Patient Outcomes

In this short video, STS members exchange viewpoints on a new study that found patients with postoperative PE had increased 30-day mortality, reintubation, and readmission rates, which was presented at the 2024 STS Annual Meeting.

Robbin Cohen, MD, Cedars-Sinai at Huntington Hospital, is joined by the study’s lead author, Andrea L. Axtell, MD, MPH, an assistant professor of surgery at the University of Wisconsin School of Medicine and Public Health, Michael Smith, MD, Norton Thoracic Institute, St. Joseph’s Hospital & Medical Center, and John Mitchell, MD, University of Colorado Health, to discuss the research methodology, findings and impact on improving patient care. 

FAIRFAX, VIRGINIA (March 11, 2024) - As use of prosthetic heart valves and implanted cardiac devices has increased, so too has the incidence of cardiovascular infection. While accurate diagnosis of this condition is critical for guiding treatment decisions that can prevent death and significant morbidity, current assessment strategies have proven insufficient. Recommendations released by 11 professional medical societies, including the Society of Thoracic Surgeons, detail a standardized approach for using PET/CT and SPECT/CT imaging to improve the evaluation and subsequent outcomes of patients with cardiovascular infection. The expert consensus statement – “18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context” – is published online in the Journal of Nuclear Cardiology, Clinical Infectious Disease, Heart Rhythm Journal, and JACC: Cardiovascular Imaging.

“The stakes are high with cardiovascular infection because the incidence is increasing and there is associated high morbidity and mortality,” says Jamieson M. Bourque, MD, MHS, FASNC, chair of the statement’s multisociety writing committee. “Other guidelines have recognized that FDG PET/CT and SPECT/CT imaging have high diagnostic accuracy with cardiovascular infection and can provide important information on the infection site, severity, cause, and whether the infection has spread outside the heart. This document does what others have not – it provides evidence-based consensus on specific clinical scenarios where FDG PET/CT and SPECT/CT add value for patient care in the context of robust multimodality imaging approaches available.”

Reflecting its multidisciplinary authorship, the statement emphasizes the complementary nature of advanced imaging modalities. It outlines the indications for echocardiography, cardiac computed tomography angiography, radiolabeled leukocyte SPECT/CT and 18F-FDG PET/CT in cardiovascular infection evaluation. The authors then provide a consensus-derived clinical indication rating of "appropriate," "may be appropriate," or "rarely appropriate" for use of 18F-FDG PET/CT and SPECT/CT in 73 clinical scenarios encompassing suspected native and prosthetic valve infective endocarditis, suspected cardiovascular implantable electronic device (CIED) infections, suspected prosthetic material infection, and suspected ventricular assist device (VAD) infection.

The expert consensus recommendations statement also includes:

• Diagnostic algorithmic flowcharts for suspected native or prosthetic valve infective endocarditis or prosthetic material/VAD infection and for suspected CIED infection;
• Teaching images from cases where 18F-FDG PET/CT and SPECT/CT studies were used in  prosthetic valve endocarditis, CIED pocket and lead infection, VAD infection and prosthetic material infection; and
• Teaching case examples where 18F-FDG PET/CT and SPECT/CT were used to assess prosthetic valve endocarditis, suspected lead CIED infection, suspected VAD infection and suspected prosthetic material infection.

“18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context” is the first document in the new American Society of Nuclear Cardiology Imaging Indications (ASNC I2) Series. Eleven partnering organizations participated in writing these recommendations and endorsed the document: The American Society of Nuclear Cardiology (ASNC), the American Association for Thoracic Surgery (AATS), the American College of Cardiology (ACC), the American Heart Association (AHA), the American Society of Echocardiography (ASE), the European Association of Nuclear Medicine (EANM), the Heart Rhythm Society (HRS), the Infectious Diseases Society of America (IDSA), the Society of Cardiovascular Computed Tomography (SCCT), the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the Society of Thoracic Surgeons (STS). The writing committee included representatives from each of the partnering organizations.

Read the consensus statement. 

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ABOUT ASNC

The American Society of Nuclear Cardiology and its 5,200 members have been improving cardiovascular outcomes through image-guided patient management for more than 30 years. As the leading society dedicated solely to the field of nuclear cardiology, ASNC establishes standards for excellence in cardiovascular imaging through the development of clinical guidelines, professional medical education, advocacy and research development. ASNC provides peer-reviewed original articles through its official publication, The Journal of Nuclear Cardiology. For more information, visit http://www.asnc.org.

ABOUT STS

Founded in 1964, The Society of Thoracic Surgeons is a not-for-profit organization representing more than 7,700 cardiothoracic surgeons, researchers, and allied healthcare professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. The Society’s mission is to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy.

During this session, investigators unveiled findings from the largest multicenter study of post-arterial switch operations (ASO) that resulted in increased survival rates for adolescents and adult patients – as well as an increase in the potential for these patients to require cardiac reoperations to address arterial switch related complications that arise later in life.

At day two's presentation on “Burden of Reoperative  Cardiac Surgery among Adolescents and Adults Who Have Undergone Prior Arterial Switch Operation: Society of Thoracic Surgeons Database Analysis,” Bret Mettler, MD, from Johns Hopkins University, examined a multi-year assessment of the prevalence and types of cardiac surgical interventions in patients who previously underwent ASO using data from the STS National Database. 

“Anatomical repair of transposition of the great arteries (TGA) and related anomalies by arterial switch operation (ASO) achieves a normal anatomic and physiologic cardiac configuration,” said Dr. Mettler.  “And as survival rates have increased, so have the potential for these patients to require cardiac reoperations to address resulting ASO-related complications.”

As most reoperations involved multiple procedures, the presentation examined how a hierarchical stratification of procedure categories was established, with each eligible surgical hospitalization assigned to the single highest applicable hierarchical category.
  
Dr. Mettler's presentation also examined implications for surgical counseling, post-operative clinical surveillance, and therapeutic management. An analysis of the role of procedural prevalence, timing, categories, trends, and the growing number of reoperations was discussed.

Shortly after the 60th STS Annual Meeting began, a packed crowd attended the "Trends and Research from the STS Adult Cardiac Surgery Database (ACSD)" session, beginning with a presentation by Michael E. Bowdish, MD, of the Smid Heart Institute, Cedars-Sinai Medical Center. He looked back at the origins of the ACSD, which was established in 1989 to collect information on cardiac surgery procedures, track outcomes, and provide insights into opportunities for quality improvement. 

Today – more than three decades later – the Database offers more than nine million recorded procedures making it one of the most comprehensive, robust, and sophisticated contemporary clinical databases in use.   

For example, 95% of centers performing coronary artery bypass grafting (CABG) in the United States, and 97% of patients receiving CABG are included in the STS ACSD. Every year 10% of the participating sites undergo a data audit assessing data accuracy and completeness with strict thresholds to pass quality control. Continuous education of data managers is a further element to ensure data quality. 

"STS ACSD is a vital source of data for outcomes research quality improvement, with overall volumes that are stable with notable trends in aortic surgery," said Dr. Bowdish.

The STS ACSD has provided the foundation for national benchmarking in adult cardiac surgery through the development of regularly updated and recalibrated risk models and performance metrics, the availability of feedback reports to database participants and individual surgeons, quality-improvement efforts, voluntary public reporting, and comparative effectiveness research. 

Two STS 2024 sessions featured late-breaking research covering new findings on a research study focused on resectable early stage non-small-cell lung cancer and a study that used data to define characteristics associated with long-term survival following esophagectomy for cancer.

Impact of Surgical Factors on Event-Free Survival in the Randomized, Placebo-Controlled, Phase 3 KEYNOTE-671 Trial of Perioperative Pembrolizumab For Early Stage Non-Small-Cell Lung Cancer

In a talk given by presenting author Jonathan David Spicer, MD, PhD, of McGill University, he discussed new findings from the KEYNOTE-671 research study, focused on resectable early stage non-small-cell lung cancer (NSCLC), which have unveiled a significant breakthrough in the treatment landscape. 

The study, titled "Impact of Surgical-Related Data on Event-Free Survival in KEYNOTE-671," demonstrated that neoadjuvant therapy with pembrolizumab plus chemotherapy did not delay surgery. "Results showed that neoadjuvant pembrolizumab plus chemotherapy with adjuvant pembrolizumab provided meaningful improvement in EFS," said Dr. Spicer. "This was shown when compared with neoadjuvant chemotherapy alone for resectable early stage NSCLC – regardless of clinical nodal status, baseline disease stage, or type of surgery."

Longitudinal Follow-up of Elderly Patients After Esophageal Cancer Resection in the Society of Thoracic Surgeons General Thoracic Surgery Database

In this study, Justin Blasberg, MD, of Yale School of Medicine, used the STS General Thoracic Surgery Database linked to the Centers for Medicare and Medicaid Services data to define characteristics associated with long-term survival following esophagectomy for cancer. The analysis included 4,798 patients from 207 STS sites who underwent esophagectomy between 2012-2019. "The researchers found that Medicare patients undergoing esophagectomy for cancer exhibit identifiable predictors for long-term survival and readmission," noted Dr. Blasberg. "The absence of pathologic T and N downstaging increases the risk for long-term mortality and readmission."

These findings suggest opportunities to enhance clinical practice and improve outcomes for Medicare patients undergoing esophagectomy for cancer.