The Power to Tell Your Story

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When a biologic aortic valve prosthesis fails, the patient often faces a high risk valve replacement through repeat open heart surgery. A new technique, known as Valve-in-Valve, uses minimally invasive techniques to introduce a collapsible aortic heart valve into the damaged valve in order to restore function. This procedure avoids the need to open the chest or use cardiopulmonary bypass (heart-lung machine), according to Leo Ihlberg, MD, PhD, a cardiothoracic surgeon at the Heart and Lung Center of Helsinki University Hospital, Finland, who will be presenting the results of a new study at the 93rd AATS Annual Meeting in Minneapolis on May 6, 2013.

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Inherited ventricular arrhythmias are an important cause of morbidity and sudden cardiac death in children who have structurally normal hearts. Despite conventional medical therapy, some of these children remain symptomatic with recurrent life-threatening arrhythmias, syncope, or frequent discharges from implantable cardioverter defibrillators (ICDs). Video-assisted thoracoscopic left cardiac sympathetic denervation (VATS-LCSD) is a minimally invasive procedure that can help many of these children with refractory cardiac arrhythmias. The results of a single-center experience with VATS-LCSD will be presented during the Congenital Heart Disease Session of the 93rd AATS Annual Meeting in Minneapolis by Dr. Sophie C. Hofferberth, MBBS.

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Adults with end-stage respiratory failure and pulmonary hypertension requiring ECMO (extracorporeal membrane oxygenation) have been “bridged” toward lung transplantation with novel lung assist devices such as the Novalung. This and related devices work based on pumpless application of oxygenators. A presentation by David M. Hoganson, MD, and colleagues from Washington University School of Medicine in St. Louis at the Congenital Heart Disease Session of the 93rd AATS Annual Meeting describes the first time application of this technology to newborns and small children.

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Anemia increases operative mortality and morbidity in non-cardiac and cardiac surgical procedures. Anemic surgical patients may require more blood transfusions, raising the risk of transfusion-related complications and increasing costs. For those reasons, optimizing patient readiness by correcting anemia prior to surgery is an important clinical goal. A simple new protocol has been proposed that helps correcting anemia using a single, high dose of recombinant human erythropoietin (HRE) administered only two days prior to surgery. The results of a randomized study will be presented by Luca Weltert, MD, Cardiac Surgery Department of the European Hospital in Rome, during the Plenary Scientific Session of the 93rd AATS Annual Meeting in Minneapolis.

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Lung cancer is associated with very high mortality, in part because it is hard to detect at early stages, but also because it can recur frequently after surgical removal. The question arises as to what is the best way to follow lung cancer patients after surgery in order to spot problems early enough, before symptoms become obvious, so that patients may still be eligible for new interventions. In this study presented at the 93rd AATS Annual Meeting, investigators from the University of Toronto departments of Thoracic Surgery and Diagnostic Radiology show that minimal dose computed tomography (MnDCT) of the thorax offers much greater sensitivity at detecting new or recurrent lung cancer, with equivalent amount of radiation, compared to conventional chest x-rays.

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Tumors have the potential to grow locally and invade neighboring organs. Some chest tumors may invade one of the great vessels of the body, the aorta. Surgical removal of these tumors is very challenging and necessitates the support of a heart-lung machine. Therefore there is an increased risk of complication and death. In a small series of patients, placing a stent within the aorta facilitated the subsequent removal of tumor and eliminated the need for heart-lung bypass. A report of these results is presented by Stéphane Collaud, MD, MSc, at the Emerging Technology and Techniques Forum of the 93rd AATS Annual Meeting in Minneapolis on May 8, 2013.

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For more than 40 years, patients under 65 years of age requiring heart valve replacement have had to choose between a mechanical valve that offers life-long durability but requires aggressive warfarin anticoagulation or a biological (cow or pig) valve that will wear out in 10-20 years but does not require anticoagulation. Aggressive warfarin anticoagulation is accompanied by significant annual risk of bleeding, while inadequate anticoagulation of a mechanical artificial valve has been associated with high risk of clotting problems that can cause strokes.

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The American Association for Thoracic Surgery Annual Meeting is the oldest and largest cardiothoracic surgery meeting in North America. The 93rd will be held at the Minneapolis Convention Center, Minneapolis, MN, USA, on May 4-8, 2013. Approximately 2500 professionals are expected to attend.

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The American Association for Thoracic Surgery (AATS), a professional organization of surgeons dedicated to the diagnosis, treatment, and cure of diseases of the chest, strongly supports the United States Preventive Services Task Force (USPSTF) draft recommendation for lung cancer screening of asymptomatic smokers.

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AATS and three cardiovascular professional societies today released an overview of transcatheter therapies for mitral regurgitation. Intended to “help frame subsequent discussions” among the field’s various stakeholders, the document highlights critical issues that should be considered as the technologies are integrated into clinical practice.

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Surgeons in France have successfully replaced the aortic valve in two patients without opening the chest during surgery. The procedure, using totally endoscopic aortic valve replacement (TEAVR), shows potential for improving quality of life of heart patients by offering significantly reduced chest trauma. It is described in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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Long-term survivors after esophagectomy with gastric pull-up can enjoy a satisfying meal and good quality of life according to a new study from a team of researchers at the University of Southern California Keck School of Medicine, Los Angeles. This study concluded that pessimism about the long-term quality of life after an esophagectomy on the part of treating physicians and patients is unwarranted. It is published in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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Reports of the two earliest tissue-engineered whole organ transplants using a windpipe, or trachea, created using the patient's own stem cells, were hailed as a breakthrough for regenerative medicine and widely publicized in the press. However, two leading transplant surgeons in Belgium warn of the dangers of media attention, and urge that tracheal bioengineering be demonstrated as both effective and safe before further transplants take place. Their views are published in an Editorial in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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Surgical aortic valve replacement generally improves patients’ symptoms and prolongs survival. However, the perceived risk of surgical aortic valve replacement in patients over 80 may result in surgery being denied or a recommendation for alternative therapy. Investigators at the Mayo Clinic challenge the way these patients have been managed. They report that repeat sternotomy in patients over 80 who have previously had coronary bypass graft surgery can be done with low risk. Their findings are published in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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Investigators propose that NASA’s “threat and error model” – derived from analyzing >30,000 commercial flights and which explains >90% of crashes – is directly applicable to pediatric cardiac surgery.

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The use of transplant organs from animals (xenotransplantation) could help to compensate for the shortage of human organs available for transplant. NIH researchers have demonstrated that by using hearts from genetically engineered pigs in combination with target-specific immunosuppression of recipient baboons, organ survival can be significantly prolonged. This has potential for paving the way for the use of animal organs for transplantation into humans.

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A major new study using data from the National Cancer Data Base details the impact of annual hospital volume on 30- and 90-day mortality rates. Investigators found that major lung surgery has become progressively safer over the last few decades, although higher death rates at low-volume hospitals and an unexpected increase in mortality at 90 days compared to 30 days were observed. The study further suggests that choosing a center that performs major lung surgery regularly can have a strong impact on survival.

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High-risk operable lung cancer patients have poorer quality of life scores than the normal U.S. population. However surgery can still be undertaken safely: Low global quality of life scores were not associated with lower survival, recurrence-free rate, or for higher risk for adverse events following sublobar resection, a major surgical procedure.

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Children with a heart defect called transposition of great arteries (TGA) are born with the two major blood vessels (aorta and the main lung artery) arising from the wrong sides of the heart. Consequently, blood is pumping inappropriately between the lungs and the rest of the body, a fatal condition unless surgically treated. The surgery of choice, the arterial switch operation (ASO), is usually performed within the first few weeks of life. In a retrospective analysis of 30 years of experience performing ASOs, Hanna A. Jensen, MD, PhD, and the rest of the team led by Victor Tsang, MD, FRCS, from the Great Ormond Street Hospital for Children NHS Foundation Trust in London, suggest that 90-day outcomes may give a more revealing picture than the traditional reliance on 30-day data. She is presenting the results of this research at the 94th AATS Annual Meeting in Toronto.

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A new study presenting data from 17 cardiac surgical centers in Virginia, representing 100 surgeons and 99% of cardiac operations performed in the state, demonstrates that, even today, significant variations – among surgeons and hospitals - still exist in the performance of mitral valve repair vs replacement for moderate to severe mitral regurgitation. Significant associations were observed between the propensity for MV repair and both institutional and surgeon annual volume, although increasing surgeon volume appears to be the much stronger predictor.

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Researchers at the University of Louisville School of Medicine are using breath analysis to detect the presence of lung cancer. Preliminary data indicate that this promising noninvasive tool offers the sensitivity of PET scanning, and has almost twice the specificity of PET for distinguishing patients with benign lung disease from those with early stage cancer. Michael Bousamra II, MD, Associate Professor, Department of Cardiovascular and Thoracic Surgery, is presenting the results of the study at the AATS 2014 Conference on April 29, 2014.

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A new technique that brings CT imaging into the operating room will allow surgeons to precisely demarcate and remove small sub-centimeter lung nodules, leaving as much healthy tissue as possible, according to Raphael Bueno, MD, of Brigham and Women’s Hospital in Boston. His team is presenting the results of this late-breaking research at the 94th AATS Annual Meeting in Toronto, ON, Canada on April 30, 2014.

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A quick overview of the 94th AATS Annual Meeting, Toronto, April 26-30, 2014 plus 8 featured presentations.

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Less aggressive anticoagulation therapy, combined with low-dose aspirin, can be used safely in conjunction with a newer generation mechanical heart valve. These findings from the first phase of a randomized clinical trial are published in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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Investigators from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) have successfully transplanted hearts from genetically engineered piglets into baboons’ abdomens and had the hearts survive for more than one year, twice as long as previously reported. This was achieved by using genetically engineered porcine donors and a more focused immunosuppression regimen in the baboon recipients, according to a study published in The Journal of Thoracic and Cardiovascular Surgery, an official publication of the American Association for Thoracic Surgery.

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The American Association for Thoracic Surgery (AATS) has released new evidence-based guidelines for the prevention and treatment of perioperative and postoperative atrial fibrillation (POAF) and flutter for thoracic surgical procedures. The guidelines are published in The Journal of Thoracic and Cardiovascular Surgery.

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Over the last 15 years, survival of children with congenital heart disease (CHD) has greatly improved, so that currently there are more adults than children living with CHD. Consequently, people with CHD of all ages are undergoing pulmonary valve replacement (PVR) with bioprosthetic valves. In this retrospective review of all patients with CHD who underwent bioprosthetic PVR over an 18-year period at Boston Children’s Hospital, investigators found that young age and small body weight predisposed patients toward re-intervention, as did the type of valve used.

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When educating medical students or residents to perform highly technical procedures, there is always a challenge to balance the educational mission with maintaining quality results and optimal patient care. This report compared outcomes of cardiac surgery residents to those of attending physicians in performing coronary artery bypass grafting. It found no differences in patient outcomes or graft patency between the residents and attending surgeons.

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For patients in the early stage of non-small cell lung cancer, surgical resection yields optimal outcomes. Prior investigations have shown that different resection procedures have very different outcomes, with pneumonectomy associated with three-fold higher mortality than other resection types. While it is understandable that pathological and physiological factors influence a surgeon’s choice of surgery for a particular patient, the results presented in this study suggest that physician discomfort with the operative complexities of a procedure may lead to selection of a technique associated with less favorable outcomes.

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Hospital readmission rates after major thoracic surgery can run as high as 10-17%. Alarmingly, readmission after pulmonary resection for lung cancer has been associated with worse outcomes, including higher mortality. Thus, reducing readmissions after thoracic surgery can both save lives and reduce healthcare costs. Studies in internal medicine and cardiology have shown that programs that improve the transition from hospital to post-discharge care can be effective in decreasing emergency room visits and re-hospitalization. This study from McMaster University describes for the first time the benefits of an active, post-discharge intervention that begins in the hospital for patients who have undergone thoracic surgery.

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The National Emphysema Treatment Trial (NETT) was a multicenter, randomized, controlled clinical trial comparing the efficacy of lung volume reduction surgery (LVRS) plus medical management with rehabilitation to medical management plus rehabilitation in patients with severe emphysema. In 2003, the results of NETT demonstrated that LVRS could improve lung function in patients with emphysema, and that the procedure led to improved survival. Yet, adoption of LVRS has been very slow with concerns expressed regarding safety and long-term efficacy. In this presentation, Dr. Ginsburg will present the results of ten years of’ experience with LVRS for emphysema.

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New evidence suggests that lung cancer surgery patients are at higher risk of developing venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), than previously thought, with elevated risks of complications or death. When thromboemboli occur, they may be asymptomatic or attributed to post-surgical pain or complications, and may reflect both the lung cancer itself as well as compromised lung function after surgery. These incidents may also be ascribed to an inconsistent approach to prevention that currently exists among thoracic surgeons and hematologists who care for these patients. Three presentations at the 95th Annual Meeting of the American Association for Thoracic Surgery explore the problem of venous thromboembolism (VTE) after surgery for lung cancer.

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According to the American Cancer Society, in 2015 about 17,000 new cases of esophageal cancer will be diagnosed, and about 15,600 people will die from the disease. While the 5-year survival rate in the 1960s and 1970s was only about 5%, improvements in diagnosis, treatment, and management have led to improved survival. However, information is lacking about what happens to long-term survivors of esophageal cancer. A presentation at the AATS Annual Meeting shows that while five-year survival is up to 39%, these patients still face many health risks and should be monitored for 10 years or more.

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Meeting at a glance

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Cardiac surgeons often “crack open” the flat bone that forms the middle front section of the chest, known as the sternum, in order to reach important structures. When a sternal wound infection (SWI) occurs, serious complications and even death may result. Implanting antibiotic-laden sponges between the sternal halves before closure has been adapted to prevent infections. While a recent report questioned this practice, a meta-analysis in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery, clearly established that the sponges do work.

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Statins have been shown to reduce complications from cardiovascular surgery. To determine whether statins might also help those undergoing major lung surgeries, a team at Memorial Sloan Kettering Cancer Center conducted a well-designed study that randomized patients to receive either a statin or placebo before and after surgery. They found that patients undergoing major lung resection experienced fewer complications overall, however, the differences between groups for specific complications or changes in inflammatory markers failed to reach statistical significance, according to a report in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS).

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Hypoplastic left heart syndrome (HLHS) is a congenital defect in which the left side of the heart does not develop properly, impairing normal circulation. A series of surgeries can help restore heart function. A new study in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery, found use of a ring-reinforced cylinder instead of the usual non-reinforced conduit improved survival, reduced need for re-interventions, and induced physiological changes that may make patients better candidates for recovery after future surgeries.

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New molecular tools are emerging to identify lung adenocarcinomas during pulmonary resection. The results of a proof-of-concept study suggest that lung cancer fluorescent imaging during surgery using targeted molecular agents may soon be a reality. While the methodology still needs refinement, the technique holds the possibility of precise visualization of tumor margins, detection of other tumors or metastases, localization of small malignant ground glass opacities, and accurate identification of lymph nodes containing metastatic cancer cells.

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About 2% of the U.S. population has mitral valve regurgitation, which left untreated, can remain mild or lead to arrhythmia or heart failure. Timing of surgery is a matter of controversy, with guidelines suggesting “watchful waiting” or medical treatment until heart failure or poor function becomes apparent. Now a report in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS), finds that allowing patients to reach these “surgical triggers” doubles the risk of postoperative mortality and heart failure compared to those who undergo early surgery.

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For children born with life-threatening hypoplastic left heart syndrome (HLHS), reconstructive surgeries can restore blood circulation. While the most common corrective approach is the three-stage Norwood procedure, an alternative strategy, hybrid palliation, allows deferral of the more complex reconstructions to when the child is somewhat older and better able to successfully recover from major surgery. A report in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS), evaluates whether an arterial shunt in the hybrid palliation may be a better source for the pulmonary blood supply than the more frequently used venous shunt.

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With mounting concerns about postoperative seizures, doctors at The Children’s Hospital of Philadelphia placed 161 neonates who had undergone cardiac surgery on continuous EEG monitoring. They found that 8% of the neonates experienced EEG seizures and 85% of these were unrecognized clinically. Many of the seizures were severe, and the seizure group faced a higher risk of death, according to a report in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS).

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The ideal management strategy for primary cardiogenic shock is a matter of debate. After some early discouraging experiences, the use of extracorporeal life support for patients with cardiogenic shock is having a resurgence. A report from researchers in Padua, Italy finds that patients who have an acute onset of cardiogenic shock, for example following a heart attack, and are placed on extracorporeal life support, fare better than those who have a chronic cardiac pathology. In an accompanying editorial, Dr. Vivek Rao of the University of Toronto puts the findings of the study, such as a 59% survival to hospital discharge rate, in perspective.

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In the 40 years between 1970-2010, the proportion of patients with diabetes undergoing coronary artery bypass grafting (CABG) escalated from 7% to 37%. The results of a large study from Cleveland Clinic just published in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS), documents the five-fold increase in the proportion of patients with diabetes undergoing this procedure between 1970 and 2010. These patients have more postoperative complications and decreased long-term survival than those without diabetes, and represent a growing challenge to reining in healthcare costs.

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Tricuspid regurgitation (TR) occurs when the heart’s tricuspid valve leaks, allowing blood to flow back from the right ventricle to the right atrium. TR can be secondary to disorders of left-sided heart valves (mitral or aortic). At the 96th AATS Annual Meeting, investigators present the results of a long-term study of patients who underwent mitral valve (MV) repair. They found that although newly developed TR after MV repair was rare, the risk could increase in older patients with atrial fibrillation and impaired heart function.

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Analysis of data from the National Cancer Data Base (NCDB) demonstrates that the survival rates of patients with Stage IIIA NSCLC who underwent surgery increased more than three-fold for those who received four quality measures as part of their care. The study, presented by Pamela Samson MD, MPHS, of Washington University in St. Louis at the 96th AATS Annual Meeting, also shows a wide variability in compliance with quality measures, with only 12.8% of almost 8,000 eligible patients having received all four interventions. The study highlights the importance of implementing these recommended steps into actual practice.

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The TRANSFORM trial was designed to evaluate the safety and performance of an investigational rapid deployment aortic valve replacement (RDAVR) system for patients with severe aortic stenosis. Presented at the 96th AATS Annual Meeting, investigators showed that more than 96% of TRANSFORM patients had survived after one year and only 0.2% required reoperation. Cardiac function improved in 73%. Compared to conventional treatment, this procedure required significantly less cross-clamp and cardiopulmonary bypass times, even when smaller incisions were used.

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Researchers at Mayo Clinic (Rochester, MN) have identified risk factors for unplanned readmissions following esophageal resection. The results of their new study provide complete follow-up data for all patients undergoing esophagectomy at a high volume center over a one-year period in order to identify risk factors associated with unplanned readmissions. Karen J. Dickinson, MD, presents the results of this research at the 96th AATS Annual Meeting on behalf of the Thoracic Surgery Research Team at Mayo Clinic.

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Up to 50% of patients with soft tissue sarcoma (STS) develop lung metastases. Effective systemic therapies for metastatic STS are currently limited; when possible, surgical removal of the lung metastases (known as pulmonary metastasectomy, PM) is the preferred treatment. However, guidelines for the performance of PM for STS do not exist and decisions to operate are often made on an individual basis. In a presentation at the 96th AATS Annual Meeting, researchers from Memorial Sloan Kettering Cancer Center share the results of their experience with more than 500 patients with pulmonary metastases from STS and describe prognostic factors associated with improved survival.

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For children with severe heart failure, the only available means of life support are ventricular assist devices (VADs) placed outside the body. These devices are associated with significant risks and the need for hospital management. In conjunction with the National Heart, Lung and Blood Institute, investigators have now developed a miniaturized implantable VAD for small children (the Infant Jarvik 2015). The results of testing the device in live sheep are presented at the 96th AATS Annual Meeting.

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During heart surgery, it is sometimes necessary to temporarily stop cardiac activity, a process known as cardioplegia. Specific myocardial protection techniques are necessary for pediatric use. At the 96th AATS Annual Meeting, cardiac surgeons present the results of a prospective, randomized trial of pediatric heart surgery patients that shows that the del Nido cardioplegia solution, a new, long-acting agent, offers significant advantages over conventional cardioplegia, including reduced cardiopulmonary bypass and aortic cross-clamp times and faster onset of action.