Clinical Decision-Making

STS 2023, SAN DIEGO — The best practices for tricuspid valve surgery gained definition Sunday at STS 2023 as experts took the first steps to end the tricuspid’s undeserved reputation as the “forgotten valve.” Qiudong (Kevin) Chen, MD, MS, research resident at Cedars-Sinai Medical Center Smidt Heart Institute in Los Angeles, California, presented the Richard E. Clark Memorial Paper, which demonstrated that: ·       For non-endocarditis-related tricuspid regurgitation (TR), isolated tricuspid valve repair is associated with a lower risk of operative mortality (in-hospital or 30-days post-operative) than valve replacement. ·       In the same population, beating heart surgery (repair or replacement) is associated with a lower risk of pacemaker implant, renal failure, and post-operative blood transfusions than surgery under cardioplegic arrest. However, no mortality benefit was identified. ·       Higher pre-operative Model for End-Stage Liver Disease (MELD) scores were associated with higher operative mortality, especially for patients with MELD scores 20 or above. Increased levels of tricuspid valve regurgitation are associated with worse survival rates, and operative mortality can be up to 11% in patients undergoing isolated surgery. Both these factors contributed to the need for this analysis on a larger population level in order to start uncovering optimal surgical strategies. Senior authors for this study were Dr. Michael Bowdish and Dr. Joanna Chikwe. Dr. Chen and his surgeon colleagues conducted their review using the STS National Database™, which he called a “powerful, comprehensive tool” that allowed his team to review procedural trends and volumes from 2012 to 2019 across the US. He noted several limitations in the analysis, including lack of long-term outcomes and incomplete etiology. From the Adult Cardiac Surgery Database, physician-scientists initially identified 14,704 patients who underwent isolated tricuspid valve surgery and further narrowed this to 6,507 patients with non-endocarditis-related tricuspid regurgitation, who were assessed in the study. Although tricuspid regurgitation is common, the study confirmed that this disorder is extremely undertreated. Tricuspid repair and replacement remain rare surgeries nationwide: the investigators found that 93% of US medical centers performed five or fewer of these procedures annually. A majority of procedures were conducted with patients under cardiac arrest, followed by surgeries on patients with beating hearts and a small minority performed on patients with fibrillating hearts. “I believe these findings suggest that in this patient population, tricuspid repair may be a safer option when feasible,” Dr. Chen said. He was joined by senior co-authors Michael E. Bowdish, MD, MS, Jad Malas, MD, and Amy Roach, MD, all also from Cedars-Sinai, in this study. “Surgical outcomes for isolated TR are poor, and we can do better by generating additional clinical evidence by identifying those patients with TR and operating on them early,” added James Gammie, MD, professor of surgery at Johns Hopkins Medicine, who served as discussant. Putting tricuspid regurgitation in perspective, Dr. Gammie noted that about 1.6 million people in the US have significant TR, making the disease almost as prevalent as aortic stenosis.

This scientific presentation covered in this article was part of the STS 2023 session “Perspectives from Asia: Aortic Disease, Coronary Disease, and Mechanical Circulatory Support,” and is available in Annual Meeting Online. Access or purchase it here. For Asian patients with aortic disease, determining whether to take a surgical or conservative approach to treatment may depend on much more than size. “Given my particular interest in aortic surgery and participation in the recently released American College of Cardiology/American Heart Association guidelines, I was asked to try to answer this question,” said Edward P. Chen, MD, from Duke University School of Medicine in Durham, North Carolina. “As I dug deeper, I found that the answer is considerably more complicated than a simple yes or no.” In terms of comparative studies, data that can help to quantify aortic disease risk can vary significantly in populations identified as “Asian,” Dr. Chen said. Even as body habitus fluctuates from region to region, the risk of adverse events may be based not only on the diameter of the aorta, but also aortic diameter indexed to both body surface area and height. “As it turns out, despite what I heard occasionally when I was growing up,  Asians do not all look the same.” Environmental and cultural factors throw another wrench: A patient who is a Japanese national, for example, might have a markedly different lifestyle than an ethnically Japanese patient living in the West. “When I was a medical student, for instance, I learned there was a high incidence of gastric cancer in Japan," Dr. Chen said. "But Japanese people living in the US have more colorectal cancer, which could potentially be explained by differences in both diet and environmental conditions.” The incidence of comorbid conditions—as well as access to health care—ranges widely in patient cohorts across the globe. When Dr. Chen began researching his presentation, he reached out to Dr. Kay-Hyun Park of Seoul, Korea, president of the Asian Society for Cardiovascular and Thoracic Surgery, for an additional perspective. Dr. Park’s blunt reply: “I (and probably any Asian surgeon) cannot represent the entire ‘Asia’ and deliver the ‘Asian perspective,’ because I have no means to grasp what they are doing in the other Asian countries.” Dr. Park added, “Even in my own neighborhood in Korea, their aggressiveness is quite varied.” He went on to say that, in areas where patients might have more limited access to state-of-the-art surgical care, a surgeon might err more aggressively on the side of surgery—not knowing when they might get to see that patient again. Acknowledging the limitations and complexity at work, Dr. Chen and his coauthors aimed to design the latest guidelines to assist the clinician in making the best decisions for each patient on a case-by-case basis. The presentation was part of a session hosted jointly by STS and the Asian Society for Cardiovascular and Thoracic Surgery, “Perspectives from Asia: Aortic Disease, Coronary Disease, and Mechanical Circulatory Support,” moderated by S. Christopher Malaisrie, MD, and Wilson Y. Szeto, MD.   “Shared decision making is going to be the key here,” Dr. Chen said. “Yes, we don't actually have all the answers. But what we should do is take the data we have and try to individualize it to every patient we take care of, and not have a uniform umbrella policy. Particularly here in the United States, with the potpourri of diverse ethnic groups we take care of, it’s important to use the guidelines along with the data we have, the patient’s known measurable anatomic factors as well as lifestyle considerations, and one’s own experience and clinical judgment to make the best decision possible for the patient.”

STS 2023 DAY 3 — Today is your chance to give input as cardiothoracic surgeons work to establish vital guidelines in pediatric surgery for congenital heart defects. Several of the nation's foremost surgeons will present their studies to date that will be the foundation for STS practice guidelines and consensus documents.  On Monday, January 23 at 11:55 a.m. PT, Jeffrey P. Jacobs, MD, a professor of surgery and pediatrics at the University of Florida in Gainesville, and Tara Karamlou, MD, MSc, from Cleveland Clinic in Ohio, will chair the highly collaborative session "It's All About the Data—Evidence Based Guidelines for Congenital Heart Surgery." These and other surgeons involved in the multi-institutional research want your feedback. This session will showcase the extensive research conducted to date by the Evidence Based Task Force for Congenital Heart Surgery and offer participants opportunities to contribute their own insights. Dr. Jacobs leads the task force, which is undertaking three projects where consensus on optimal care approaches does not exist: Strategies for Left Ventricular Recruitment in Neonates and Borderline in Left Heart Structures, chaired by Dr. Karamlou, Bahaaldin Alsoufi, Chief of Cardiothoracic Surgery at Norton’s Children’s Hospital in Louisville, Kentucky, and Eric Feins, MD, from Boston Children’s Hospital in Massachusetts. Management of Neonates and Infants with Coarctation, chaired by Elizabeth Stephens, MD, PhD from Mayo Clinic in Rochester, Minnesota, and Hani Najm, MD, from Cleveland Clinic in Ohio. Indications and Timing of Pulmonary Valve Replacement in Repaired Tetralogy of Fallot, chaired by Jennifer Nelson, MD, from Nemours Children’s Hospital in Orlando, Florida, and James St. Louis, MD, Section Chief of Pediatric and Congenital Heart Surgery from Children’s Hospital of Georgia in Augusta. "It has truly been an honor for me to observe the dedication and professionalism of these STS leaders as they pursued, with great scientific rigor, the best answers available to three very challenging clinical dilemmas," Dr. Jacobs says. "I am certain that the tremendous effort devoted to these studies will generate important knowledge that will ultimately improve the lives of many babies and children with congenital heart disease." These initiatives followed the call in 2022 by STS President John Calhoon, MD, to improve cardiothoracic surgery across the world. From there, the STS Workforce on Evidence Based Surgery created three Task Forces addressing some of the most pressing and unanswered surgical issues, including the congenital heart surgery group.    Research presented today will lead to publication of an STS Clinical Practice Guideline in The Annals of Thoracic Surgery and two STS Expert Consensus documents later this year.

STS 2023, SAN DIEGO—Frailty in patients has existed as a nebulous marker of a patient’s physiological ability to tolerate surgery, but a simple visual assessment at the bedside is not reliable. Surgeons at STS 2023 urged others to go beyond the “eyeball” test. This issue is taking on increased importance as our large, Baby Boomer population and older patients reach a point when they may have severe disease and need cardiothoracic surgery. Physicians have long believed that a measurement of frailty is useful, but agreement remains elusive on how to best measure it. Armir Kiankhooy, MD, from Adventist Health in St. Helena, California, added that physicians’ implicit biases about age, obesity, and other characteristics may creep into and skew quick visual assessments, when in fact the assessment may be inaccurate. For instance, a higher level of frailty has been found in young adults than previously suspected, and frailty permeates all age groups.  Indicators of frailty can include malnutrition, cognitive and speech impairment, ambulatory ability, sarcopenia, and others. “If you are not doing some kind of assessment for your patients in frailty or other vulnerabilities, you are probably only seeing half the risk in your patients,” said Rakesh Arora, MD, from University Hospitals in Cleveland, Ohio. “We need a more comprehensive plan. We need to know how quickly they will bounce back from the stress of surgery.” Tools to assess frailty are increasing, and Dr. Arora recommended the Clinical Frailty Scale, a comprehensive assessment of 70 variables, but acknowledged that it may be too time- consuming for institutions with more limited resources. Instead, he advised that clinicians assess the frailty factors that are more manageable. These can include gait speed, chair rises, balance tests, and grip strength assessment for physical abilities, and potentially a Mini-COG test for memory loss and other indicators of cognition. “If you do the chair rise test, some basic cognitive assessment, a baseline hemoglobin, and a baseline serum, that probably is just as good as a more comprehensive test,” Dr. Arora said. All is not lost for patients with suboptimal frailty scores to undergo surgery. “Pre-habilitation” can help them improve their health through targeted exercise, nutrition and assistance with psychosocial issues and better prepare them for the OR.

STS 2023, SAN DIEGO – “Quality people, consistency, communication, and collaboration” were declared the winning combination in the debate “For the Post-operative Patient in the ICU, Who Is in Charge and Who Is the Consultant? Surgeon or Intensivist?” on Day 1 of STS 2023. Over the last two decades, changing reimbursements, time demands on surgeons, and hiring practices have pushed surgeons and intensivists together for post-surgical care of patients—not always with the best results. Today, with a host of different circumstances at different institutions, significant variations in post-operative critical care exist across the country. Moderator Joseph Zwischenberger, MD, a cardiothoracic surgeon at University of Kentucky HealthCare in Lexington, stood ready to blow his harmonica in case tempers flared. While there were distinct differences of opinion, 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 (UTHSC) and Martin Zammert, MD, a surgical critical care physician who heads the cardiothoracic unit at Lahey Hospital & Medical Center in Burlington, Massachusetts, also highlighted the vital need for true surgeon-intensivist partnership. “The surgeon knows the patient’s anatomy, physiology, and social issues best,” Dr. Carpenter said. “It is the surgeon who takes responsibility and criticism for poor outcomes. So in those cases where there is not clear agreement on what the next best step is, the ultimate decision needs to be made by the surgeon.” A clear answer to the question posed did not emerge from the research both experts presented on length of stay, in-hospital mortality, and readmission rates. They turned to their real-life experiences to make their cases about the best direction and who should have ultimate authority in the ICU—where patient status can change rapidly and quick decisions need to be made about everything from mechanical ventilator support to choice of statins and vasopressors to care withdrawal. Dr. Zammert had another perspective. “Bad outcomes in the ICU are mainly non-surgical, so I don’t think the question should be ‘Who is in charge?’ I think the question we should ask ourselves is, what kind of intensivists do we want in our units?” Both agreed that cardiac critical care is distinct from other intensive care, and that intensivists need training in identifying and avoiding the postoperative complications that commonly occur following cardiac surgery. Intensivists need specific proficiencies in cardiac intensive care, and surgeons need to understand ICU post-operative care in order to foster mutual trust and respect. Dr. Zammert added that understanding how each type of specialist thinks and reasons, and keeping each other informed, create a foundation for a good relationship. “We are here to be a partner with you, not an opponent,” Dr. Zammert added. “This should never be an arranged marriage.” Along with audience members, both discussants advocated for structured rotations and experiential cross-learning for both specialties in the ICU and the OR. Dr. Carpenter, who is also Residency Program Director of Integrated Thoracic Surgery at UTHSC’s Long School of Medicine, noted that in this effort nationwide, “some programs are doing it better than others.”

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.

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.”