Clinical Decision-Making

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. 

Overall survival rates of esophageal cancer have risen in the past 50-plus years, from 5% in 1970 to 22% in 2023. Yet, no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that incorporate input from surgeons, radiation oncologists, and medical oncologists have been available, until now. 

The Society of Thoracic Surgeons, American Society for Radiation Oncology, and American Society of Clinical Oncology have co-authored the first comprehensive guideline on the management of esophageal cancer. Published today in The Annals of Thoracic Surgery, the guideline addresses key clinical subject areas pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer. 

The guideline delivers recommendations for the use of induction chemotherapy, optimal radiation dose, value and timing of esophagectomy, use of chemotherapy vs. chemoradiotherapy before surgery, approach and extent of lymphadenectomy, and the value of adjuvant therapy after resection.

“These comprehensive guidelines address areas critical for standardizing and improving care and outcomes for esophageal cancer patients,” says study investigator Stephanie Worrell, MD, clinical associate professor and thoracic section chief at the University of Arizona in Tucson. “The recommendations are based on a comprehensive review of innovations and advancements in the most recent literature.”

For the first time, The Society of Thoracic Surgeons joined the Korean Society for Thoracic and Cardiovascular Surgery (KSTCVS) in their presentation of the Heart Valve Disease Forum (HVDF), an annual conference that delivers the latest developments on the basis, cause, diagnosis, treatment, and future of valve disease.

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The forum, held September 15-16, 2023, in Dragon City, Yongsan, Seoul, was led by the President of the HVDF, Dr. Kyung Hwan Kim, and organized by co-program directors Dr. Joon Bum Kim of Asan Medical Center of Ulsan College of Medicine and Dr. S. Chris Malaisrie of Northwestern University, who commented “STS was thrilled to partner with the KSTCVS on this international event, highlighting transpacific expertise on valves.”

Dr. Kim remarked, “By co-hosting the forum with STS, we brought together the world’s top scholars in related fields for discussion and achieved the best conference experience.”

More than 300 surgeons, residents, and other medical students attending the conference heard from luminary surgeons and professors on today’s hottest topics impacting the specialty, including TAVI, innovative SAVR, and endocarditis, and trained on surgical techniques in wet labs. “The dynamic, case-based discussions and interactive wet labs with skilled faculty inspired the next generation of cardiac surgeons," said Dr. Malaisrie.

Dr. Thomas MacGillivray, president of STS, delivered several talks, including one on “Crisis Management in the Operating Room and Surgeon Leadership.”

At this year’s conference, particular emphasis was placed on connecting young surgeons responsible for the future of heart valve surgery with proven STS surgeon leaders through a mentor-mentee program. It was an exclusive opportunity for early career attendees to gain invaluable guidance on navigating their career paths and overcoming challenges from leaders.

“The heart valve symposium was a wonderful success and a historical event that stands out among the meeting’s 30-year history,” said Dr. Kim. “Our Korean colleagues agreed that collaborating with STS was the best thing in terms of excellence of lectures, one-to-one teaching in the wet lab, an exciting mentorship program, and beautiful times spent outside of the conference room.”

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In 2022, the cardiothoracic surgical community turned to The Annals of Thoracic Surgery for insights on best practices for patient care, quality metrics from the STS National Database™, a glimpse at the future of surgical techniques, and much more. 

Among the top articles in 2022—in both usage and citations—were the STS/AATS Clinical Practice Guidelines on the Management of Type B Aortic Dissection, as well as an article elucidating why STS and the American Association for Thoracic Surgery did not endorse the 2021 ACC/AHA/SCAI coronary revascularization guidelines. The latter, as explored in the cover story of this issue of STS News, informed new analyses that account for the increased risks in patients with multivessel coronary artery disease, and that support coronary artery bypass grafting as the best first approach in these patients. 

The second most-viewed and most-cited article was “Current and Future Applications of Virtual, Augmented, and Mixed Reality in Cardiothoracic Surgery,” a topic that reinforces the STS community’s interest in adopting promising new techniques and technologies to further enhance their skills. 

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COVID-19 is still very much a relevant topic, as surgeons continue to discover the toll COVID infections—and delays in care exacerbated by lockdown—have taken on their patients in the long term. “Pulmonary Parenchymal Changes in COVID-19 Survivors,” “The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717,103 Patients,” and “One-Year Outcomes with Veno-venous Extracorporeal Membrane Oxygenation Support” appeared among The Annals’ 10 most popular articles in usage, citations, and overall views.  

STS National Database-driven research graced the top 10 in citations. “Concordance of Treatment Effect,” “Sex Differences in Coronary Artery Bypass Grafting Techniques,” and the unveiling of the new Failure to Rescue quality metric provided guidance for evidence-based quality improvement.  

Novel, condition-specific applications and their implications for surgeons appeared among highly-read topics, including the surgical perspective on neoadjuvant immunotherapy in non-small cell lung cancer, rescue blanket as a provisional seal for penetrating chest wounds, lymphatic disorders and their management in patients with congenital heart disease, and topical vancomycin for reducing the incidence of deep sternal wound complications after sternotomy. 

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STS Members have complimentary access to the journal. Read the latest at annalsthoracicsurgery.org. 

For patients with multivessel coronary artery disease, contemporary data analyses demonstrate that the optimal treatment is coronary artery bypass grafting (CABG), and that new downgraded recommendations for CABG could put patients at risk. 

During the STS 59th Annual Meeting in January, researchers presented compelling findings, comparing outcomes for patients who underwent CABG versus those who opted for percutaneous coronary intervention (PCI).   

“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. His team’s presentation, “Contemporary Artery Bypass Grafting versus Multivessel Percutaneous Coronary Intervention in 100,000 Matched Medicare Beneficiaries,” revealed that patients with blockages in multiple arteries who opt for CABG—rather than for PCI—are less likely to die from their condition, less likely to need additional surgery, and less likely to have a subsequent heart attack. 

“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.”

- J. Hunter Mehaffey, MD 

The background and rationale for this research project started with the publication of the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. “The cardiac surgery world was really shocked, because the guidelines downgraded the indications for CABG from a class 1 recommendation to a class 2B,” Dr. Mehaffey explained.  

Much of the decision to downgrade was based on the guideline committee’s goals to focus on the most recent data, to help ensure that they were capturing contemporary stent technology, Dr. Mehaffey explained. The guidelines therefore relied heavily on the multicenter ISCHEMIA trial, published by Maron et al in 2020. 

“ISCHEMIA wasn’t a study that was designed to look at CABG versus medical therapy in terms of survival,” said Joseph F. Sabik III, MD, chair of the Department of Surgery at UH Cleveland Medical Center in Ohio. “It was really a study that was done to look at initial conservative strategy versus an initial invasive strategy.”  

Dr. Mehaffey’s multidisciplinary team—including both surgeons and cardiologists—performed a statistical analysis of Medicare outcomes data in patients 65 and older from 2018 to 2020, including propensity score balancing to help ensure that the groups of patients who underwent stenting versus those who underwent bypass surgery were well matched in order to compare their outcomes. 

The analysis demonstrated a significantly lower hospital mortality for the patients who underwent CABG compared to those who underwent PCI. 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 PCI. 

“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,” Dr. Mehaffey said.  

Meanwhile, Dr. Sabik’s team analyzed the past 2 years’ outcomes in the STS National Database™, which captures nearly every adult cardiac surgical procedure in the United States. “We wanted to examine how representative ISCHEMIA is for patients undergoing surgery, to see if the results are applicable,” Dr. Sabik said. 

They discovered that, based on the eligibility criteria for the ISCHEMIA trial, only about one-third of patients who underwent CABG would have been included in the study. A third would have been excluded because they had left main disease, and the other third would have met other exclusion criteria. 

“ISCHEMIA wasn’t a study that was designed to look at CABG versus medical therapy in terms of survival. It was really a study that was done to look at initial conservative strategy versus an initial invasive strategy.”  

- Joseph F. Sabik III, MD

Compared with that of the STS population, it turned out that patients who met ISCHEMIA criteria tended to have less severe disease. They didn’t have the same extent of coronary artery blockage or comorbid conditions. They tended to be younger, and they were less likely to have hypertension, diabetes, a previous stroke, peripheral vascular disease, or renal dysfunction, Dr. Sabik said. ISCHEMIA participants also were less likely to have had a myocardial infarction and more likely to have better left ventricular function. 

“Though the authors of ISCHEMIA did their best to represent patients undergoing revascularization, the study wasn’t truly representative of patients with triple-vessel disease having surgery today,” concluded Dr. Sabik. “That’s why we don’t think it should have been used to downgrade coronary surgery recommendations. People are making decisions based on these guidelines, and it may not be in the best interest of patients.” 

“This is not about surgery. It’s not about PCI, it’s not about medical therapy. It’s about making sure that patients get the right treatment, so they can have the best long-term outcomes.” 

- Joseph F. Sabik III, MD

During the 2023 C. Walton Lillehei Lecture, Peter K. Smith, MD, outlined a series of narratives that can cloud a provider’s decision-making when choosing their approach to coronary artery disease. He illuminated the nuances of commonly cited trials such as SYNTAX and FAME, detailed the evolution of common percutaneous approaches, and explained how belief in the advantages of PCI becomes murkier when the arguments aren’t equivalent. 

"There was exhaustive discussion of the age of the ‘CABG versus medical therapy’ evidence,” Dr. Smith said. “And then we entered the spin zone of indirect comparisons of ‘CABG versus medical therapy, CABG versus Stent X, Stent X versus Stent Y, Stent Y versus medical therapy—therefore CABG versus medical therapy.’ And, of course, ‘Those were all old stents and medical therapy is markedly improved now.’ This is what occurs when a core belief system is at risk.” 

“We need to work at a local level with cardiology, with heart teams, in order to make the right decisions for patients,” urged Dr. Smith. 

“This is not about surgery,” added Dr. Sabik. “It’s not about PCI, it’s not about medical therapy. It’s about making sure that patients get the right treatment, so they can have the best long-term outcomes.” 

STS 2023 registrants can watch Dr. Mehaffey’s presentation, Dr. Smith’s Lillehei Lecture, and Dr. Sabik’s late-breaking session, “The ISCHEMIA Trial Does Not Reflect Patients Undergoing Coronary Surgery: An STS Cardiac Surgery Database Analysis,” as part of their free Annual Meeting Online access. Those who didn’t register can purchase Annual Meeting Online—with special discounts for STS Members—and Resident/Fellow Members can access it for free. Visit sts.org/AMonline.