Dor and Toupet Fundoplication Compared

Transcription

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VOL. 7
C ATHERINE H ARRELL /E LSEVIER G LOBAL M EDICAL N EWS
2011 Presidential Address
Dr. Irving L. Kron presented a timely and poignant analysis of the
need for better surgical mentorship at the AATS Annual Meeting
in Philadelphia. See highlights from his address on page 12.
Waiting List Survival
Better for PAH Patients
B Y M A R K S. L E S N E Y
Else vier Global Medical Ne ws
PHILADELPHIA – Although
mortality on the waiting list is
still a problem, the long-term
survival after lung transplantation of patients with
pulmonary
arterial hypertension
has significantly improved over time, a study has
shown.
In the study, pulmonary arterial hypertension (PAH) was classified as idiopathic (iPAH) or
associated with congenital heart
diseases or connective tissue diseases. Patients were divided into
1997-2004 and 2005-2010 cohorts.
Out of 2,918 patients referred
to the program between January 1997 and September 2010,
316 (11%) presented with PAH
(World Health Organization
Group 1).
In these patients, PAH was
classified as iPAH (123 patients),
congenital (77 patients), connective (102 patients), and other (14). The number of referrals
was similar between 1997-2004
and 2005-2010. Follow-up was
completed
until September
2010 for all
patients.
Among
the
100
PAH patients listed for lung
transplantation (LT), 57 underwent bilateral LT and 22 had
heart LT. Eighteen patients on
the waiting list died, and three
are still waiting. The waiting list
mortality was higher for patients with connective tissue diseases, Dr. Marc de Perrot said at
the annual meeting of the
American Association for Thoracic Surgery..
No patient with iPAH has
See PAH Patients • page 8
Dor and Toupet
Fundoplication
Compared
Post-myotomy results appear similar.
BY DIANA MAHONEY
SAN ANTONIO – Partial
fundoplication improves dysphagia and regurgitation
symptom scores in those patients undergoing laparoscopic Heller myotomy for
esophageal achalasia, regardless of whether the fundus is
laid over the anterior esophagus or wrapped around the
back of it, a multicenter study
has shown.
Previous studies have
demonstrated that partial fundoplication minimizes the
likelihood of developing gastroesophageal reflux disease
(GERD), but none has systematically compared the risks
and benefits associated with
wrapping the gastric fundus
anterior to the esophagus
(Dor fundoplication) or posterior to the esophagus
(Toupet fundoplication), Dr.
Arthur Rawlings said at the
annual meeting of the Society
of American Gastrointestinal
and Endoscopic Surgeons.
“The type of fundoplication
that should be performed is
controversial, and currently
determined by surgeon’s
choice rather than scientific
evidence,” he said. “Some surgeons advocate the Dor because they say it’s less
complicated to perform,
[avoids] the need for complete
posterior dissection, completely disrupts the posterior
esophageal ligament, and does
cover the exposed esophageal
mucosa.” On the other hand,
he noted, “other surgeons advocate for a Toupet fundoplication because it keeps the
edges of the myotomy separated and possibly provides
better reflux control.”
To compare symptom fre-
•
NO. 6
•
JUNE 2011
I N S I D E
News
Skip SCIP?
Results not promising for SSI
infection goals. • 3
Residents’ Corner
TSRA News
A new International Network
of Young CT Surgeons and
openings for the TSRA
Executive Committee. • 4
General Thoracic
Helping Hernias
Early repair of diaphragmatic
hernias prevents later
complications. • 7
From the AATS
91st AATS Annual
Meeting Highlights
Speeches, elections, and
decision making in
Philadelphia. • 11
See Compared • page 7
ACS Survey: Academic Surgeons Happier
BY BRUCE JANCIN
BOCA RATON, FLA. – Academic surgeons work longer
hours compared with private
practice colleagues, yet they
experience greater career satisfaction, and significantly less
burnout and symptoms of depression, a new analysis shows.
Indeed, being a surgeon in a
private practice environment
proved to be an independent
predictor of burnout in a mul-
tivariate analysis that controlled for other factors associated with burnout, including
nights on call, hours worked,
and surgical subspecialty, Dr.
Charles M. Balch reported at
the annual meeting of the
American Surgical Association.
These were among the central findings of a follow-up
analysis of a survey of nearly
8,000 members of the American College of Surgeons (ACS)
conducted in 2008. This analysis focused on town vs. gown
differences in distress and career satisfaction.
For example, 77.4% of 2,272
surgeons in academic practice
indicated that if they had it to
do it over again, they would
still become a surgeon, compared with 64.9% of 4,240 private practice surgeons who
had that response. And although 61.3% of academic surgeons said they’d recommend
that their children become
See Happier • page 2
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NEWS
JUNE 2011 • THORACIC SURGERY NEWS
Academic Surgeons
Happier
•
MDs, only 43.7% of those in private
practice said they would do so. In a multivariate analysis, being a private practice
surgeon was independently associated
with a 47% increased likelihood of career
dissatisfaction, compared with academic practice, according to Dr. Balch of
Johns Hopkins University, Baltimore.
The initial report of the survey results
several years ago garnered widespread
attention because it uncovered surprisingly high levels of distress among surgeons overall. The prevalence of
burnout (as assessed using a validated assessment tool) was 40%, whereas 30% of
surgeons screened positive for symptoms of depression. That report focused
on the substantial differences found in
distress rates among 14 surgical subspecialties (Ann. Surg. 2009;250:463-71).
The new analysis revealed that most of
the factors associated with burnout and
career satisfaction were different for academic and private practice surgeons. For
academic surgeons, the three factors that
were independently associated with
burnout were trauma surgery, hours
worked, and nights on call. Factors that
from page 1
appeared to protect academic surgeons
from burnout were pediatric surgery, cardiothoracic surgery, being male, and children who were older than age 22 years, .
In a private practice environment, the
factors associated
with burnout were
urologic surgery,
31%-50% of time
devoted to nonclinical activities, and incentive-based pay,
hours worked and
nights on call. Factors negatively associated with burnout
were older children, a physician spouse,
less than 10% of time devoted to nonclinical activities, and older age.
Dr. Timothy J. Eberlein, a discussant,
noted that several of the surgical specialties with particularly high burnout
rates – vascular surgery, urologic surgery,
and otolaryngology – are all high-volume specialties with declining reimbursement. In contrast, cardiothoracic
surgery, although certainly a stressful occupation, had the fourth-lowest prevalence
of burnout of the 14 surgical specialties
studied, behind ob.gyn., orthopedics, and
pediatric surgery. Perhaps this is because
cardiothoracic surgeons make liberal use
of physician extenders, suggested Dr. Eberlein of Washington University in St. Louis.
Pediatric surgery’s status as the surgical specialty with the least burnout may
have to do with the environment that is
characteristic of
children’s hospiCardiothoracic
tals: supportive,
surgeons had the
nurturing, and
fourth-lowest
perhaps
more
prevalence of
emotionally reburnout of the
warding for pracsubspecialties in
titioners, he said.
the study.
Regardless, Dr.
Eberlein said that
DR. BALCH
he was struck by
what seem to be extraordinarily high levels of burnout among surgeons overall,
whether in academia or private practice.
It’s especially troubling because the average age of survey respondents was roughly 50 years, a time in life when people in
most professions are at the height of their
productivity. How do these burnout rates
compare with those of other professions,
such as law or business? he asked.
Dr. Balch said that most professions
haven’t undertaken this sort of detailed
analysis. But other medical specialties
that deal with life-and-death issues daily
– such as medical oncology, anesthesiology, and critical care medicine – also have
high rates of burnout and depression.
He added that because the ACS takes
these issues seriously, the college commissioned a new 53-question membership survey late last year. It devoted
special attention to addiction and personal wellness issues. Roughly 7,000 surgeons completed the survey. The data
are being analyzed, and results will be
presented later this year.
Several audience members declared
that the 40% prevalence of burnout that
was identified in the 2008 survey is bafflingly at odds with their own observations. They wondered whether the
survey, which was completed by 32% of
recipients, might have been subject to response bias, with unhappy surgeons perhaps being more inclined to fill out a
lengthy 64-item questionnaire.
Dr. Balch said that, if anything, the
survey results actually underestimate the
full scope of burnout and depression.
Evidence from other fields suggests that
individuals with these forms of distress
are less likely to participate in surveys.
The survey was funded by the ACS.
Dr. Balch had no financial conflicts. ■
Data Back APACHE III for Predicting 30-Day Mortality
HUNTINGTON
BEACH,
CALIF. – The lack of a standard
scoring system for predicting
morbidity and mortality makes
it difficult to compare surgical
ICU outcomes within and across
institutions, but a recent study
has found the APACHE score
superior to others.
Because these scores help
guide treatment – for instance,
when to start and stop Xigris
(drotrecogin alfa [activated]) for
sepsis – it’s important to use
the best system, said Dr. Kavin
Shah of the medical center in
New Hyde Park, N.Y., who presented the results at the annual
Academic Surgical Congress
He and his colleagues compared the APACHE (Acute Physiology and Chronic Health
Evaluation) I and III scores, SAPS
(Simplified Acute Physiology
Score), and MODS (Multiple Organ Dysfunction Score) to see
which best predicted 30-day mortality in the surgical ICU (SICU).
Using admission data from
the medical center’s SICU database, the team scored 2,833 patients with each system.
Predictions were matched with
actual mortality. Patients were
at least 18 years old, and 53%
were male. In all, 73% were admitted from elective or emergency surgery. The 30-day SICU
mortality was 10.9%, which was
similar to that of SICU mortality rates at other institutions.
APACHE III beat the competition, as assessed by the area
under receiver operating characteristic curves (AUROC); an
AUROC of 1 would indicate a
perfect predictor.
APACHE III’s AUROC was
0.8615, with a standard error
(SE) of 0.013. The SAPS AUROC was 0.8489, with an SE of
0.013; the APACHE I AUROC
was 0.8234, with an SE of 0.014;
and the MODS AUROC was
0.8071, with an SE of 0.015 (P
less than .01).
APACHE III incorporates
more data and allows more frequent rescoring than do other
systems, which makes it harder
to use, but Dr. Shah said he believes the slight predictive advantage is worth the effort when a
SICU admits 90 patients a month,
as is the case at his center.
“The numbers add up. Even [a
small advantage] is going to improve care and save hundreds or
thousands of lives over a longenough time span,” he said.
The researchers plan to validate the results by examining
the SICU data from a stister institution. APACHE IV (the latest
version, which has more parameters) will be added to the
comparison if the databases
have the required information,
Dr. Shah said.
–M.A. Otto
T HORACIC S URGERY N EWS
AMERICAN ASSOCIATION
FOR THORACIC SURGERY
Editor Yolonda L. Colson, M.D., Ph.D.
Associate Editor, General Thoracic
Michael J. Liptay, M.D.
Associate Editor, Adult Cardiac John G. Byrne, M.D.
Associate Editor, Cardiopulmonary Transplant
Richard N. (Robin) Pierson III, M.D.
Associate Editor, Congenital Heart William G. Williams, M.D.
Executive Director Elizabeth Dooley Crane, CAE, CMP
Associate Executive Director Cindy VerColen
Editorial Associate Lisl K. Jones
Resident Editor Stephanie Mick, M.D.
Resident Editor Christian Peyre, M.D.
THORACIC SURGERY NEWS is the official newspaper of the American Association
for Thoracic Surgery and provides the thoracic surgeon with timely and
relevant news and commentary about clinical developments and about
the impact of health care policy on the profession and on surgical practice
today. Content for THORACIC SURGERY NEWS is provided by International
Medical News Group, LLC, an Elsevier company, and Elsevier Global
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The ideas and opinions expressed in THORACIC SURGERY NEWS do not
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American Association for Thoracic Surgery and Elsevier Inc., will not
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©Copyright 2011, by the American Association for Thoracic Surgery
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Page 3
NEWS
3
SCIP Hasn’t Improved Key SSI Outcomes
Following the Surgical Care Improvement Program
prevention measures seemed to make no difference.
BY BRUCE JANCIN
BOCA RATON, FLA. – Adherence to
Surgical Care Improvement Program
measures that are aimed at preventing
surgical site infections has not had the desired effect, according to a large national Veterans Affairs study.
There is widespread agreement that
reducing surgical site infections is a worthy quality improvement goal. These infections are associated with a twofold
increase in mortality, a 60% increase in
ICU admission, and a fivefold greater
likelihood of hospital readmission after
discharge.
But the VA study results showing that
the SCIP hasn’t reduced surgical site infection rates call into question whether
the program is worth continuing.
“SCIP adherence is not informative to
third-party payers, administrators, or
patients. The policy of continued SCIP
measurement for public reporting and
payment should be reevaluated,” Dr.
Mary T. Hawn declared in presenting
the VA study findings at the annual
meeting of the American Surgical Association.
SCIP is a multiyear partnership that
was initiated in 2003 with the goal of reducing surgical morbidity and mortality
at U.S. hospitals. Among the 10 national
organizations that are represented on
the SCIP steering committee are the
American College of Surgeons, the
American Hospital Association, the U.S.
Department of Veterans Affairs, the Centers for Medicare and Medicaid Services,
the Agency for Healthcare Research and
Quality, the Centers for Disease Control
and Prevention, and the Joint Commission.
Dr. Hawn presented a retrospective
study of 60,853 procedures performed at
112 VA hospitals during 2005-2009. The
outcome measure was the combined
rate of superficial and deep surgical site
infections (SSIs) occurring within 30 days
of surgery.
The independent variables were adherence to each of five SCIP surgical
site infection prevention measures that
hospitals are required to collect and report. The five measures are timely administration of a prophylactic
antibiotic, timely discontinuation of the
antibiotic, appropriate antibiotic coverage, hair removal, and normothermia
for colon procedures.
In addition, investigators tracked the
impact of rates of adherence to all five
measures in a given case, a combined
metric they called composite SCIP.
This was the first study to use individual patient-level data for evaluating
SCIP. Investigators were able to adjust
for the presence of comorbid conditions that are known to affect the risk
of SSIs, such as diabetes, dyspnea, and
corticosteroid use, noted Dr. Hawn of
the University of Alabama at Birmingham.
The overall SSI rate was 6.2%. It
didn’t vary significantly over the 5-year
study period, which began when the
SCIP measures were first implemented
in the VA system. Rates of adherence to
the five SCIP measures quickly climbed
to high levels during the first 6 months,
probably because of the VA’s pay-for-per-
formance incentives, she explained.
A first look at the data suggested that
SCIP might be performing as intended.
For example, there was an 81% adherence rate to the composite SCIP measure, and surgical cases meeting that
standard had a 45% lower SSI rate than
did those in which all five measures
weren’t met. However, when patientlevel SSI risk
factors were introduced in a multivariate
logistic
regression analysis, there was no
longer any association between SCIP
adherence and SSI
rates.
SCIP adherence rates ranged from a
high of 86.4% for orthopedic surgery to
a low of 60.4% for colorectal procedures. Adherence rates for gynecologic
and vascular procedures were 85.9% and
81.6%, respectively.
In a separate analysis, Dr. Hawn and
her colleagues looked at the relationship
between a hospital’s adherence to SCIP
measures and the institutional SSI rate.
Once again, they found that there was
none. The difference in hospital rates of
SCIP adherence accounted for a mere
2% of the variation in hospital-wide SSI
rates.
Dr. Hawn said that it is particularly
troubling, in light of the VA data, to consider that public reporting of the SCIP
adherence rates is being used to guide patients to what are supposed to be highquality hospitals. “Are we really guiding
patients to the right hospitals?” she
asked.
Discussant Dr. David B. Hoyt noted
that the collection of SCIP data consti-
tutes a huge cost for American hospitals.
“It’s essential that quality measurement systems put in place actually correlate with improvement in quality.
This study today is a critical example of
how a well-intended process can in fact
fail to reduce surgical infections. Overall, the SCIP program does not achieve
its goal,” said Dr.
Hoyt, executive
‘The policy of
director of the
continued SCIP
American College
measurement for
of Surgeons.
public reporting
“The data coland payment
lection burden has
should be
increased in the
reevaluated.’
last several years,
and unless indicaDR. HAWN
tors that are ineffective are dropped, the expense of
adding new indicators cannot be accommodated,” he added.
Dr. Donald E. Fry commented that the
SCIP measures are valid. The trouble is,
they’re not inclusive.
“To paraphrase Paul Simon, ‘There
must be 50 ways to get an SSI.’ And antibiotics are only a small portion of that,”
said Dr. Fry, executive vice president at
Michael Pine and Associates, Chicago, an
analytic health care consulting firm.
“I hope that this presentation will be
a significant stimulus for us to go forward with not measuring silly process
measures. This is not synchronized
swimming. We need to be measuring
outcomes. We need objective measures
of what it is we’re trying to do, looking
at how good hospitals do it well and
bad ones don’t do it so well, and coming up with an entire strategy for SSIs,”
he said.
The SCIP study was funded by the VA.
Dr. Hawn declared having no relevant financial interests.
■
Featured in the JTCVS
The following articles are featured from the June
2011 issue of the Journal of Thoracic and Cardiovascular
Surgery.
Editorial
The surgical and interventional hybrid era:
Experiences from China
Shengshou Hu
Reflections of the Pioneers
Beginning of percutaneous coronary interventions: Zurich 1976–1977
Marko Turina
Congenital Heart Disease
Primary sutureless repair for ‘‘simple’’ total anomalous pulmonary venous connection: Midterm results in a single institution
Bobby Yanagawa, Abdullah A. Alghamdi, Andreea Dragulescu, et al.
Sutureless repair for primary surgical management
of ‘‘simple’’ total anomalous pulmonary venous
connection was compared with conventional repair.
A higher rate of decline in postoperative right ventricular systolic pressure was seen in the sutureless
repair group. The outcomes of survival and devel-
opment of pulmonary vein stenosis were not different.
General Thoracic Surgery
Multicenter analysis of high-resolution computed
tomography and positron emission tomography/computed tomography findings to choose
therapeutic strategies for clinical stage IA lung
adenocarcinoma
Morihito Okada,, Haruhiko Nakayama, Sakae Okumura, et al.
This multicenter study using a phantom study to
correct inter-institutional variability of PET/CT
findings shows that maxSUV is a significant preoperative predictor for surgical outcomes. HRCT
and PET/CT findings are important to select therapeutic strategies for treating clinical stage IA adenocarcinoma of the lung, such as sublobar
resection.
Acquired Cardiovascular Disease
Effectiveness of dabigatran etexilate for thromboprophylaxis of mechanical heart valves
Stephen H. McKellar, Stuart Abel, Christopher L.
Camp, Rakesh M. Suri, Mark H. Ereth, and Hartzell
V. Schaff
Mechanical valve prostheses necessitate lifelong anticoagulation. Warfarin has limitations, including
1% to 2% per year stroke incidence. Dabigatran
etexilate does not have warfarin’s limitations but
has not been tested in this setting. Positive preclinical data show that dabigatran etexilate may
provide an alternative to warfarin for patients with
mechanical valves.
Evolving Technology/Basic Science
Calcification of allograft and stentless xenograft
valves for right ventricular outflow tract reconstruction: An experimental study in adolescent
sheep
Willem Flameng, Ramadan Jashari, Geofrey De Visscher,
Lindsay Mesure, and Bart Meuris
This experimental study shows the superiority of
pulmonary homografts over aortic homografts for
right ventricular outflow tract reconstruction. Stentless porcine xenografts and bovine jugular vein
conduits are an acceptable alternative because they
have low cusp calcification and no leaflet tearing or
cusp immobilization. However, significant wall calcification develops despite any anticalcification
treatment.
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Page 4
RESIDENTS’ CORNER
4
CLINICAL CHALLENGE
Test Your Knowledge of Dealing With Air Embolism
56-year-old male is undergoing
an aortic valve replacement
through a full sternotomy with
standard aortic and right atrial cannulation at a temperature of 34 degrees.
You are preparing to place your last annulus suture when you notice a large
bolus of air travel through your arterial line, into the arterial perfuser and
into the patient’s aorta.
A
Directed questions:
1. What organ is at greatest risk for
damage due to massive air embolism?
2. What is the first instruction you
should give to your perfusionist
when you first note an air embolism?
3. What is the first instruction you
should give to your anesthesiologist?
4. What strategy can be used to “deair” the cerebral circulation?
5. What neuroprotective strategies can
be employed intraoperatively?
6. What therapeutic adjuncts can be
employed postoperatively to minimize neurologic sequelae?
7. What is most common source of air
emboli?
8. What routine strategies can be employed to minimize the risk of massive air embolism?
Key Points and Answers to
Questions:
1. The greatest concern from massive
air embolism is a stroke. Massive air
embolism is rare with an estimated
frequency of less than 0.01% but
carries a significant morbidity and
mortality.
2. Upon detection of air embolism, the
cardiopulmonary bypass machine
should be stopped to avoid further
injection of air into the arterial circulation. An expeditious search for
the source of the air should take
place and steps taken to de-air the
circuit to be able to resume cardiopulmonary bypass.
3. The patient should be placed in steep
trendelenberg position to minimize
further travel of air into the cerebral
circulation. Hopefully, air will return
into the proximal aorta and can be aspirated or drained via the aortotomy.
4. Retrograde cerebral perfusion can
be performed to flush the air from
the cerebral circulation. A cannula
can be inserted into the superior
vena cava and perfused with cold
blood (< 20 degrees) in a retrograde
fashion. The aorta may need to be
opened to allow egress of air from
the cerebral circulation.
5. In addition to retrograde cerebral
perfusion, deep hypothermia and
corticosteroids might be beneficial.
Hypothermia decreases brain oxygen
consumption and allows for more
time for retrograde perfusion under
circulatory arrest.
6. Postoperatively, continued use of
steroids and moderate hypothermia might be beneficial and some
have recommended barbiturate
coma to minimize brain metabolism. Reports suggest a benefit of
hyperbaric oxygen therapy in the
immediate postoperative period.
The benefit of hyperbaric oxygen
therapy appears greatest when instituted within about 5 hours of
surgery and seems less efficacious if
there is a delay in the initiation of
therapy.
7. The most common source of air emboli is unremoved air from the cardiac chambers.
8. Important strategies include careful
inspection of the arterial circuit for
air prior to initiation of bypass,
stringent use of cardiopulmonary
bypass safety alarms which monitor
the reservoir level and bubble monitors to detect air in the cardiopulmonary bypass circuit, compulsive
de-airing maneuvers at conclusion
of surgery, and careful examination
for residual intracardiac air with
transesophageal echo.
Select References and Additional
Resources
P Hammon JW. (2008). Extracorporeal Circulation: Perfusion System. In
Cohn LH (Ed), Cardiac Surgery in the
Adult. (3rd edition, 350-370). New
York: McGraw-Hill.
P Kern JA, Arnold S. Massive Cerebral
Embolization: Successful Treatment with Retrograde Perfusion.
Annals of Thoracic Surgery. 69: 1266,
2000.
P Mills NL, Ochsner JL. Massive air
embolism during cardiopulmonary
bypass: causes, prevention and management. Journal of Thoracic and Cardiovascular Surgery. 80:708–717, 1980.
P Utley JR. Techniques for avoiding
neurologic injury during adult cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 10(1):
38-44, 1996.
P Ziser A, Adir Y, et al. Hyperbaric oxygen therapy for massive arterial air
embolism during cardiac operations.
Journal of Thoracic and Cardiovascular Surgery. 117(4): 818, 1999.
This Challenge was provided by Resident
Medical Editor, Dr. Christian Peyre.
News From the TSRA
The International Network of Young
Cardiothoracic Surgeons
Traditionally young international cardiothoracic surgeons and residents have been restricted in sharing ideas
and problems to annual meetings or in monthly journal articles. In turn, Facebook has largely been used by
residents only to see what co-residents have been up to
over the weekend!
No longer. A new Facebook group, the International Network of Young Cardiothoracic Surgeons (iNYCTS) was recently founded by the Thoracic Surgery
Residents Association (TSRA), the Surgical Training and
Manpower Committee of the European Association for
Cardiothoracic Surgery (EACTS), and several other international organizations in the hope of fostering international relations between young cardiothoracic
surgeons.
The creation of this group represents an innovation
in the cardiothoracic surgery community; there is no
similar social network or society aimed at those who
will be instrumental in the future of the speciality,
young cardiothoracic surgeons.
By joining this unrestricted group, young cardiothoracic surgeons all over the world are able to share new
ideas, techniques and problems. The easy flow of communication provided by this electronic social network
allows for promotion of events and courses within the
cardiothoracic community. Whether through discussions of how to manage an innominate vein tear at sternotomy or how the latest stapler works in real world
conditions, the iNYCTS has already increased the sharing of ideas worldwide; in the short 3 months that the
group has been in existence, almost 600 members have
joined and posted over 20,000 ideas.
To join in the discussion, “Like” the Facebook page
at “International Network of Young Cardiothoracic
Surgeons (http://www.facebook.com/iNYCTS).”
TSRA Call for Applications
The Thoracic Surgery Residents Association (TSRA) is
announcing four open positions on the TSRA Executive Committee for the 2011-2012 academic year. Each
Executive Committee member will be nominated for
a position as the TSRA representative for a national organization such as the Residency Review Committee
(RRC), The Society of Thoracic Surgeons (STS), the
American Association for Thoracic Surgeons (AATS),
and the Association of American Medical Colleges
(AAMC). The TSRA representative is required to attend
the national meetings for his/her respective organization, attend the TSRA meetings at the STS and AATS
Annual Meetings, and serve as an active participant in
the TSRA.
In addition to the Executive Committee, there are
two subcommittees of the TSRA that have open positions for the upcoming year.
The Education Committee works closely with the
Joint Council for Thoracic Surgery Education ( JCTSE)
and the Thoracic Surgery Directors Association (TSDA)
to advance surgical education among students, residents, and faculty in our specialty.
The Communications Committee acts as a liaison between the TSRA and other national organizations,
such as the STS, the AATS, and the AAMC, to ensure
that our voice is being heard nationally and internationally.
These positions require dedication and time beyond
your clinical responsibilities. You may apply for a position if you are beginning or continuing a cardiothoracic
residency in July 2011; you must remain a resident
through June 30, 2012 to be considered.
To apply, please send the following:
P A letter of intent (one page) outlining your desire to
be involved in TSRA and your vision of the future of
cardiothoracic training;
P A letter from your Program Director stating your
leadership potential as well as confirming financial support and schedule flexibility to attend national meetings;
P Your curriculum vitae; and
P Rank order of which committees you would prefer
to join (e.g. 1-Communication, 2-Executive, 3-Education). Please note that omission of any committee in
your rank list will have no bearing on your application
to the other committees.
All materials should be e-mailed to TSRA Secretary,
Dr. Jason Williams, at [email protected] no
later than Wednesday, June 15, 2011. For more information about the TSRA, visit www.TSRAnet.org. ■
Some Online Resources
AATS Resident Resources:
www.aats.org/TSR/index.html
CTSNET Residents Section:
www.ctsnet.org/sections/residents
Thoracic Surgery Directors Association:
www.tsda.org
Thoracic Surgery Foundation for Research and
Education:
www.tsfre.org
Thoracic Surgery News:
www.thoracicsurgerynews.com
Thoracic Surgery Residents Association:
www.tsranet.org
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ADULT CARDIAC
5
Two-Year Data Indicate MitraClip Safety, Durability
B Y C A R O L I N E H E LW I C K
NEW ORLEANS – T he durability and
safety of treating mitral regurgitation
with a percutaneous device as compared
with that of surgical repair or replacement persisted at 2 years, based on an updated analysis of the EVEREST II trial
results presented at the annual meeting
of the American College of Cardiology.
“Our fundamental finding is that outcomes are very stable between 1 and 2
years of follow-up,” Dr. Ted Feldman,
principal investigator, announced at a
press briefing. The 2-year follow-up results show both approaches reduced MR,
and meaningful clinical benefits persisted, said Dr. Feldman of the NorthShore
University HealthSystem in Evanston, Ill.
Clinical outcome measures at 2 years
showed MR grade and left ventricular
(LV) volumes remained stable between
1 and 2 years in both groups. The intergroup comparison showed a more favorable reduction in MR and a greater
reduction in LV diastolic volume with
surgery at 1 and 2 years, and no difference in systolic volume reduction. Also,
NYHA functional class was stable between years 1 and 2. “Interestingly, the
inter-group comparison showed a more
favorable NYHA class outcome at both
years with the clip,” he reported.
EVEREST II (Endovascular Valve
Edge-to-Edge Repair Study) is a prospective, multicenter, randomized controlled
phase II trial comparing the safety and efficacy of the MitraClip System with mitral valve surgery in the treatment of MR.
The study enrolled 279 patients with 3+
or 4+ MR who were either symptomatic
or were asymptomatic with a baseline left
ejection fraction of 60%. Approximately
half of the patients had New York Heart
Association (NYHA) functional class III
or IV heart failure.
At the meeting, Dr. Feldman presented two analyses of the 2-year data. The
composite primary efficacy endpoint
was freedom from death, MV surgery for
valve dysfunction (for device patients) or
re-operation (for surgery patients), and
MR greater than 2+ at 12 months.
In the intention-to-treat analysis, the
primary composite endpoint was met at
2 years by 52% of the percutaneous
group and by 66% of the surgery group;
in the 1-year analysis, these figures were
55% and 73%, respectively.
More patients receiving the clip later
underwent MV surgery (22%) compared
to the few patients in the surgery arm
who required re-operation (3.6%). There
was no significant difference in mortality or recurrent MR.
In the second analysis, there was no
statistical difference in the effectiveness
endpoint between the two arms of the
study. “When subsequent surgery within 90 days on device patients is considered a success, we see similarly stable
results at 1 and 2 years,” he noted.
In this analysis, the primary endpoint
was met at 2 years by 63% of the percutaneous group and by 66% of the
surgery group. By removing the subse-
quent need for MV surgery as an end
point event, 6.2% of the percutaneous
group and 3.6% of the surgery group
had MV surgery or re-operation.
There was no difference in the KaplanMeier mortality plot for the intention-totreat analysis at any time point, he
stressed. At 1 year, 95% of the patients
in each arm were alive; at 2 years, 91%
of the surgery arm and 90% of the percutaneous arm were still alive.
Freedom from MV surgery/re-opera-
tion, however, favored the surgical arm:
96% versus 78% at 2 years. The “need for
surgery in patients in the clip group was almost entirely in the first several months; after 6 months the curves overlapped at 1 and
2 years,” he observed. “Importantly, 78% of
device patients are free from MV surgery
at 2 years.” When early failures were excluded, there were no differences in need
for MV surgery or reoperation.
At a press conference, Dr. Feldman explained that the two analyses “answer dif-
ferent questions.” “The intention-to-treat
analysis gives the patient the odds of success with the clip at the end of the year,”
he said. “It tells them that 78% will be free
of the need for surgery at 2 years, and 97%
will have NYHA functional class I or II.”
The second analysis answers the question, ‘What if I am in the 20% needing
surgery?’ It counts the combined strategy of the clip, with surgery as needed.
Dr. Feldman reported consulting and research monies from Abbott Vascular. ■
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01_2_6_7_8ts11_6.qxp
6
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Page 6
GENERAL THORACIC
Minimally Invasive Esophagectomy Has Low Mortality
BY BRUCE JANCIN
BOCA RATON, FLA. — Minimally
invasive esophagectomy has advanced
to the point where it offers significant advantages over open esophagectomy in
terms of operative morbidity and mortality, judging by results of a single-center review of 980 cases.
Published series indicate that the operative mortality of open esophagectomy is
8%-21%, although a few high-volume
medical centers have reported rates as low
as 3%.
“There is a perception among patients
and physicians that open esophagectomy
is to be avoided at all costs because of it
substantial morbidity,” Dr. James D.
Luketich said at the annual meeting of
the American Surgical Association.
In his review of 980 consecutive, elective, nonurgent, minimally invasive
esophagectomies, the 30-day mortality
was just 1.8%. Median operative time
was 6.7 hours, which dropped to 4 hours
in cases that were not done by residents.
The median ICU stay was 2.0 days, with
a median hospital length of stay of 8
days. A median 21 lymph nodes were dissected, and 98% of cases had negative
surgical margins.
“A less invasive surgical approach for
esophageal cancer would improve the
standard of care by reducing morbidity
and shortening hospital stays and time to
return to daily activities. If successful,
surgeons might see more early-stage referrals from Barrett’s patients now in
surveillance,” added Dr. Luketich,
professor of surgery and chief of the
Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh
Medical Center.
Using a modified Ivor-Lewis approach involving
laparoscopic conduit preparation,
videothoracoscopic esophageal mobilization, and an
intrathoracic anastomosis is preferable to the McKeown approach when the
minimally invasive route is chosen. It entails fewer conduit complications and
lower mortality, Dr. Luketich said.
In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal
mobilization, laparoscopic conduit
preparation, and neck anastomosis,
whereas 51% were treated via the modified Ivor-Lewis approach.
This was a nonrandomized study, but
patients in the two study arms were essentially the same in terms of baseline
characteristics. In all, 95% were operated
on for malignant disease, 80% were men,
and 31% received preoperative
chemotherapy and/or radiotherapy. Patients who were operated on in the most
recent years of the series underwent the
Ivor-Lewis approach because Dr.
Luketich has come to prefer it. He noted
that most trainees
are more comfort‘Laparoscopyable with it; they
VATS–chest
have far more exanastomosis is
now our preferred perience with operating in the chest
approach to most
than the neck.
esophageal
F u r t h e r m o re ,
cancers.’
outcomes are better than results
DR. LUKETICH
with the McKeown
approach. Indeed, the 30-day mortality
rate was just 1.2% with the Ivor-Lewis
minimally invasive esophagectomy chest
(MIE-chest) approach vs. 2.5% with the
McKeown MIE-neck approach. The major morbidity rate was 31% in the MIEchest group, significantly less than the
36% with the MIE-neck group. This difference was driven by the increased risk
of laryngeal nerve injury with the McKeown approach. The incidence of vocal cord paresis or paralysis was 8% in the
MIE-neck patients, compared with 1% in
the MIE-chest group.
Rates of other complications were
closely similar in the two groups: 6% for
empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart
failure, and 5% for anastomotic leak requiring surgery.
Quality of life assessments using the
Short Form-36 indicate that by 90 days,
post-MIE patients scored in the age-adjusted normal range. “I think by 90 days
the patients have bounced back,” Dr.
Luketich added.
“Laparoscopy–VATS [video-assisted
thoracic surgery]–chest anastomosis is
now our preferred approach to most
esophageal cancers,” he concluded.
Discussant Dr. David J. Sugarbaker
called Dr. Luketich’s study “a landmark
paper.”
“Dr. Luketich has ... developed a procedure that is rapidly becoming a standard of care worldwide. This is the
largest experience reported to date,” noted Dr. Sugarbaker, professor of surgical
oncology and chief of the division of
thoracic surgery at Brigham and
Women’s Hospital and Harvard Medical
School, Boston.
Dr. Luketich declared that he had no
financial conflicts of interest.
■
Harvard Medical School
Department of Continuing Education
7th Triennial
Brigham Cardiac Valve Symposium
October 20-21, 2011
Fairmont Copley Plaza Hotel - Boston, Massachusetts
Offered by the
Brigham and Women’s Hospital
Divisions of Cardiac Surgery, Cardiovascular Medicine
and Cardiac Anesthesia
Co-sponsored by the
American Association for Thoracic Surgery
Course Directors
R. Morton Bolman, III, M.D., Patrick T. O’Gara, M.D. and
Stanton K. Shernan, M.D.
TO REGISTER OR VIEW COURSE INFORMATION ONLINE, VISIT:
WWW.CME.HMS.HARVARD.EDU/COURSES/CARDIAC
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Page 7
GENERAL THORACIC
Fundoplication
Compared
•
from page 1
quency and severity as well as physiological differences
associated with the two procedures, Dr. Rawlings of
Washington University, St. Louis, and his colleagues
conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five
sites in 2003-2008 were randomized to the Dor or
Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point
(0-4) Likert scale preoperatively and at 2-6 weeks, 6
months, and 12 months postoperatively. They also
evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a
composite DeMeester pH score, he said.
Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12month pH studies for 24 of the 49 patients who were
randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure,
Dr. Rawlings said. The results reported at the meeting
represent those obtained for the patients for whom pHtesting results were available, he explained.
In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr.
Rawlings said. “Statistically significant improvements
were observed in both groups for all but heartburn and
chest pain measures,” he noted. Specifically, in the Dor
group, the preoperative solid dysphagia, heartburn, and
regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3
improved to 1.0, 0.3, and 0.1, respectively, he said.
There was no significant difference between the two
groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid
reflux was experienced by 42% of the Dor patients and
Frailty Score Predicts Chance
Of Postop Institutional Care
7
just 21% of the Toupet patients, said Dr. Rawlings. The
difference between the median DeMeester pH scores
at 6 months for the Dor (7.2) and Toupet (2.2) groups
did not reach statistical significance, he said.
In a subgroup analysis of individuals with abnormal
reflux scores regardless of fundoplication procedure,
“the only thing that fell out as significant was heartburn
frequency and severity,” Dr. Rawlings stated.
The findings indicate that both the Dor and Toupet
procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings.
The differences in pathological acid reflux between the
two groups, though not statistically significant, “do
support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure,” he said.
This study was supported a SAGES research grant.
Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.
■
Benefits With Uncomplicated
Diaphragmatic Hernia Repair
CHICAGO – One in three elderly veterans re-
quired discharge to an institutional care facility following major elective surgery in a
prospective cohort study of 223 patients. Surgical specialties included general, thoracic,
vascular, and urology.
The chance of being discharged to an institution rose dramatically from 5% if an individual patient had 0 to 1 frailty traits to 21%
with 2 or 3 traits, 76% with 4 or 5 traits, and
89% with 6 or 7 traits, lead author Dr. Thomas
Robinson said at the annual meeting of the
Western Surgical Association.
The comparisons were significant at a P value of .01, except for the 4 or 5 traits vs. 6 or
7 traits (P = .31). On the basis of their research,
“we have [developed] a standardized sheet
that can be put up on the clinic door, and the
surgeon can walk up and review the sheet
and understand the burden of frailty of an
individual patient and counsel them appropriately,” Dr. Robinson said.
The 223 veterans in the study had an average age of 73 years. The majority were male
(96%), and all had lived at home before undergoing an elective major operation requiring postoperative ICU admission at the
Denver Veterans Affairs Medical Center.
In a univariate analysis, patients discharged
to institutional care were significantly older
than those who went home (77 vs. 72 years),
and significantly more likely to have any functional dependence (76% vs. 16%), a get-upand-go test time of at least 15 seconds (67%
vs. 8%), a Charlson comorbidity index of 3 or
more (86% vs. 42%), increased American Society of Anesthesiologists score (3.0 vs. 2.8),
a hematocrit less than 35% (44% vs. 6%), an
albumin less than 3.4 g/dL (66% vs. 10%), a
Mini-Cog score of 3 or less, and at least one
fall in the prior 6 months (61% vs. 17%).
The number of medications, body mass index, weight loss, and depression were not significantly associated with discharge
institutionalization, said Dr. Robinson of the
University of Colorado at Denver.
Intraoperative variables including length of
operation, blood loss, transfusion, and type of
surgery were also similar between groups.
On logistic regression analysis, two frailty
characteristics were found to be most closely
related to discharge to an institutional care facility: prolonged time on the get-up-and-go
test of 15 seconds or more (odds ratio 13.0, P
value less than .0001) and dependence in one
or more activities of daily living (OR 5.7, P less
than .0001), he said.
The get-up-and-go test measures the time
needed to rise unassisted from a chair, walk
several feet, and return to the chair. Mean
length of institutional stay at a nursing home,
skilled nursing facility, or rehabilitation facility was 25 days (range, 3-112 days).
During a discussion of the study, Dr.
Charles Scoggins of the University of
Louisville (Ky.), asked whether the score predicts postop complications. “Yes, they absolutely do,” responded Dr. Robinson.
“We have groups of cardiac patients that
were scored in complications and then validated in colorectal operations. I’d go one step
further and say that frailty across surgical
specialties can predict postoperative outcomes
whether they be complications, dispensation
to an institutional care facility, [or] in our previous paper, 6-month mortality.”
The accumulation of four frailty markers
predicted 6-month mortality with a sensitivity of 81% and specificity of 86%. In addition,
the functional frailty characteristic of dependence in one or more activities of daily living
was found to be most closely related to 6month mortality, a finding reinforced by the
study (Ann. Surg. 2009;250:338-47).
Invited discussant Dr. Travis Webb of the
Medical College of Wisconsin, Milwaukee, said
that increasing evidence points to factors beyond simple age as predictors of mortality,
morbidity, and the need for skilled nursing care
in the posthospitalization time period. He said
the need for accurate information on these
predictors will become increasingly important
as the number of elderly surgery patients swells.
It is estimated that 55% of all operations in the
United States are being performed on patients
aged 65 years and older.
Dr. Robinson said screening is particularly
valuable if done in the operative clinic and that
screening results have changed the decision to
have surgery, the scope of the surgery, and patient and family expectations.
■
PHILADELPHIA – Current
clinical practice is to repair symptomatic diaphragmatic hernias to
avoid complications such as obstruction or gangrene. However,
practice patterns are based largely on limited data from institutional case series, according to Dr.
Subroto Paul and his colleagues at
Cornell University in New York.
Mortality was significantly high-
sion in 31,127 (16.1%) and 651
(0.3%) patients, respectively. Mortality was significantly higher in
patients who were admitted with
obstruction or gangrene (4.5% vs.
27.5%, respectively), compared
with patients who were admitted
for an elective hernia repair (1%).
Morbidity from pneumonia and
sepsis was also significantly higher in patients
who were admitted for
obstruction or gangrene.
Symptomatic admission was associated with
more intensive hospitalization, as evidenced by
significantly increasing
length of stay – 6 days
(uncomplicated) vs. 9
days (obstruction) vs. 17.5
days (gangrene) – and the
need for mechanical venDr. Subroto Paul presented his results
tilation (3.6% vs. 9.7 vs.
at the AATS Annual Meeting.
41.3%, respectively).
Based on their mortality data,
er in those patients with uncomplicated hernia who went on to the authors also performed a lifereadmission with obstruction or time risk analysis that suggested
gangrene, Dr. Paul said at the an- that elective repair is associated
nual meeting of the American As- with a favorable risk-benefit prosociation for Thoracic Surgery, file for patients in their 50s, 60s,
where he presented an analysis of and perhaps early 70s.
“In this large national database
the National Inpatient Sample
study, the prevalence of diaphrag(NIS) database.
Over a 10-year period, 193,554 matic hernia per hospital admission
patient admissions were identi- is 1:2,000. Admissions resulting
fied for the primary diagnosis of from gangrene or obstruction are
diaphragmatic hernia of any type. not uncommon and are associated
An uncomplicated diaphragmatic with worse outcomes than [is rehernia was the diagnosis in pair] in uncomplicated hernias.
“This analysis suggests the prac161,777 (83.6%) admissions. Of
these, 38,764 (24.0%) patients un- tice of repair of uncomplicated diderwent an elective repair of their aphragmatic hernia may avoid the
hernia as the principal procedure morbidity and mortality associated with either obstruction or ganfor their admission.
A diagnosis of diaphragmatic grene,” he concluded.
Dr. Paul reported that he had
hernia with obstruction or gangrene was the reason for admis- no relevant disclosures.
■
CATHERINE HARRELL/ELSEVIER GLOBAL MEDICAL NEWS
B Y P AT R I C E W E N D L I N G
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Page 8
CARDIOPULMONARY TRANSPLANT
New Heart Allocation Algorithm Appears Effective
BY SUSAN LONDON
SAN DIEGO – A new allocation algorithm designed
to improve regional sharing of donor hearts with sicker patients before allocation locally to less-sick patients
appears to be having the intended effects, according to
a national cohort study of nearly 12,000 adult patients,
those who were wait-listed after the new algorithm was
implemented were 17% less likely to die on the waiting
list or to become too sick for transplantation, researchers
reported at the annual meeting of the International Society for Heart and Lung Transplantation.
And reassuringly, “the shift in hearts to sicker transplant candidates has not resulted in higher early posttransplant mortality.” said lead investigator Dr. Tajinder
P. Singh, a pediatric cardiologist at Children’s Hospital Boston.
These findings suggest that the new algorithm has
been effective “not only from a utilitarian view, which
means most benefit for most people, but even from the
fairness or justice perspective by granting hearts to sicker people,” he commented.
An attendee asked whether patterns might differ at
the local or regional level vs. the national level, given
that some centers in the New York City area, for example, feel they have been hurt by the new algorithm.
Dr. Singh replied that because of small patient numbers
and regional variations, it was not possible to get a reliable picture at those levels.
“The demand for donor hearts continues to exceed
their supply,” he said, “The United Network for Organ
Sharing has periodically modified the allocation algorithm in the United States” to improve waiting list outcomes. The last such modification, implemented in July
2006, expanded the sharing of these scarce organs
across a geographic region, making them available first
to the sickest patients (those with status 1A or 1B) in a
Waiting List
region before allocating them locally to less-sick patients.
“The goal of such a change was to lower national
[waiting list] mortality without a concurrent increase
in posttransplant mortality, and that consideration is
more than theoretical because sicker patients will be at
higher risk of dying post transplant,” he explained. “The
early outcome trends after the allocation change have
AFTER ADJUSTMENT FOR NUMEROUS
POTENTIAL CONFOUNDERS, PATIENTS IN
ERA 2 WERE 17% LESS LIKELY TO DIE OR
WORSEN WHILE ON THE WAIT LIST.
been supportive, but regional analyses have questioned
the merits of the new allocation.”
The investigators studied all patients aged 18 years or
older who were placed on the waiting list for primary
heart transplantation between July 1, 2004, and June 30,
2009, and who were undergoing transplantation of only
a heart. For comparison, the patients were split according to when they were listed into “era 1” (before
the date of implementation of the new algorithm) and
“era 2” (after that date). Study results were based on
11,864 patients in total; 38% were listed in era 1 and
62% were listed in era 2.
Patients in the two eras were similar with respect to
most sociodemographic and medical factors, except
that those in era 2 were more likely to be aged 60 years
or older (32% vs. 28%), to receive mechanical support
(14% vs. 13%), and to be sicker, as indicated by having
a transplantation status of 1A (20% vs. 19%) or 1B (38%
vs. 32%), for instance.
Overall, 13% of the patients studied either died or
had a worsening of their condition that prevented
transplantation while they were on the waiting list, the
study’s primary end point, Dr. Singh reported.
Before statistical adjustment, patients in era 2 were
14% less likely than their counterparts in era 1 to die
or worsen while on the wait list (hazard ratio, 0.86; P
= .005). And this benefit was evident among both status 1A patients and status 1B patients individually.
After adjustment for numerous potential confounders, patients in era 2 were 17% less likely to die
or worsen while on the wait list (HR, 0.83; P = .001).
The benefit was similar in most subgroups, except that
by race, it was mainly limited to white patients. Other
risk-reducing factors included having an implantable
cardioverter defibrillator (HR, 0.87) and having a continuous-flow left ventricular assist device (HR, 0.56).
Overall, 65% of the patients ultimately underwent
transplantation. Compared with their counterparts in
era 1, era 2 transplant recipients had a shorter median
wait time before receiving a heart (55 vs. 63 days; P less
than .001) and were more likely to be status 1A at transplantation (48% vs. 37%; P less than .001). The donor
ischemic time was longer for recipients in era 2 (3.3 vs.
3.2 hours; P = .02), but the small difference was probably not clinically important, according to Dr. Singh.
The lack of a greater difference in ischemic time –
despite the sharing of organs over larger geographic areas in the latter era – was not surprising, he said. “The
way it occurred, it went from local to within 500 miles,
say. It may be broader regional sharing, but it’s not long
distance to get to [the heart] and bring the heart in to
the surgery.”
There was no rise in the rate of in-hospital mortality post transplantation with the new algorithm. In fact,
“interestingly, in-hospital mortality was lower rather
than higher [in era 2], even though sicker patients were
getting transplanted,” Dr. Singh commented, with a
rate of 5.3% in era 2, compared with 6.3% in era 1.
Dr. Singh reported having no conflicts of interest. ■
VADs as Bridge to Cardiac Retransplantation
PAH Patients • from page 1
BY SUSAN LONDON
died on the waiting list since 2005; 25%
died before that time, he and his associates at Toronto General Hospital
found.
After LT, the 30-day mortality decreased from 24% in the first cohort to
6% in the second, a significant difference. The 10-year survival was 56% after bilateral LT and 49% after heart LT,
a nonsignificant difference.
However, the 10-year survival was
significantly worse for iPAH patients at
42% vs. 70% for the remaining patients
(P = .01). The 10-year survival was best
for connective tissue disease (69%) and
congenital (70%) patients.
Lung transplantation is a viable option for about a third of the patients presenting with PAH, according to Dr. de
Perrot. He added that extracorporeal
life support may help reduce the waiting list mortality, particularly for iPAH
patients. Overall, the 30-day mortality
for patients after lung transplantation
has improved significantly over time.
“Patients with connective tissue diseases have a high mortality on the waiting list, but enjoy excellent long-term
survival after transplant,” Dr. de Perrot
concluded.
Dr. de Perrot reported receiving
speaker and teaching honoraria from
Actelion.
■
SAN DIEGO – Ventricular assist de-
vices appear to be a “reasonable strategy” for supporting certain patients who
have failing cardiac grafts and are waiting for a new heart, concludes a retrospective review of more than 1,500
patients who had a second transplant.
In the group who had retransplantation at least 1 year after their first transplantation, median survival was about 7
years. There was no difference between
patients bridged with a ventricular assist
device (VAD) and those who did not
have bridging with any type of mechanical circulatory support (MCS), said
Dr. David L. S. Morales at the annual
meeting of the International Society for
Heart and Lung Transplantation.
But survival was poor for those who
were bridged after any interval with extracorporeal membrane oxygenation
(ECMO) and for those who underwent
retransplantation because they had primary graft failure or a hyperacute rejection, regardless of whether they were
mechanically supported.
“The use of ECMO to bridge any patient to retransplantation does not appear judicious, nor does the use of MCS
to bridge patients with primary graft failure or hyperacute rejection to retrans-
plantation,” said coinvestigator Dr.
Morales of the departments of surgery
and pediatrics at the Texas Children’s
Hospital in Houston. “However, the use
of VADs to bridge patients to transplant after a year could be reasonable.”
The investigators analyzed data from
the United Network for Organ Sharing
(UNOS) database for 1,535 patients who
underwent cardiac retransplantation
during 1982-2009. Results showed that
just 8% of the patients were bridged to
retransplantation, with a VAD in about
two-thirds of cases and ECMO in the
other third. The patients bridged to retransplantation were significantly more
likely than were their nonbridged counterparts to have primary graft failure or
hyperacute rejection (54% vs. 11%) and
significantly less likely to have chronic
rejection (16% vs. 63%).
By and large, bridged patients underwent retransplantation early, with 64%
in the VAD group and 76% with ECMO
retransplanted within 3 months of their
primary transplantation, compared with
just 12% of their nonbridged peers.
“Regardless of MCS, patients retransplanted for primary graft failure or hyperacute rejection do not do well,” Dr.
Morales commented. In patients with
these indications for retransplantation,
the 1-year mortality rate stayed at 83%,
In the entire study population, medi-
an overall survival after retransplantation was 6.1 years in nonbridged patients, significantly longer than the 1.5
years in VAD-bridged patients and the 30
days in ECMO-bridged patients.
In patients who underwent retransplantation at least 1 year after primary
transplantation, median survival was
similar in nonbridged and VAD-bridged
patients, at 7.0 and 6.9 years. Survival
was significantly shorter – just 6 months
– in the ECMO group.
As for study limitations, “it is very important to note that we do not know the
number of patients placed on MCS as a
bridge to transplant who died while on
support,” he pointed out.
Despite the more favorable findings
for VAD bridging, his pediatric patients
needing retransplantation in adolescence often have chronic vasculopathy
in their graft, Dr. Morales said. “They
are a very, very difficult group to support
with mechanical support with LVADs
because we have to continue the immunosuppression,” and the patients often die from infections as a result.
“It’s one of the reasons I’m interested in the total artificial heart ... completely [stopping] immunosuppression I
think will help bridge those patients,”
Dr. Morales has research/consulting
relationships with Berlin Heart, Syncardia
Systems, and CircuLite.
■
THOR_9.qxp
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Page 1
ON YOUR MARK
Accuracy matters most in the thoracic aorta. TALENT CAPTIVIA zeroes in
with tip capture for controlled deployment and precise placement,1 hydrophilic coating to facilitate stent graft delivery,
longer lengths—up to 200mm—for fewer passes up tight iliacs. 2
Get right to your solution at medtronicendovascular.com/talentcaptivia
Here to deliver.
F R O M
P I P E L I N E
T O
PAT I E N T
10ts11_6.qxp
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Page 10
DEVICES, DRUGS & TRIALS
CLINICAL TRIALS TRACK
Cardiothoracic Surgery Research at the NHLBI
he Cardiothoracic Surgery Research Program is an
intramural research program within the National
THeart,
Lung, and Blood Institute at the NIH in Bethesda Md. The Director of the laboratory is Dr. Keith A.
Horvath,
Currently the program focuses on three major research areas, represented by sections: cell-based therapy, bioengineering, and transplantation. In their
2010 quadrennial report, the group detailed 4 years
of significant translational research”representing the
return of cardiothoracic research to the NHLBI after
a hiatus since 1990,” according to Dr. Horvath.
The Cellular Biology Section is focused on cell-based
therapy for myocardial ischemia using adult bone-marrow-derived mesenchymal stem cells (BMSCs).
Their research aims are focused on a large animal
model to test the effects of BMSCs on chronic myocardial ischemia, to study the fate and differentiation
of BMSCs after administration, and to further investigate gene expression patterns of BMSCs under both
normoxic and hypoxic conditions.
The group has already demonstrated the benefits of
direct injection of autologous BMSCs in to chronically ischemic myocardium.
Direct injection of autologous BMSCs into the ischemic myocardium showed regional ventricular wall
thickening demonstrating significant improvement after cell treatment, whereas saline treated animals
Indications
The Talent® Thoracic Stent Graft System is intended for the endovascular repair of fusiform aneurysms and saccular aneurysms/
penetrating ulcers of the descending thoracic aorta in patients
having appropriate anatomy, including:
• Iliac/femoral access vessel morphology that is compatible with
vascular access techniques, devices, and/or accessories;
• Non-aneurysmal aortic diameter in the range of 18–42 mm; and
• Non-aneurysmal aortic proximal and distal neck lengths
≥ 20 mm
Contraindications
The Talent® Thoracic Stent Graft is contraindicated in:
• Patients who have a condition that threatens to infect the graft.
• Patients with sensitivities or allergies to the device materials
Warnings and Precautions
• Read all instructions carefully. Failure to properly follow the
instructions, warnings and precautions may lead to serious
consequences or injury to the patient
• The Talent Thoracic Stent Graft System should only be used
by physicians and teams trained in vascular interventional
techniques, including training in the use of this device. Specific
training expectations are described in the Instructions for Use.
• Consider having a vascular surgery team available during
implantation or reintervention procedures in the event that
conversion to open surgical repair is necessary.
• Do not attempt to use the Talent® Thoracic Stent Graft with the
Captivia Delivery System in patients unable to undergo the necessary preoperative and postoperative imaging and implantation
studies as described in the Instructions for Use.
• The Talent Thoracic Stent Graft System is not recommended
in patients who cannot tolerate contrast agents necessary for
intra-operative and post-operative follow-up imaging.
• The Talent Thoracic Stent Graft System is not recommended in
patients exceeding weight and/or size limits which compromise
or prevent the necessary imaging requirements as described in
the Instructions for Use.
showed no improvement compared to baseline as assessed by echocardiography.
Global function was also improved following BMSC
injection and increased vascularity was found in the
BMSC group compared to saline injected controls.
BMSCs isolated from transgenic pigs designed to express enhanced green fluorescent proteins as the donors
showed that allogeneic injection of the green BMSCs
is safe, with no observable side effects or signs of graft
versus host disease were observed.
The green cells were found migrating from the injected area into deeper layers of myocardium over the
course of 1 to 6 weeks. By immunofluorescent staining, the green cells were associated with smooth muscle actin or vWF positive cells, suggesting that the
transplanted cells were contributing to the formation
of new vessels.
They found no evidence that these cells were associated with the new generation of cardiac myocytes,
which suggests that the benefits of this therapy may
be due to angiogenesis not the regeneration of cardiac
myocytes. Gene profiling of the cells before and after
transplantation showed that genes such as VEGF,
HIF1-a, PDGF, ANGPT2 and CXCL14 were significantly up-regulated.
A clinical trial will be conducted at the NIH Heart
Center at Suburban Hospital, Bethesda, and will follow the direct injection of BSMCs into ischemic areas
in patients after coronary artery bypass grafting
(CABG) or transmyocardial revascularization.
The Transplantation Section at CSRP has focused on
• Prior to the procedure, pre-operative planning for access and
placement should be performed. See Instructions for Use for more
detail. Key anatomic elements that may affect successful exclusion of the aneurysm include severe neck angulation, short aortic
neck(s) and significant thrombus and/or calcium at the arterial
implantation sites. In the presence of anatomical limitations, a
longer neck length may be required to obtain adequate sealing
and fixation. See Instructions for Use.
• The use of this device requires administration of radiographic
agents. Patients with preexisting renal insufficiency may have an
increased risk of renal failure postoperatively.
• The safety and effectiveness of this device in the treatment of
dissections have not been established
• Inappropriate patient selection may contribute to poor device
performance.
• The long-term safety and effectiveness of this implant have
not been established. All patients with endovascular aneurysm
repair must undergo periodic imaging to evaluate the stent graft
and aneurysm size. Significant aneurysm enlargement (>5 mm),
the appearance of a new endoleak, or migration resulting in an
inadequate seal zone should prompt further investigation and
may indicate the need for additional intervention or surgical
conversion.
• Intervention or conversion to standard open surgical repair
following initial endovascular repair should be considered for
patients experiencing enlarging aneurysms and/or endoleak. An
increase in aneurysm size and/or persistent endoleak may lead to
aneurysm rupture.
• Failure to align the connecting bar with the outer bend of the
target vessel may increase the likelihood of endoleaks post
implantation.
• During general handling of the Captivia Delivery System, avoid
bending or kinking the graft cover because it may cause the
Talent® Thoracic Stent Graft to prematurely and improperly
deploy.
• The retrieval of the tip must be carefully monitored with
fluoroscopic guidance to ensure that the tip does not cause the
Talent® Thoracic Stent Graft to be inadvertently pulled down.
developing a clinically relevant large animal cardiac
xenotransplantation model, using genetically engineered pig hearts place in baboons.
Efforts are being focused on appropriate immunosuppression through drugs, stem cell, and genetic-engineering of donor hearts. These research efforts
involve a working collaboration with Mayo Clinic,
University of Pittsburgh, University of Maryland,
Beth Israel Hospital, NIH Swine Center in Missouri,
and Revivicor.
The Bioengineering Section is focused on developing
and applying engineering technologies with devices,
imaging and robotics with the goal of achieving “stateof-the-art minimally invasive cardiac operations.
“By enhancing precision and consistency, these novel procedures will improve clinical outcomes and expand the cohort of patients that can be treated.”
The current work focuses on beating heart aortic
valve replacement under real-time MRI guidance. Feasibility studies have been completed and long term animal studies are underway.
Active and passive markers have been added to the
prostheses and delivery device to aid visualization and
allow placement of the valve with the precision
achieved in an open surgical procedure in 1/100th the
time. The current goal is to translate this work into a
clinical trial.
This column will keep track of these and other research efforts conducted by the CSRP, especially as they
move from preclinical to clinical applications of their
advanced research.
■
MRI Safety and Compatibility
Non-clinical testing has demonstrated that the Talent Thoracic
Stent Graft is MR Conditional. It can be scanned safely in both 1.5T
and 3.0T MR systems under certain conditions as described in the
product Instructions for Use. For additional information regarding
MRI please refer to the product Instructions for Use.
Adverse Events
Potential adverse events include (not arranged in any particular
order): Amputation, Aneurysm Enlargement, Balloon rupture,
Breakage of the metal portion of the device, Cardiac Failure/
Infarction, Conversion to open surgery, Death, Deployment difficulties, Edema, Endoleak, Erectile Dysfunction, Erosion with fistula
or pseudoaneurysm, Failure to deploy, Gastrointestinal complications, including: adynamic ileus, bowel (ileus, transient ischemic,
infarction, necrosis), Graft twisting and/or kinking, Hemorrhage/
Bleeding, Inaccurate placement, Infection and fever, Insertion and
removal difficulties, Intercostal pain, Neurological complications,
including: change in mental status, spinal cord ischemia with
paraplegia, paraparesis and/or paresthesia, Cerebral Vascular
Accidents (CVA), Transient Ischemic Attacks (TIA), neuropathy, and
blindness, Prosthetic thrombosis, Pulmonary complications, Renal
failure, Rupture of graft material, Ruptured vessel/aneurysm, Stent
graft migration, Vascular complications including: thrombosis,
thromboembolism, occlusion (arterial and venous), vessel dissection or perforation, collateral vessel occlusion, vascular ischemia,
tissue necrosis, Wound healing complications.
Please reference product Instructions for Use for more information regarding indications,
warnings, precautions, contraindications and adverse events.
CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician.
www.medtronicendovascular.com
Medtronic
3576 Unocal Place
Santa Rosa, CA 95403
USA
Tel: 707.525.0111
Product Services
Tel: 888.283.7868
Fax: 800.838.3103
CardioVascular LifeLine
Customer Support
Tel: 877.526.7890
Tel: 763.526.7890
References
1. Data on file, deployment accuracy test. Bench test data may not be indicative
of clinical performance Medtronic Vascular; Santa Rosa, CA; 2009.
2. Data on file, number of devices implanted at initial procedure test. Medtronic
Vascular; Santa Rosa, CA; 2010
11_15ts11_6.qxp
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Page 11
NEWS FROM THE AATS
11
AATS Annual Meeting Wrap-Up
M ARTIN A LLRED /E LSEVIER G LOBAL M EDICAL N EWS
T
Dwight C. McGoon Award given
annually by the Thoracic Surgery
Residents Association (TSRA), for
“Excellence in Resident Education.”
• The 14th Annual C. Walton Lillehei
Resident Forum Award was presented to Dr. Damien J. LaPar of the
University of Virginia for his outstanding abstract submission, manuscript preparation, and
presentation.
The C. Walton Lillehei Resident Forum Award was presented to Dr. Damien J.
LaPar (center) by Brett Thompson (left), St. Jude Medical, and Dr. Irving L. Kron.
Sex and Gender: The Impact on Disease and Patient Outcomes session
were well received by attendees. A
webcast of the program will be available on the AATS website
(www.aats.org) this summer.
Rounding out the educational experience was the exhibit area featuring the Cardiac Hybrid OR, Thoracic
Hybrid OR, and brand new Hybrid
ICU. These Hybrid Technologies©
were multipurpose interventional operating room suites that demonstrated the ways to integrate digital
imaging diagnostics, as well as radiologic, catheterization and surgical capabilities.
Participants took advantage of the
exhibit area to discuss business, view
new innovations in the field as well as
listen to several educational talks.
Highlights of the Annual Meeting included;
• The Presidential Address by Dr.
Irving L. Kron entitled “Surgical
Mentorship.”
• The Basic Science Lecture by Dr.
Susan B. Shurin titled “Public Support of Biomedical Research.”
• The Honored Speaker Lecture by
Dr. Michael J. Mack titled “The Only
Constant Is Change.”
• A late breaking clinical trial presentation by Dr. D. Craig Miller on behalf
of the PARTNER (Placement of
AoRTic TraNscathetER Valves)
Stroke Substudy Group (available
online at www.aats.org).
• Dr. Marc R. de Leval received the
Scientific Achievement Award for his
extraordinary scientific contributions
to the specialty.
• Dr. John R. Doty received the
• A late breaking session moderated
by Dr. John D. Puskas on Coronary
Artery Disease in 2011 and Beyond.
• A fourth simultaneous scientific session on Aortic/Endovascular
Surgery.
To learn more about meeting highlights, view the AATS Daily News at
http://www.thoracicsurgerynews.
com/aats-annual-meeting.html.This
newspaper is the one-stop source
for all the Philadelphia meeting coverage.
At its Annual Business meeting on May
10th, the AATS Council inducted the
following members to positions
within the AATS Council.
• Dr. Craig R. Smith of New York, NY
was inducted as the Association’s
92nd President;
• Dr. Hartzell V. Schaff of Rochester,
MN was named President-Elect,
• Dr. David J. Sugarbaker of Boston,
MA was elected to serve as Vice
President;
• Dr. Thoralf M. Sundt, III of Boston,
MA was elected to serve as Secretary;
• Dr. Duke E. Cameron of Baltimore,
MD was elected to serve as Treasurer;
• Dr. Ralph J. Damiano, Jr., of St.
Louis, MO was appointed chair of
the AATS Education Committee,
which also includes appointment to
the AATS Council. Also elected to
Council, Dr. Lars G. Svensson of
Cleveland, OH, who will join Drs.
Joseph S. Coselli, Lawrence H.
Cohn, Hiroshi Date, Bartley P. Griffith, Irving L. Kron, and Vaughn A.
Starnes to form the 2011-2012
AATS Council.
The membership endorsed the following actions based on the recommendations of the Council:
• Agreed to develop a joint program
with the TCT sponsor, the Cardiovascular Research Foundation during
our 2012 Annual Meeting in San
Francisco.
• Agreed to expand the partnership
with the American College of Cardiology (ACC) by 1) extending the annual Heart Valve Summit held in
Chicago; 2) co-sponsoring a Spotlight
session on Transcatheter Heart Valves;
and 3) conducting a joint session at
the ACC’s 2012 Annual Congress.
• Authorized the development of a
two-day stand alone scientific program in the area of general thoracic
surgery to be conducted in the fall of
2012.
• Approved the conduct of the Mitral
Conclave under the direction of Dr.
David Adams which attracted almost
1,000 professionals to New York City
and the continuation of the Aortic
Symposium in 2012 under the direction of Drs. Randy Griepp and Steve
Lansman.
• Agreed to participate in a course
conducted by the Japanese Association for Thoracic Surgery. This is in
• Developed an In Vivo Large Animal
Models Course, which was led by
Dr. Bart Griffith. The course preceded the 3rd stand alone Grant
Writing Workshop in Bethesda and
Baltimore, Maryland.
• Expanded the AATS Leadership
Academy program by sponsoring
an advanced program for Division
Chiefs and also agreed to implement an international forum during next year’s Annual Meeting for
selected members who are responsible for conducting formal training
programs.
• Assumed administrative responsibilities for the Adult Cardiac and General Thoracic Surgery Biology Clubs.
• Approved the establishment of an ad
hoc Evidence Based Guidelines
Committee.
• Authorized a membership survey
providing members with an opportunity to individually volunteer for
committee appointments.
• Authorized the development of a
website to supplement the publication of Thoracic Surgery News under the direction of Dr. Yolanda
Colson.
• Established an annual 360-degree review process for the editors and associate editors of the association’s
M ARTIN A LLRED /E LSEVIER G LOBAL M EDICAL N EWS
he 91st AATS Annual Meeting
was a tremendous success. The
meeting, which took place May 7
– 11, 2011 in Philadelphia, Pa, attracted over 2,600 cardiothoracic surgeons
and other professionals specializing in
cardiothoracic surgery. The program,
including the newly added Physician
Assistant/Nurse Practitioner/Perfusionist program, Non-Technical Skills
for Surgeons (NOTSS) program, and
Dr. Susan B. Shurin, Acting Director of the National Heart, Lung and Blood
Institute, National Institutes of Health, presented the Basic Science Lecture at
the AATS Annual Meeting in Philadelphia. Her lecture was titled “Public
Support of Biomedical Research.” Dr. Shurin put a decidedly optimistic spin
on the future of thoracic surgeons in research. “There has never been more
opportunity to advance surgical research,” she stated.
addition to ongoing joint participation in programs with EACTS, ESTS
and the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS).
• Partnered with the National Heart,
Lung, and Blood Institute (NHLBI)
to develop a two day Symposium
with over 125 attendees to prioritize
consensus on key research gaps requiring NIH leadership.
journal and three sister scientific
publications.
• Agreed to conduct an annual executive session with the leadership of
the STS to identify those areas in
which our two organizations might
work most closely for the benefit of
our specialty.
• Expanded our five year commitment
Continued on following page
11_15ts11_6.qxp
12
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Page 12
NEWS FROM THE AATS
Continued from previous page
Elected the following thirty-seven
surgeons to Active membership:
Gorav Ailawadi, M.D.,
Charlottesville, VA
Lishan Aklog, M.D.,
Phoenix, AZ
Rafael Andrade, M.D.,
Minneapolis, MN
Vinay Badhwar, M.D.,
Orlando, FL
Faisal Bakaeen, M.D.,
Houston, TX
Thomas Beaver, M.D.,
Gainesville, FL
Lael-Anson Best, M.D.,
Haifa, Israel
Andrea Carpenter, M.D.
San Antonio, TX
Haiquan Chen, M.D.,
Shanghai, China
Traves Crabtree, M.D.,
St. Louis, MO
Juan Crestanello, M.D.,
Columbus, OH
Eric Devaney, M.D.,
C ATHERINE H ARRELL /E LSEVIER G LOBAL M EDICAL N EWS
to financially support the TSFRE.
• Continued its annual Strategic Planning process and authorized conducting six targeted focus group
discussions during this Annual Meeting intended to provide Council
with member input into the future
directions of the organization.
P
Dr. Michael J. Mack presented the Honored Speaker lecture “The Only Constant
Is Change” at this year's annual meeting. Dr. Mack is chairman of the board for
the Cardiopulmonary Research Science & Technology Institute and the medical
director of cardiovascular services, Baylor Health Care System. He focused on
the need for surgeons to adapt to continous technological change.
Ann Arbor, MI
Paul Fedak, M.D.,
Calgary, AB, Canada
Michael Firstenberg, M.D.,
Columbus, OH
Seth Force, M.D.,
Atlanta, GA
Mark Galantowicz, M.D.,
Columbus, OH
Changqing Gao, M.D.,
Beijing, China
Jeffrey Heinle, M.D.,
Houston, TX
Wayne Hoftstetter, M.D.,
Houston, TX
Krishna Iyer, M.D.,
New Delhi, India
Ranjit John, M.D.,
Minneapolis, MN
Kamal Khabbaz, M.D.,
Boston, MA
Brian Kogon, M.D.,
Atlanta, GA
Igor Konstantinov, M.D.,
Melbourne, Australia
Benjamin Kozower, M.D.,
Charlottesville, VA
Michael Lanuti, M.D.,
Boston, MA
Virginia Litle, M.D.,
Rochester, NY
Xiao-Cheng Liu, M.D.,
Tianjin, China
Mathias Loebe, M.D.,
Houston, TX
Mahender Macha, M.D.,
Jackson, MS
Noboru Motomura, M.D.,
Tokyo, Japan
Christian Pizzaro, M.D.,
Wilmington, DE
Patrick Ross, Jr., M.D.,
Columbus, OH
Edward Sako, M.D.,
San Antonio, TX
Rakesh Suri, M.D.,
Rochester, MN
Thorsten Wahlers, M.D.,
Cologne, Germany
Gerhard Ziemer, M.D.,
Tuebingen, Germany
Please make plans to attend the 92nd
Annual Meeting of the American Association for Thoracic Surgery to be
held at the Moscone West Convention Center, in San Francisco, CA,
April 28 – May 2, 2012.
American Association
for Toracic Surgery
2011
Heart Valve
Summit
Medical, Surgical and
Interventional Decision Making
Co-sponsored by:
October 13 – 15, 2011
JW Marriott Chicago
Program Directors
David H. Adams, M.D., F.A.C.C.
Steven F. Bolling, M.D., F.A.C.C.
Robert O. Bonow, M.D., M.A.C.C.
Howard C. Herrmann, M.D., F.A.C.C., F.S.C.A.I.
Accreditation
Space is Limited! Register
today at www.aats.org/valve.
Physicians
The American Association for Thoracic Surgery is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
This live activity is approved for AMA PRA Category 1 CreditsTM
Nurses
The American College of Cardiology foundation is accredited as a
provider of continuing nursing education by the American Nurses
Credentialing Center’s commission on Accreditation.
©2011 American College of Cardiology. H11144
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NEWS FROM THE AATS
13
2011 AATS Presidential Address
urgical mentorship must focus
on going beyond didactic teaching to truly transforming our
residents and fellows into capable thoracic surgeons. It
must teach the critically important
components of
technical surgery,
the juxtaposition of
hands and brain
that cannot be
learned by simply
being told, or from
observing, but
from actually doing, according to
Irving L. Kron,
MD, in his presidential address given at the AATS
Annual Meeting on
Monday, May 9,
2011.
Dr. Irving L. Kron
And therein lies
the problem for
the current trainees, according to Dr.
Kron. For “developing these clinical
skills is probably the most difficult
thing that we do. And, as Dr. Norman
Shumway stated in his AATS presidential address, ‘the hardest thing
about cardiac surgery is getting to
do.’”
The problem is real, according to Dr.
Kron, who pointed out that he has
heard of graduating residents who literally could not operate and went out
into the real world, often at the expense of their patients and their own
careers.
“Let me lay the gauntlet down. This
should never occur! We have failed our
students, either by failing to teach, not
giving them more time, or failing to
counsel those few who should not be
surgeons.”
Why should you teach and mentor
surgery? he asked. Training residents
allows you to expand the range of your
surgical skills to all those patients you
come to treat.
“Most importantly, you protect the
patients of the future and perhaps
eliminate learning curves. If we can do
this, then we will truly contribute to
the welfare of our present and future
patients.”
“What is the best way to teach
S
surgery?” Dr. Kron asked. “There has
been a great deal of effort in streamlining residencies, resulting in the integrated programs out of medical
school. There also
has been an increased interest in
simulation. Rick
Feins and his colleagues have done
an outstanding job
with the Boot Camp
in teaching with the
use of simulation
technology. We are
much more focused
on use of sophisticated models, such
as Web learning.
Unfortunately, we
have basically ignored teaching our
residents to operate.”
The reason is not
lack of interest, according to Dr. Kron, but a lack of clarity of how to best to do this. There are
different styles of teaching surgery, and
there has been no attempt to standardize the teaching of technical procedure. There are real and legitimate
obstacles to teaching surgery, he pointed out. Many believe that observation
is the best way to learn surgery. Others
believe that helping a resident is committing malpractice.
“As a matter of fact, this was quoted
to me by a prominent congenital surgeon. There is no question in my mind
that he felt strongly that the best person to do that operation was himself.
However, that certainly limited his ability to improve the next generation and
perhaps improve the care for his own
patients.”
Time constraints are also a problem.
Dr. Kron agreed that attending surgeons have time constraints in academic and private institutions, with many
patients to look after and meetings to
attend. But the main obstacle to teaching is the question as to whether the
quality of the operation diminishes if a
resident is involved during surgery,
even under supervision.
“There is no question that unsupervised care will lead to disasters,” Dr.
Kron said. He cited the Libby Zion
case in New York that led to the present work-hour restrictions, noting
that the issue there was more about
lack of supervision, than just the fact
that it was a resident involved. In
terms of evidence, however, there are
no publications in cardiac surgery that
demonstrate that helping a resident
hurts the outcome of the operation.
“Conversely, there have been multiple publications demonstrating that
complex procedures such as mitral
surgery and off-pump coronary
surgery can be successfully accomplished by supervised residents,” Dr.
Kron said.
What are the elements of truly
teaching surgery? he asked. “I think
most of us feel that they are pretty
straightforward. You must be handson. You can’t teach from the office.”
The first part is preparation: You
must be there from the beginning and
plan the operation ahead of time with
the resident. The resident and the faculty member must be organized
enough to know what is going on. Ideally, the attending and resident each
operate in most cases.
A lot of it is helping the resident, but
some of it is the resident watching the
attending doing complex maneuvers,
according to Dr. Kron. However, the
resident can’t learn just by reading or
observing. Dr. Kron said.
Dr. Kron cited the important concept of heuristics, which are rules of
thumb that experts learn through trial
and error.
As examples of surgery-related
heuristics, he pointed out that there are
motor heuristics, which include handling tissues and anastomoses; perceptual, meaning that “the trained eye”
learns to recognize anatomic variants;
and cognitive, which involve “planning
a movement and checklists.”
Heuristics help with common problems in teaching surgery. An example
would be creating or planning proper
geometry of anastomoses.
“Surgical geometry is absolutely critical. Our former AATS president Tom
Spray has mentioned that a mark of a
good surgeon is being able to properly
cut a patch without a whole lot of
planning. Residents tend to focus on
hemostasis rather than creating a patulous anastomosis.
“They need to be able to visualize
what it should look like instead of worrying about one stitch at a time. This
requires preparation before the operation. Simulation will definitely help
here, particularly as it relates to repetitive tasks such as anastomoses,” said
Dr. Kron.
Addressing the wider aspects of
mentorship, he quoted a Buddhist
‘[OUR RESIDENTS] ARE
OUR ‘SURGICAL’
CHILDREN. WE MUST
LOVE AND CHERISH
THEM ALL.’
proverb that states, ‘‘if you save a life,
you are responsible for that life forever.” He applied this philosophy to residents, saying,
“They become our heritage and responsibility forever. They are the fabric of our programs. We need to help
them obtain work, subsequently help
them through tough cases, and infrequently help them in their darkest
hour.
Dr. Kron tied this lesson to his own
tragic experience in dealing with the
death of his youngest son, Brian.
“Mentorship is more than just about
technical surgery, but about life. We as
teachers must convey this to our residents and students. Balance is everything. We must be able to look after
our families, our friends, and ourselves.
Teaching this aspect of humanity will
make us better physicians and surgeons.
“If one stays obsessed with just the
technical aspects of surgery, one will
forget what makes us human.
“We must teach surgical mentors the
proper side of the table to stand on,
and how to let their egos stand down
in pursuit of the greater good. It is
without question that we can improve
our teaching of these complex operations,” Dr. Kron said.
“No resident should complete a program incompetent to perform surgery.
They are our ‘surgical’ children. We
must love and cherish them all,” Dr.
Kron concluded.
■
Apply For AATS Awards Online
AATS Online Award
Applications
Now Available at
www.aats.org,
Deadline July 1, 2011
David C. Sabiston Research
Scholarship 2012 – 2014 provides an opportunity for research, training and
experience for North American surgeons committed to
pursuing an academic career
in cardiothoracic surgery.
• Research program must be
undertaken within the first
three years after completion of
an approved North American
cardiothoracic residency.
• Applications for the scholarship must be submitted during the candidate’s first two
years in an academic position.
• The scholarship will begin
July 1, 2012 and conclude on
July 1, 2014.
• The Scholarship provides
an annual stipend of $80,000
per year paid to the host institution for direct salary support
and related research expenses.
Deadline: July 1, 2011
Evarts A. Graham Memorial
Traveling Fellowship, 2012 –
2013 grants support for training of international surgeons
who have been regarded as
having the potential for later
international thoracic surgical
leadership.
• Candidate must be a nonNorth American who plans a
cardiothoracic surgery training program in a North American center and who has not
had extensive (exceeding a total of six months in duration)
clinical training in North
America prior to submitting
an application.
• Candidate should have
completed his/her formal
training in general surgery
and in thoracic and cardiovascular surgery, but should not
have reached a senior position.
• The Fellowship provides a
stipend of $75,000 US, a major
portion of which is intended
for living and travel expenses
incurred when visiting other
medical centers.
Deadline: July 1, 2011
11_15ts11_6.qxp
14
5/25/2011
2:56 PM
Page 14
NEWS FROM THE AATS
First AATS Mitral Conclave a Success
he first-ever AATS Mitral Conclave was held on May 5th and 6th.
The world’s leading experts in mitral valve disease convened to discuss
management guidelines, imaging,
pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term
results.
“With 39 faculty and 250 presentations, including selected abstracts and
videos, our goal was to have a comprehensive meeting focused on mitral
valve disease that would allow attendees to gain exposure to all of the
common approaches used in the top
centers throughout the world,” said
Program Director David H. Adams,
MD. “We continue to see tremendous
progress in our understanding of mitral disease intervention, and a great
interest among surgeons in learning
and advancing mitral valve repair
strategies,” said Dr. Adams, chairman
of the department of cardiothoracic
surgery at the Mount Sinai Medical
Center, New York.
More than 1,000 individuals – including about 800 physicians – from 66
countries participated. Industry support
was provided by Edwards Lifesciences
LLC (Premier Platinum), Metronic, Inc.
(Platinum), Abbott Vascular (Gold),
C OURTESY AATS
T
Dr. David H. Adams was the program
director of the AATS Mitral Conclave.
Sorin Heart Valves (Gold), and St. Jude
Medical Inc. (Bronze).
“I figured we might get 250 physicians, and would have considered that
a success. This is fantastic,” said AATS
President Irving L. Kron, MD.
Presentations included lectures, expert video sessions, and “Presentations
on Demand,” accessible on video
screens positioned in the exhibit hall.
In a plenary address, Robert O. Bonow,
MD, said that current valvular heart
disease guidelines are based largely on
expert opinion rather than evidence
from clinical trials. Referring
to the 2008 revised joint guidelines from the American College of Cardiology/American
Heart Association and the
2007 European Society of Cardiology
guidelines, he said, “Unfortunately, the
evidence base underpinning them is
limited by an inadequate number of
randomized clinical trials. We really
need to provide more evidence-based
information to devise true guidelines
and performance measures.”
The question of whether mitral
valve repair should be considered in all
patients with severe mitral valve regurgitation is still being debated.
“It’s at least likely that certain patient
subsets would benefit, but current data
are insufficient to determine which
ones,” said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that
patients considered eligible for repair
be referred to an “experienced center,”
but don’t provide criteria for determining that status. Moreover, individual
surgeon volume and experience clearly
predict successful mitral repair outcomes, even within one institution.
Dr. Bonow is optimistic that useful
data will come from two ongoing trials
sponsored by the National Heart,
Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.
Dr. Adams presented the Mitral
Conclave Career Achievement Award
to the legendary Alain F. Carpentier,
MD, whose 1983 landmark paper,
“Cardiac Valve Surgery – the ‘French
Correction,’ ” is credited with heralding the modern era of mitral valve reconstructive surgery. Professor
Carpentier delivered the Conclave
Honored Lecture.
A series of “mini debates” addressed
controversies surrounding the use of
annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients
versus for some), and the correct approach for specific clinical scenarios of
tricuspid valve disease.
The next Aortic Symposium will be
held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3,
2013, both in New York. Proceedings
from the 2011 Mitral Conclave will be
published in an upcoming supplement
to The Journal of Thoracic and Cardiovascular Surgery.
■
Foundation for the Advancement
of CardioThoracic Surgical Care
8th ANNUAL CARDIOVASCULAR - THORACIC (CVT) CRITICAL CARE 2011
Latest Concepts, Protocols & Technology to Increase Speed of Recovery, Safety & Patient Comfort
Save the Date
Thurs, Sept 22 - Sat, Sept 24, 2011
Omni Shoreham Hotel • Washington DC
Jointly Sponsored by:
Endorsed by:
Multi-Disciplinary CME Conference for the CVT Critical Care Team
Surgeons, Interventionalists, Intensivists, Anesthesiologists, Hospitalists,
Critical Care Nurses, Nurse Practitioners, Physician Assistants, Cath Lab Technicians,
Perfusionists, Pharmacists, Respiratory Therapists & Nutritionists
HIGHLIGHTS FOR 2011
• Latest Pharmacology for Hemodynamics
NEW IN
2011
NEW IN
2011
NEW IN
2011
• VAD/ECMO Managment Lastest Technology
NEW IN
2011
• Latest Pain Management & Physical Therapy
• Catheter-Based Aortic Valve Replacement
• Ultrasound in the CVT ICU
• Cardiopulmonary Resuscitation Workshop
NEW IN
2011
• Renal Replacement Therapy
• Lung Transplantation
• Heparin-Induced Thrombocytopenia (HIT)
• Cerebral Function Monitoring
• Nutritional Support
NEW IN
2011
• Implementing Evidence-Based Guidelines
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME)
through the joint sponsorship of the American Association for Thoracic Surgery and the Foundation for the Advancement of CardioThoracic Surgical Care.
The American Association for Thoracic Surgery is accredited by the ACCME to provide continuing medical education for physicians.
This activity has been approved for AMA PRA Category 1 Credit(s)TM
For more information & to register, visit www.facts-care.org or call 202-775-9379
11_15ts11_6.qxp
5/25/2011
2:56 PM
Page 15
NEWS FROM THE AATS
15
NIH News, Awards, and Grants
Mentored Research Scientist
Development Award
The purpose of the NIH Mentored
Research Scientist Development
Award (K01) is to provide support and
“protected time” for an intensive, supervised career development experience in the biomedical, behavioral, or
clinical sciences leading to research
independence. Prospective candidates
are encouraged to contact the relevant NIH staff for IC-specific programmatic and budgetary
information. For more information
please visit: http://grants.nih.gov/
grants/guide/pa-files/PA-11-190.html
Independent Scientist Award
The NIH has announced an Independent Scientist Award (K02). This award
is intended to foster the development
of outstanding scientists and enable
them to expand their potential to make
significant contributions to their field
of research. The K02 award provides 3,
4, or 5 years of salary support and
“protected time” for newly independent scientists who can demonstrate
the need for a period of intensive research focus as a means of enhancing
their research careers. Prospective candidates are encouraged to contact the
relevant Institute or Center (IC) staff
for IC-specific programmatic and budgetary information. For more information, visit: http://grants.nih.gov/grants/
guide/pa-files/PA-11-191.html
Basic Research in Calcific Aortic
Valve Disease
The purpose of this NIH FOA is to encourage innovative molecular and
physiological research that could lead
to early diagnosis or effective medical
therapy for calcific aortic valve disease.
Applications from investigators in related fields (for example, mineralization
and bone physiology, extracellular matrix physiology, and molecular imaging) are strongly encouraged.
Applications are due October 11, 2011.
For more information, please visit:
http://grants.nih.gov/grants/guide/
rfa-files/RFA-HL-12-015.html
Pulmonary Vascular-Right
Ventricular Axis Research Program
The NIH announced an FOA to solicit
research grant applications from organizations proposing to study right ventricular (RV) function/dysfunction and
disease. Utilizing a multidisciplinary
and collaborative team approach, this
program will foster research which
will lead to improved diagnostics and
therapeutics for RV disease, particularly in the setting of lung vascular disease. Human subjects research grants
(http://grants.nih.gov/ grants/policy/
hs/) must be proposed and applicants
are strongly encouraged to use the
multiple principal investigator approach to study the right ventricularpulmonary vascular axis. Applications
are due October 11, 2011. For information visit: http://grants.nih.gov/grants/
guide/rfa-files/RFA-HL-12-015.html
Pilot Studies to Develop and Test
Novel, Low-Cost Methods for the
Conduct of Clinical Trials
This NHLBI funding announcement
solicits R01 applications that develop
and test new, low-cost methods to conduct clinical trials. Responsive applicants will address four challenges to
the conduct of clinical trials: (1) minimize specialized infrastructure, (2)
minimize visits designed solely for the
trial, (3) explore novel methods of ob-
taining consent that minimize burden,
and (4) employ low-cost methods of
monitoring study conduct. The proposed methodology must be tested in
a pilot trial. New and innovative designs that have not been tested in previous studies but hold potential for
increasing the efficiency and reducing
the cost of conduct of clinical trials are
especially encouraged. Applications are
due by October 13, 2011. For information visit: http://grants.nih.gov/grants/
guide/rfa-files/RFA-HL-12-019.html
Appeals of NIH Initial Peer Review
There are revisions to the NIH policy
concerning appeals of the initial peer
review process. These revisions will become effective for all competing applications (“applications” below) received
for the January 25, 2011 due date (October 2011 Council round) and after. Visit:
http://grants.nih.gov/grants/guide/
notice-files/NOT-OD-11-064.html ■
J U S T LAUN C HED!
T H E O F F I C I A L N E W S PA P E R O F T H E A M E R I C A N A S S O C I AT I O N F O R T H O R A C I C S U R G E RY
A totally new site has been designed for thoracic surgeons.
· Specialty news and events in real time
· Galleries of clinical images, videos, and podcasts
· Commentaries and residents’ news
· Topic-specific newsletters
· And much more
w w w. t h o r a c i c s u r g e r y n e w s . c o m
THOR_16.qxp
4/21/2011
9:57 AM
Page 1
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Dor and Toupet Fundoplication Compared

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