multidisciplinary team that included cardiac surgeons, cardiologists, and researchers at West Virginia University. The analysis demonstrated a significantly lower hospital mortality for the patients who underwent CABG compared to those who underwent stenting. Additionally, the researchers found a marked reduction in both 30-day and 3-year readmissions for myocardial infarction. CABG patients were also significantly less likely to need any additional stenting or intervention on their coronary arteries during those 3 years, and—most significantly—those who underwent CABG had a nearly 60% reduction in death at 3 years compared to those who had stenting. “Regardless of your specialty, these data demonstrate the importance of assessing longitudinal outcomes to help ensure we’re making optimal treatment recommendations for our patients,” Dr. Mehaffey said. MORE ON THIS TOPIC AT STS 2023 To fully understand the implications of the latest science--which demonstrates that CABG is superior to stenting in multivessel coronary artery disease, don't miss: C. Walton Lillehei Lecture by Peter K. Smith: "Treatment Selection for Coronary Artery Disease: The Collision of a Belief System with Evidence" Monday, 9:00 a.m. PT "The ISCHEMIA Study Does Not Reflect Patients Undergoing Coronary Surgery: An STS Adult Cardiac Surgery Database Analysis" by Joseph F. Sabik III, MD Monday, 11:30 a.m. PT

STS 2023 Day 1 — General thoracic surgeons should not miss this presentation that challenges lobectomy as the gold standard treatment for patients with smaller lung tumors. Surgical segmentectomy, as opposed to lobectomy, should be considered for patients whose lung cancer has been downstaged following neoadjuvant chemoimmunotherapy, STS 2023 presenters say. On Saturday, January 21 at 9:45 a.m. PT, Charles Logan, MD, from Northwestern University Feinberg School of Medicine in Chicago, will present “Pathologic Downstaging Following Neoadjuvant Chemoimmunotherapy for Locally Advanced Lung Cancer is Associated with Survival Comparable to Early Stage-Matched Disease.” The study is part of the STS 2023 session “Is the Hype Real? Targeted and Immunotherapy in Resectable Non-Small Cell Lung Cancer.” Recent randomized clinical trials suggest that a lung resection accomplished by segmentectomy may be the best approach for treating small tumors in early-stage, non-small cell lung cancer (NSCLC). This study takes the investigation further by suggesting that patients with stage IIIA cN2 lung cancer downstaged after neoadjuvant chemoimmunotherapy and lobectomy have similar survival to patients with small tumors who undergo segmentectomy. Those who receive segmentectomy may benefit from improved quality of life and greater ability to tolerate toxic adjuvant suppressive immunotherapies—compared to patients with small tumors who undergo lobectomy. “We hope to spark a discussion among those who care for lung cancer patients whether patients whose malignancies have been downstaged after neoadjuvant therapy should be candidates for segmentectomy. We think the available data point toward ‘yes,’ but a randomized clinical trial may be needed to answer this definitively,” Dr. Logan says. Segmentectomy potentially offers other advantages over lobectomy for these patients because a smaller resection minimizes the amount of functional lung tissue removed. Research into targeted therapies for NSCLC has also escalated, offering the possibility that more patients will be downstaged after neoadjuvant treatment and may not need to have an entire lobe removed. Dr. Logan is a postdoctoral research fellow and surgery resident at Northwestern, and senior study co-authors Samuel Kim, MD, Ankit Bharat, MD, and David Odell, MD, MMSc, are also from Northwestern.

Tomorrow morning at STS 2023, surgeons will introduce the first-ever STS risk model that will help adults living with congenital heart disease better understand their risk of dying from a cardiac operation. “Patients who have repaired congenital conditions often need ongoing care throughout their lifetime,” said presenter Jennifer S. Nelson, MD, MS, from Nemours Children’s Health in Orlando, Florida. “Sometimes this care is for the congenital condition, but they can also develop acquired heart disease problems later in life, just like anyone else.” These patients may have different factors contributing to their mortality risk than the general adult cardiac patient population. But until now, the extent of risk from those factors hasn’t been comprehensively evaluated. While the STS Congenital Heart Surgery Database contains a trove of information about congenital surgery outcomes—and the STS Adult Cardiac Surgery Database captures nearly every adult heart surgery in the US—the former doesn’t capture adult risk factors such as hypertension and liver disease, and the latter doesn’t provide the fine details of congenital surgeries. So the extent to which risks overlap as a child “graduates” from a congenital registry to an adult registry has been difficult to mine. “With this project, we’ve been able to incorporate additional relevant preoperative risk factors with the types of procedures patients are having, to evaluate what seems to influence their risk for operative mortality,” Dr. Nelson said. To form the adult congenital heart disease (ACHD) model, Dr. Nelson’s team added 47 new variables, for procedures and diagnoses, to existing STS adult risk model variables. They were able to calibrate the model within demographic, procedural, and diagnosis subgroups, achieving excellent discrimination for operative mortality. The team also sought to make future data curation as easy for Database participants as possible, introducing a new adult congenital data collection module that will create an automatic destination in the congenital database for any patient aged 18 or older.   “Moving forward, we will be obtaining much more relevant information pertaining to adults with congenital heart disease,” said Dr. Nelson. “We’ll get the best of both worlds—details of congenital heart conditions and prior operations, and we’ll be able to understand more about hemodynamics and the impact of traditional cardiovascular risk factors on cardiac surgery outcomes for adults.” “It is not going to be a simple task to introduce a new data collection module,” Dr. Nelson continued. “But it’s really worth the investment of time and energy and we owe it to our patients. We’ve done a great job taking care of infants and children with congenital heart disease, we’ve helped them grow up. Now that they’re adults, they deserve the best ongoing care from us.”

STS 2023 Day 1 — Avoiding unnecessary perioperative opioids remains imperative, and today’s “Contemporary Operative Pain Management” session is essential for surgeons to glean the latest opioid-sparing approaches to pain management. The session will be presented on Saturday, January 21, at 11 a.m. PT and is moderated by Daniel Engelman, MD, from Baystate Medical Center, professor of surgery at the University of Massachusetts Chan Medical School in Springfield, Massachusetts, and Alison Ward, MD, from Emory Healthcare, assistant professor of surgery at Emory University School of Medicine in Atlanta, Georgia. “This session will be a truly multidisciplinary session drawing from the expertise of surgeons, anesthesiologists, and physiotherapists to discuss optimizing post-operative pain management,” Dr. Ward says. Acute, post-operative pain from heart surgery is inevitable and can result from a variety of causes. However, there is a growing concern regarding the incidence of new, persistent opioid use following cardiac surgery, which research has shown may still happen in up to 15 % of patients. The session will showcase alternative approaches to opioid-based analgesia for pain control that also facilitates patient mobility. These include multimodal analgesia involving more than one class of medication to target different receptors along the pain pathway. In addition, the rapidly expanding options in regional anesthesia for cardiothoracic surgery, such as nerve blocks, will be discussed for integration into the overall pain management plan. The Contemporary Operative Pain Management session includes six presentations:          New Persistent Opioid Use After Cardiac Surgery          Sternotomy Without Mobility Restrictions          Does Surgical Approach Impact Postoperative Pain?          Cardiac Surgery Without Opioids          Non-Pharmaceutical Approaches to Pain Management         Panel Presentation with Open Audience Discussion Dr. Engelman is President of the Enhanced Recovery After Surgery Cardiac Society and Senior Perioperative Editor of The Annals of Thoracic Surgery. He says he especially looks forward to the open exchange of ideas during the panel portion of the session. STS 2023 attendees will bring novel approaches to pain management back to their institutions, broadening their pain control strategies and employing new techniques that can decrease or even end the root causes of their patients’ pain and symptoms, as well as reduce length of hospital stay. 

In today’s Vivien T. Thomas Symposium at STS 2023, attendees will hear how they can help to mitigate disparities in care for patients undergoing congenital surgery—and how these steps can make a difference in care throughout patients’ lifetimes. “Clearly, health equity is one of the most important drivers of outcomes across a lifetime,” said Tara Karamlou, MD, MSc, who will present during today’s Vivien Thomas Symposium. “If you’re 80 and part of an underserved population, living below the poverty line, you’ve lived your life to that point. For a child in that situation, we as healthcare providers have a responsibility to address inequities in care, and to understand that some populations are uniquely at risk.” An important step in addressing patient care disparities lies in tackling provider disparities, Dr. Karamlou points out. “We know from extensive literature that if women take care of women, if African Americans take care of African Americans, the outcomes are better. If a provider is culturally competent, they can relate to those patients such that they come back for their visits, they stay in touch with their health care team.” Dr. Karamlou noted the importance of recognizing social determinants of health as new tools—such as the new STS adult congenital surgery risk model, which will be unveiled this morning at STS 2023—are implemented in the clinical setting. “Going forward, in addition to capturing mortality, factors such as quality of life and other patient-reported outcomes will need to be folded into the risk model,” she said. Whether attendees are adult cardiac surgeons, congenital cardiac surgeons, or thoracic surgeons, it’s critical to understand that adult congenital surgery is one of the most rapidly growing fields in the specialty, and that patients who have congenital conditions have unique risk factors. “Those patients circumscribe the entire cardiothoracic care spectrum,” Dr. Karamlou said. “An adult congenital patient is still an adult congenital patient, whether they’re undergoing CABG, a pulmonary valve repair, a diaphragm plication, or a lung transplant, you need to adequately capture and adjust for the risk of your patients.” “Whatever specialty you’re in, more accurately doing that among this growing population is going to pay dividends not just for you as a surgeon, but also for your program,” Dr. Karamlou added, “so that you can adequately get credit for the complexity of your operation.” “Social Determinants of Health: Mitigating health disparities across a patient’s lifespan in congenital cardiac surgery” will be presented today as part of the Vivien Thomas Symposium, beginning at 2:45 p.m. PT.  

STS 2023 DAY 1 — Watch surgeons and intensivists square off about who’s in charge in the ICU as STS hosts a friendly debate bringing two top specialists together to help attendees develop the best care models for their institutions.  On Saturday, January 21 at 9:45 a.m. PT, a multidisciplinary panel will present the CT Ethics Forum, “For the Post-operative Patient in the ICU, Who Is in Charge and Who Is the Consultant? Surgeon or Intensivist?” As reimbursement changed for surgeons outside the OR, and as surgeons’ time for ICU care became unpredictable, intensivists began to enter the post-operative ICU arena. Andrea J. Carpenter MD, PhD, a cardiothoracic surgeon and Assistant Dean for Health System Science at University of Texas Health Science Center in San Antonio, will advocate for surgeon-directed management. Martin Zammert, MD, a surgical critical care physician who heads the cardiothoracic unit at Lahey Hospital & Medical Center in Burlington, Massachusetts, will make the case for intensivist-directed management. Both physicians will seize their best chance to persuade attendees about the merits of their specialty informing decision-making in a critical care setting. From their perspectives, a spectrum of opportunities will emerge for attendees to create the best care model at their institutions within available resources. “The bottom line is that the best model is a well-managed, protocol-driven team with clear lines of communication and shared responsibility. The caveats are challenging and involve deep respect and trust among the caregivers,” says debate moderator Joseph Zwischenberger, MD, a cardiothoracic surgeon at University of Kentucky HealthCare in Lexington. “Titles, egos, zealous trainees, and nursing bias can foil the best laid plans.” Dr. Zwischenberger adds that this ideal state is a delicate balance, reached by well-trained intensivists, surgeons and nurses, robust protocols, and buy-in from all concerned.