Clinical Decision-Making

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. 

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.

     

STS News, Fall 2022 — With nearly as many women as men presenting with signs of ischemia in today’s health care settings, clinicians should keep in mind that coronary artery disease (CAD) goes beyond vessel obstruction, especially in female patients—and should take advantage of tools like advanced imaging to see past anatomic walls. “More and more, I think we're recognizing that, when they’re designed for the identification of primarily obstructive CAD, conventional approaches can lead to repeated testing, especially in women,” said Viviany R. Taqueti, MD, MPH, from Brigham and Women’s Hospital in Boston, Massachusetts. “And yet, often without differentiating who’s truly at risk.” Obstructive CAD is just one phenotype of ischemic heart disease, and perhaps just the tip of the iceberg when physicians take into consideration the entirety of coronary circulation, Dr. Taqueti said. A physician needs to spot other pathologies such as diffuse non-obstructive CAD and coronary microvascular dysfunction, which can certainly impact patients’ cardiovascular outcomes, she explained. As an example, Dr. Taqueti referred to a study in Denmark that presented observational data from a large registry of more than 11,000 patients who were referred for coronary angiography. The investigators found that up to a 32% of the male patients—and a startling 65% of female patients—had no significant obstructive disease to explain their symptoms. “We need a more sophisticated toolbox that looks beyond regional wall motion abnormality or even regional perfusion abnormalities to consider and quantify absolute blood flow in the heart and quantify coronary flow reserve, or CFR,” said Dr. Taqueti. Coronary microcirculation is of course too small to be directly imaged in vivo, and it needs to be evaluated indirectly by perturbing function. A variety of technologies make this possible. Coronary microvasculature, especially in female patients, represents the future of prognosis after procedures like CABG, say experts. "Conventional approaches can lead to repeated testing, especially in women. And yet, often without differentiating who’s truly at risk.” Viviany R. Taqueti, MD, MPH In the invasive realm, historically, catheter-guided wire-based testing has provided measurements of CFR and microcirculatory resistance. But noninvasive methods, including cardiac magnetic resonance, Doppler ultrasound, and—the current gold standard—positron emission tomography, are revealing just how prevalent coronary microvascular dysfunction is in patients with angina or signs of ischemia. Data from more angiography studies demonstrated that just under half of the patients had no obstructive disease. “And these were evaluated quite objectively, using fractional flow reserve normal values above 0.8,” Dr. Taqueti explained. But from that group, a large majority—76% to 89%—had some evidence of objective coronary vasomotor dysfunction on testing. “The vast majority of these had coronary microvascular dysfunction, with a minority having pure vasospasm,” said Dr. Taqueti. “This is important because we know that impaired flow reserves—that can certainly be manifestations of coronary microvascular disease—are associated with worse outcomes in terms of cardiac mortality in our patients.” More revelations come with observational data that span multiple research centers: Even in patients with no obvious obstructive lesions or inducible ischemia on stress testing, impaired CFR is independently associated with major adverse events.  In those with significant obstructive CAD, CFR also modifies the outcome of coronary revascularization procedures, especially coronary artery bypass grafting (CABG), Dr. Taqueti pointed out. With long-term cardiovascular outcomes, patients with a severely reduced CFR who underwent CABG did as well as those with a preserved CFR to begin with (adjusted p for interaction = 0.03), suggesting that impaired CFR may serve as a marker for CABG benefit akin to diabetes or SYNTAX score, said Dr. Taqueti.     When severely impaired, coronary flow reserve is even more prognostically significant in women—and may be as useful of a marker for CABG benefit as diabetes or SYNTAX score. In women, severely impaired CFR appears to be even more prognostically significant. “You can see the divergence of the hazard for men and women with a significant interaction for sex as CFR values fall substantially below 2,” Dr. Taqueti explained. “Women appear to fare even worse at the very low range of CFR despite the fact that, when you look at anatomic findings, they are much less likely to have multivessel obstructive disease. In contrast, men were much more likely to have impaired CFR in the presence of multivessel disease—perhaps explaining their impaired flow reserves.” Dr. Taqueti encouraged physicians to consider how these factors reframe their approach to understanding CAD, and to emphasize appropriate diagnostic testing to identify risk, which can help to curb repeated conventional testing in patients at low risk. These recommendations were presented as part of the STS Coronary Conference this summer, in a session devoted to noninvasive diagnostic techniques for evaluation of high-risk ischemic heart disease. The conference united faculty and attendees from 18 countries with a multidisciplinary approach. Course director Marc Ruel, MD, MPH, who serves as STS Canadian Director, touted the camaraderie displayed by participants of all backgrounds. “Surgeons have to be the top experts at understanding the very reason why they operate—or not—on a patient,” Dr. Ruel said. “It comes down to much more than ‘I can do this,’; rather, it should be ‘It is a good idea to be doing this for the patient, and I have the skills to do it.’ The Coronary Conference aimed to achieve this: Expert knowledge and skills in the huge, knowledge-intensive area of coronary surgery.” Strong surgeons need strong cardiologists, anesthesiologists, radiologists, and other experts, Dr. Ruel said. “This is why we made the Coronary Conference so multidisciplinary and team-based, with a focus both on advanced practical knowledge and on advanced technical skills.” “We need to understand microvascular disease in order to better treat ischemia in both women and men,” Dr. Taqueti added. “Coronary microvasculature represents an exciting new frontier in cardiovascular disease reduction, and the future is pointing toward a role for coronary microcirculation in macrovessel disease prognosis. That’s something we need to think about in all our practices.”