Database

A packed house at an STS 2023 scientific session yesterday illustrated the robustness and relevance of the STS National Database™ for gleaning real-time outcomes analysis. “Virtually all cardiac operations in the United States are captured by our database,” said Ram Kumar Subramanyan, MD, PhD, from the University of Southern California’s Keck School of Medicine, who presented a report on trends in the Congenital Heart Surgery Database (CHSD) component. In addition to notable trends from each component—adult cardiac, general thoracic, congenital, and Intermacs—presenters hosted a panel discussion with questions from the audience. Participants then heard the latest findings about the performance of frozen elephant trunk (FET) versus traditional limited repair in acute type I aortic dissection as well as in postcardiotomy shock and 30-day outcomes among patients with severe left ventricular systolic dysfunction. Kyle Miletic, MD, from Henry Ford Hospital in Detroit, Michigan, unveiled findings that suggest that hemiarch plus FET was a safe operation that does not increase rates of mortality, stroke, paraplegia, or length of stay, though the investigators observed modest increases in circulatory arrest and bypass times. “While several smaller, single-center studies have shown the efficacy of the use of FET for DeBakey I aortic dissection, concerns of complications remain with this technique,” said Dr. Miletic. Therefore, his team aimed to analyze the outcomes of traditional hemiarch repair with and without FET. The STS Adult Cardiac Surgery Database was the research team’s source for a wealth of data, which they queried for all patients who underwent DeBakey I aortic repair between January 2017 and December 2020. They included all patients presenting with aortic dissection with extension distal to zone 1, excluding those who had previous aortic surgeries or total arch repairs. Patients were divided into two groups: Hemiarch and Hemiarch + FET. Dr. Miletic’s team used propensity scores to assemble a matched cohort in which those with and without FET would be balanced on key measured baseline characteristics. A multivariable logistic regression model with baseline characteristics that were different between groups was used to estimate propensity scores. Subsequent outcome analyses were based on the matched cohort. They found that there was no significant difference between the groups in 30-day mortality, stroke, paralysis, and ICU or total length of stay, and that there were fewer readmissions in the Hemiarch + FET group. Moderated by Karen Kim, MD, and Felix Fernandez, MD, MSc, the session, titled “The State of Cardiothoracic Surgery: Data and Practice Trends from the STS National Database,” also featured comments from STS President John H. Calhoon, MD, who said that it was energizing to have everyone in the room focused on improving safety and outcomes, thanking the council members, presenters, and STS staff who help to manage and curate the Database. “This is the future of STS,” Dr. Calhoon said, “and we’ve got to get this right.”

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.”

A scientific session devoted to identifying and closing gaps in health care will take place on Saturday at STS 2023. The session, beginning at 2:45 p.m. PT on January 21, will highlight evidence-proven programs that have not only identified disparities in health screening and treatment, but have successfully improved care for patients regardless of demographics, emphasized moderator Cherie P. Erkmen, MD, director of the lung screening and thoracic surgery residency programs for the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania. Dr. Erkmen said, “One of the things we struggle against in the realm of diversity, equity, and inclusion is that people are tired of just hearing, ‘There’s disparity, there’s inequity, there’s a problem.’ But then—what do we do? That’s part of the focus of this session—health equity in practice and people who have embraced it, successfully increasing their volumes and improving patient outcomes.” Assembled by Dr. Erkmen and Sara Pereira, MD, from the University of Utah Health, presentations within the Symposium include a report on gender outcomes in coronary bypass grafting, racial disparities in the inpatient management of ischemic heart disease, increasing health equity in the heart and lung transplant arenas, mitigating disparities across the lifetimes of patients who have undergone congenital cardiac surgery, and strategies to improve adherence to lung cancer screening guidelines in underserved communities, based on researchers’ experience in rural South Carolina. “Dr. Tara Karamlou has examined the entire continuum of congenital cardiac surgery, from diagnosis through adulthood, and has opened her doors to understand a very challenging population,” Dr. Erkmen explained. “Dr. Yoshiya Toyoda is a transplant surgeon at a very underserved, ‘safety net’ hospital, yet he’s the number one lung transplanter in the country for several years straight, accepting people across the whole socioeconomic spectrum.” “We have a thoracic surgeon, Dr. Ian Bostock, who’s looking at diversity in lung cancer screening—understanding where the disparities lie and lowering the barriers to screening so that they can get through the door and to the next step, which is lung cancer treatment,” Dr. Erkmen continued. “The last speaker, Dr. Martha McGilvray, has been awarded the podium for her research on racial disparities in the management of ischemic heart disease.” Stepping in as co-moderator is Clauden Louis, MD, MS, from Brigham and Women’s Hospital in Boston, Massachusetts. “I’m excited to be considered to represent such a name—the story of Vivien Thomas is incredibly important,” Dr. Louis said. “I think STS is taking a stand toward valuing our patients and valuing representation, understanding that outcomes are improved when the people taking care of you also have an understanding or a similarity, and are able to represent the population.” The session is named for Vivien T. Thomas, a Black laboratory supervisor who worked with famed physician Alfred Blalock, MD, at Vanderbilt University in the 1940s. When Johns Hopkins recruited Dr. Blalock, he refused to move unless Thomas accompanied him as a “package deal.” Thomas worked as part of Dr. Blalock's surgical team, helping develop the procedure used in the landmark 1944 "blue baby" operation. Despite his integral role in Dr. Blalock’s pioneering work, Thomas was hired and paid as a janitor and was not allowed to use the main entrance to Johns Hopkins. “He’s someone who could’ve been me,” Dr. Louis said. In addition to the Symposium, the third annual Vivien T. Thomas Lecture will take place at STS 2023. This year, the lecture is presented by Francisco G. Cigarroa, MD, and will mark the commencement of the annual meeting on Saturday morning at 8:00 a.m. “I’m excited about getting interest and participation from our thoracic surgery residents and our junior faculty,” Dr. Erkmen said. “And it's also important for people to know that there is an enduring workforce from the STS headed up by Dr. David Tom Cooke. Under his steady leadership, we've been able to accomplish many, many additions to the cardiothoracic surgery community, including workforce publications, looking at workforce disparity and health disparity, and also coordinating with other committees to make sure that diversity is always in mind as we legislate ourselves and create a program like the STS Annual Meeting.” On Monday at STS 2023, Dr. Erkmen also will present “The Cost of Being a Woman in Academic Surgery,” a session that analyzes rank and salary throughout women surgeons’ careers and demonstrates the additional hurdles they face. “We know that there is a difference in care when you are focused on the end goal—better access for everyone,” Dr. Louis said. “I’m excited to represent Dr. Vivien Thomas as a moderator for this session. And I’m excited to meet my colleagues in San Diego.” STS is still accepting registrations for the annual meeting, offering both an in-person experience and a virtual option, Plenary Livestream-Plus, which allows registrants to stream select meeting content and plenary sessions—including the Thomas Lecture—from anywhere in the world. STS 2023 is the premier forum for presenting new science, techniques, and technology in cardiothoracic surgery. Learn more at STS.org/AnnualMeeting.

A must-see session for pediatric surgeons will showcase the first study that analyzes multiple factors impacting survival of young patients with ventricular assist devices (VADs) over the last decade.  “Variables Affecting Survival in Pediatric Patients Supported with VADs: A Special Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report,” will be presented at 11:30 a.m. PT on Sunday, January 22, 2023, during the STS Annual Meeting. The presentation is part of the STS “Current Controversies in Congenital Transplantation and Mechanical Circulatory Support” session. Awais Ashfaq, MD, from Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, will report on findings. Although 10 leading children’s hospitals conducted the study, the analysis includes all 47 hospitals in the Pedimacs database of children and adolescents under age 19.  The group reviewed Pedimacs data back to the registry’s inception in 2012 through the end of December 2021, covering 1,109 patients, and identified that illness at time of VAD implantation, diagnosis, support strategy, and VAD device type all affected mortality. This study is the first step to create evidence-based guidance on VAD device choices and other decisions in care management. For instance, one finding indicates that infants and older pediatric patients with paracorporeal continuous device support, congenital heart disease, biventricular support, and Intermacs profile 1 (cardiogenic shock) had worse overall survival after six months. "For anyone in our field, and especially for those who have an interest in pediatric mechanical support, Pedimacs is invaluable,” Dr. Ashfaq says. “There is so much to learn from the data available in the database.” Pedimacs became part of The STS National Database™ in 2018 and is a joint effort among the National Heart, Lung, and Blood Institute, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and others. The North American clinic registry includes patients who receive an FDA-approved mechanical circulatory support device to treat advanced heart failure. Due to its exponential growth in terms of participation and stature, the STS National Database has become the gold standard for clinical outcomes registries among health care administrators, government officials, and payers. Dr. Ashfaq adds that the group will be taking their results and expanding them into a web-based tool to help physicians decide if patients will benefit from VADs and which device to choose.  

The trusted data in the STS National Database™ has been a cornerstone for scientific research and quality improvement for more than three decades—and recently its General Thoracic (GTSD) and Congenital Heart (CHSD) surgery databases made major leaps toward demonstrating their importance across the United States.  GTSD Participants Can Earn Credit for Transparency US News & World Report recently announced its decision to create a new Public Transparency measure to be used in its Best Hospitals rankings in Pulmonology & Lung Surgery. The measure will be based on whether a hospital elects to publicly report its lobectomy outcomes on the GTSD public reporting website as of February 12, 2023.   “This is a boon for high-performing hospitals who participate in the GTSD,” said Vinay Badhwar, MD, chair of the STS Council on Quality, Research, and Patient Safety. “Those who already are publicly reporting their outcomes to the Database now have the option to earn Transparency best rankings, and GTSD participants who were not publicly reporting were given the means to opt in last month.” Dr. Badhwar added, “For hospitals who are not GTSD participants, the time to join is now.” The next edition of Best Hospitals will feature the new Public Transparency measure, and the measure will have a weight of 3% in the adult Pulmonology & Lung Surgery specialty rankings. “The same measure will be included in the Procedures & Conditions statistical analysis, and it likely will be used in calculating the Lung Cancer Surgery ratings,” wrote US News’ Ben Harder.  This means that, by simply enrolling in the STS National Database Public Reporting initiative, hospitals can receive the transparency credit.  More than 100 thoracic surgery programs nationwide are already publicly reporting their surgical outcomes. US News will review the GTSD public reporting site in February 2023, and they release their Best Hospitals lists once a year.  If a hospital joins GTSD in 2023 and enrolls in public reporting, they will be eligible to receive the transparency credit in 2024.  "For hospitals who are not GTSD participants, the time to join is now." Vinay Badhwar, MD CHSD Makes History with Infant Surgical Trial In a first-of-its-kind multicenter, NIH-funded randomized trial within a registry, investigators have found that infants undergoing cardiopulmonary bypass surgery experienced no difference in outcomes when they received prophylactic glucocorticoids versus placebo. Results from the study, made possible by the CHSD and 24 participating sites, appeared last month in the New England Journal of Medicine.  “With an NIH award of over 5 million dollars, our team successfully conducted a multicenter, prospective, randomized, placebo-controlled, registry-based clinical trial with participants enrolled at 24 sites participating in the CHSD,” said Jeffrey P. Jacobs, MD, principal investigator for the grant, titled “Leveraging existing registry resources to facilitate clinical trials.” With data curated in the CHSD, researchers were able to randomize outcomes for 1,200 infants and newborns undergoing open-heart surgery. Glucocorticoids have been used for decades in this surgical population, but until now, their benefits have remained unconfirmed. With this CHSD analysis, the research team assessed a primary outcome composite of operative mortality, 13 individual major complications, and postoperative length of stay.  “Among infants undergoing surgery with cardiopulmonary bypass, prophylactic methylprednisolone did not significantly decrease the likelihood of a worse outcome in adjusted analysis,” the authors wrote, noting that methylprednisolone additionally was associated with increased postoperative hyperglycemia requiring insulin.  The publication of these results is a reflection of the quality and power of the Database, said Dr. Jacobs, who served on STS’s Workforce on National Databases and as chair of its Congenital Heart Surgery Database Task Force. Based on his experiences, he emphasized, “The STS Congenital Heart Surgery Database is the premier registry in the world for pediatric quality assessment and research.” Database Makes Never-Before-Seen Science Possible at STS 2023 At the upcoming STS Annual Meeting in San Diego, presenters will unveil novel scientific discoveries gleaned from the robust data curation in the STS Adult Cardiac, Congenital, General Thoracic, and Intermacs/Pedimacs Databases, including Frozen elephant trunk versus traditional limited repair in acute type 1 aortic dissection Variables affecting survival in pediatric patients supported with ventricular assist devices Targeted molecular therapy and immunotherapy for lung and esophageal cancer Postcardiotomy shock and 30-day outcomes in patients with severe left ventricular systolic dysfunction Survival outcomes for patients undergoing lung transplant Establishment of an STS adult congenital heart surgery risk model The impact of surgical strategy on isolated tricuspid valve outcomes Practice patterns in the management of tetralogy of Fallot