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The Official Newspaper of the American Association for Thoracic Surgery
VIDEO: Incoming AATS president outlines goals
BOSTON – Strengthening member engagement is a top goal for incoming AATS President Duke E. Cameron, MD.
In this video, Dr. Cameron, of Massachusetts General Hospital, Boston, shared his objectives as the next AATS leader and the direction he envisions for the specialty over the next 100 years. Dr. Cameron also discussed his hope for new online educational efforts and the importance of physician collaboration with other health professionals.
On Twitter @legal_med
BOSTON – Strengthening member engagement is a top goal for incoming AATS President Duke E. Cameron, MD.
In this video, Dr. Cameron, of Massachusetts General Hospital, Boston, shared his objectives as the next AATS leader and the direction he envisions for the specialty over the next 100 years. Dr. Cameron also discussed his hope for new online educational efforts and the importance of physician collaboration with other health professionals.
On Twitter @legal_med
BOSTON – Strengthening member engagement is a top goal for incoming AATS President Duke E. Cameron, MD.
In this video, Dr. Cameron, of Massachusetts General Hospital, Boston, shared his objectives as the next AATS leader and the direction he envisions for the specialty over the next 100 years. Dr. Cameron also discussed his hope for new online educational efforts and the importance of physician collaboration with other health professionals.
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
NSCLC Was a Key Focus of General Thoracic Session
The initial results of a phase III randomized trial comparing lobectomy to segmentectomy for small, peripheral non–small cell lung cancer (NSCLC) were presented by Kenji Suzuki, MD, of the Juntendo University Hospital, Japan.
Segmentectomy and lobectomy both proved feasible techniques for early-stage NSCLC. However, segmentectomy did not appear to be less invasive than lobectomy with regard to blood loss or the frequency of air leak, according to Dr. Suzuki.
A total of 1,106 patients (554 in lobectomy arm; 552 in segmentectomy arm) were enrolled between August 2009 and October 2014. There were 22 patients whose mode of surgery was converted from segmentectomy to lobectomy in the segmentectomy arm, resulting in 576 lobectomies and 530 segmentectomies. 
“The aim of the trial is to confirm the non-inferiority in overall survival (OS) of segmentectomy, compared with lobectomy,” said Dr. Suzuki.
Surgical complications were evaluated by the mode of surgery with an intention-to-treat analysis. As to a mode of surgery, segmentectomy was categorized into simple and complex in terms of technical difficulty; resection of the right or left S6, the left superior, and the lingular segment were defined as simple, because these procedures are easy and common.
Operative mortality was 0% in both groups. Postoperative complications, including pneumonia were not significantly different between the two groups. However, there was a significant difference in the rate of air leak detected: 3.8% in Group A and 6.5% in Group B (with no broncho-pleural fistulas being found).
Multivariate analysis showed that pack-year (PY) smoking greater than 20 vs. none was a significant predictor of postoperative complications. Significant predictors of pulmonary complications, including alveolar fistula and empyema, were typical segmentectomy (vs. lobectomy); and PY greater than 20 vs. none.
“The primary analysis of this study is planned for 2020,” said Dr. Suzuki. Those results should help to determine whether segmentectomy should be considered the standard of treatment, compared to lobectomy.
Previous research has shown that a wedge resection (WR) may be superior to stereotactic body radiation therapy (SBRT) for patients with early-stage non–small cell lung cancer (NSCLC). However, the role that the quality of the WR plays in improved outcomes is unknown, according to Seth Krantz, MD, of the NorthShore University Health System who presented the results of a database analysis of patients within the National Cancer Database (NCDB) with clinical T1-T2, N0, M0 NSCLC patients who were treated with either WR or SBRT from 2005-2012. These patients were analyzed for surgical quality markers, predictors of lymph node assessment and pathologic upstaging, and overall survival. Quality markers included the number of nodes examined and margins status.
Of more than 7,000 WR patients included (44%) had 0 LNs examined; 37% had 1-5 examined, and nearly 17% had more than 5 nodes examined. Significant predictors of having at least 5 nodes examined included younger age, fewer comorbidities, T2 tumors, and obtaining negative margins. Negative margins were obtained in the vast majority of WR patients.
“Our study confirms that nationwide, while most patients undergoing wedge resection for early stage disease receive a margin negative resection, fewer than 20% of patients had more than five lymph nodes assessed, and nearly half had no lymph nodes assessed. Pathologic assessment of lymph nodes was associated with improved long-term survival and greater utilization of adjuvant chemotherapy. Furthermore, the benefit of a wedge resection compared to SBRT, was significantly affected by the extent of lymph node assessment. 
If patients are going to be offered a wedge resection for early stage non-small cell lung cancer, every effort should be made to perform a pathologic assessment of regional lymph nodes,” Dr. Krantz concluded.
Patients at high risk for non–small cell lung cancer (NSCLC) metastases were found to have a significant rate of unsuspected lymph node metastases upon endosonographic assessment, even in the presence of radiologically normal mediastinal lymph nodes, according to a study reported by Pravachan Hegde, MD, of the University of Montreal.
A total of 22 out of 161 patients with radiologically normal mediastinum were found to be positive on combined EBUS/EUS staging. “Given the significant rate of unsuspected lymph node metastases, combined endosonographic lymph node staging should be routinely performed in staging of NSCLC in high risk patients even in the presence of radiologically normal mediastinal lymph nodes,” Dr. Hedge concluded.
The initial results of a phase III randomized trial comparing lobectomy to segmentectomy for small, peripheral non–small cell lung cancer (NSCLC) were presented by Kenji Suzuki, MD, of the Juntendo University Hospital, Japan.
Segmentectomy and lobectomy both proved feasible techniques for early-stage NSCLC. However, segmentectomy did not appear to be less invasive than lobectomy with regard to blood loss or the frequency of air leak, according to Dr. Suzuki.
A total of 1,106 patients (554 in lobectomy arm; 552 in segmentectomy arm) were enrolled between August 2009 and October 2014. There were 22 patients whose mode of surgery was converted from segmentectomy to lobectomy in the segmentectomy arm, resulting in 576 lobectomies and 530 segmentectomies.
“The aim of the trial is to confirm the non-inferiority in overall survival (OS) of segmentectomy, compared with lobectomy,” said Dr. Suzuki.
Surgical complications were evaluated by the mode of surgery with an intention-to-treat analysis. As to a mode of surgery, segmentectomy was categorized into simple and complex in terms of technical difficulty; resection of the right or left S6, the left superior, and the lingular segment were defined as simple, because these procedures are easy and common.
Operative mortality was 0% in both groups. Postoperative complications, including pneumonia were not significantly different between the two groups. However, there was a significant difference in the rate of air leak detected: 3.8% in Group A and 6.5% in Group B (with no broncho-pleural fistulas being found).
Multivariate analysis showed that pack-year (PY) smoking greater than 20 vs. none was a significant predictor of postoperative complications. Significant predictors of pulmonary complications, including alveolar fistula and empyema, were typical segmentectomy (vs. lobectomy); and PY greater than 20 vs. none.
“The primary analysis of this study is planned for 2020,” said Dr. Suzuki. Those results should help to determine whether segmentectomy should be considered the standard of treatment, compared to lobectomy.
Previous research has shown that a wedge resection (WR) may be superior to stereotactic body radiation therapy (SBRT) for patients with early-stage non–small cell lung cancer (NSCLC). However, the role that the quality of the WR plays in improved outcomes is unknown, according to Seth Krantz, MD, of the NorthShore University Health System who presented the results of a database analysis of patients within the National Cancer Database (NCDB) with clinical T1-T2, N0, M0 NSCLC patients who were treated with either WR or SBRT from 2005-2012. These patients were analyzed for surgical quality markers, predictors of lymph node assessment and pathologic upstaging, and overall survival. Quality markers included the number of nodes examined and margins status.
Of more than 7,000 WR patients included (44%) had 0 LNs examined; 37% had 1-5 examined, and nearly 17% had more than 5 nodes examined. Significant predictors of having at least 5 nodes examined included younger age, fewer comorbidities, T2 tumors, and obtaining negative margins. Negative margins were obtained in the vast majority of WR patients.
“Our study confirms that nationwide, while most patients undergoing wedge resection for early stage disease receive a margin negative resection, fewer than 20% of patients had more than five lymph nodes assessed, and nearly half had no lymph nodes assessed. Pathologic assessment of lymph nodes was associated with improved long-term survival and greater utilization of adjuvant chemotherapy. Furthermore, the benefit of a wedge resection compared to SBRT, was significantly affected by the extent of lymph node assessment.
If patients are going to be offered a wedge resection for early stage non-small cell lung cancer, every effort should be made to perform a pathologic assessment of regional lymph nodes,” Dr. Krantz concluded.
Patients at high risk for non–small cell lung cancer (NSCLC) metastases were found to have a significant rate of unsuspected lymph node metastases upon endosonographic assessment, even in the presence of radiologically normal mediastinal lymph nodes, according to a study reported by Pravachan Hegde, MD, of the University of Montreal.
A total of 22 out of 161 patients with radiologically normal mediastinum were found to be positive on combined EBUS/EUS staging. “Given the significant rate of unsuspected lymph node metastases, combined endosonographic lymph node staging should be routinely performed in staging of NSCLC in high risk patients even in the presence of radiologically normal mediastinal lymph nodes,” Dr. Hedge concluded.
The initial results of a phase III randomized trial comparing lobectomy to segmentectomy for small, peripheral non–small cell lung cancer (NSCLC) were presented by Kenji Suzuki, MD, of the Juntendo University Hospital, Japan.
Segmentectomy and lobectomy both proved feasible techniques for early-stage NSCLC. However, segmentectomy did not appear to be less invasive than lobectomy with regard to blood loss or the frequency of air leak, according to Dr. Suzuki.
A total of 1,106 patients (554 in lobectomy arm; 552 in segmentectomy arm) were enrolled between August 2009 and October 2014. There were 22 patients whose mode of surgery was converted from segmentectomy to lobectomy in the segmentectomy arm, resulting in 576 lobectomies and 530 segmentectomies.
“The aim of the trial is to confirm the non-inferiority in overall survival (OS) of segmentectomy, compared with lobectomy,” said Dr. Suzuki.
Surgical complications were evaluated by the mode of surgery with an intention-to-treat analysis. As to a mode of surgery, segmentectomy was categorized into simple and complex in terms of technical difficulty; resection of the right or left S6, the left superior, and the lingular segment were defined as simple, because these procedures are easy and common.
Operative mortality was 0% in both groups. Postoperative complications, including pneumonia were not significantly different between the two groups. However, there was a significant difference in the rate of air leak detected: 3.8% in Group A and 6.5% in Group B (with no broncho-pleural fistulas being found).
Multivariate analysis showed that pack-year (PY) smoking greater than 20 vs. none was a significant predictor of postoperative complications. Significant predictors of pulmonary complications, including alveolar fistula and empyema, were typical segmentectomy (vs. lobectomy); and PY greater than 20 vs. none.
“The primary analysis of this study is planned for 2020,” said Dr. Suzuki. Those results should help to determine whether segmentectomy should be considered the standard of treatment, compared to lobectomy.
Previous research has shown that a wedge resection (WR) may be superior to stereotactic body radiation therapy (SBRT) for patients with early-stage non–small cell lung cancer (NSCLC). However, the role that the quality of the WR plays in improved outcomes is unknown, according to Seth Krantz, MD, of the NorthShore University Health System who presented the results of a database analysis of patients within the National Cancer Database (NCDB) with clinical T1-T2, N0, M0 NSCLC patients who were treated with either WR or SBRT from 2005-2012. These patients were analyzed for surgical quality markers, predictors of lymph node assessment and pathologic upstaging, and overall survival. Quality markers included the number of nodes examined and margins status.
Of more than 7,000 WR patients included (44%) had 0 LNs examined; 37% had 1-5 examined, and nearly 17% had more than 5 nodes examined. Significant predictors of having at least 5 nodes examined included younger age, fewer comorbidities, T2 tumors, and obtaining negative margins. Negative margins were obtained in the vast majority of WR patients.
“Our study confirms that nationwide, while most patients undergoing wedge resection for early stage disease receive a margin negative resection, fewer than 20% of patients had more than five lymph nodes assessed, and nearly half had no lymph nodes assessed. Pathologic assessment of lymph nodes was associated with improved long-term survival and greater utilization of adjuvant chemotherapy. Furthermore, the benefit of a wedge resection compared to SBRT, was significantly affected by the extent of lymph node assessment.
If patients are going to be offered a wedge resection for early stage non-small cell lung cancer, every effort should be made to perform a pathologic assessment of regional lymph nodes,” Dr. Krantz concluded.
Patients at high risk for non–small cell lung cancer (NSCLC) metastases were found to have a significant rate of unsuspected lymph node metastases upon endosonographic assessment, even in the presence of radiologically normal mediastinal lymph nodes, according to a study reported by Pravachan Hegde, MD, of the University of Montreal.
A total of 22 out of 161 patients with radiologically normal mediastinum were found to be positive on combined EBUS/EUS staging. “Given the significant rate of unsuspected lymph node metastases, combined endosonographic lymph node staging should be routinely performed in staging of NSCLC in high risk patients even in the presence of radiologically normal mediastinal lymph nodes,” Dr. Hedge concluded.
McChrystal Spoke on the Need for a New Kind of Team
Monday’s Honored Guest Lecturer Gen. Stanley A. McChrystal, a retired four-star general, and former commander of U.S. and International Security Assistance Forces in Afghanistan, and of the Joint Special Operations Command, spoke on the transforming nature of leadership and teams.
His address, “Team of Teams – Rules of Engagement for a Complex World,” discussed how old organizational frameworks with a centralized leadership and silos of responsibility, similar to the standard organization charts that everyone is familiar with, are no longer sufficiently functional and efficient in a changing world. He stated how the world is not just complicated, but complex, and the nature of complexity means that it cannot be predicted and a rapid, adaptive response is necessary.He highlighted his experiences in Iraq where a terrorist group, rather than using a hierarchical organization such as Al Queda, organically developed a highly adaptable and diffuse structure, which allowed them to have their leaders taken out without heavily impacting their ability to grow and rapidly respond. It wasn’t until the U.S. military under his leadership emulated such a diffuse response and geared up their efforts many-fold, that the anti-terrorism effort began to succeed.
The cascade through the chain of command just wasn’t fast enough.“We had entered an environment where we had to resynchronize the organization every 24 hours. The entire organization.” So he established a daily conference call not just among the leadership but, instead, “connected everybody, all at the same time. We started by ordering 400 people to be on it and in a very short period of time it became 7,500, and went from 30 minutes to 90 minutes a day,” he said. And despite the fact that some people would call this ‘crazy,’ he said. “I’ll tell you it’s the most efficient thing I’ve ever been a part of in my life. In those 90 minutes, everyone in the organization got shared contextual understanding of what we were doing, what we were trying to do, and what we could do.” Leaders need to create an environment for a new kind of organization to grow.
Monday’s Honored Guest Lecturer Gen. Stanley A. McChrystal, a retired four-star general, and former commander of U.S. and International Security Assistance Forces in Afghanistan, and of the Joint Special Operations Command, spoke on the transforming nature of leadership and teams.
His address, “Team of Teams – Rules of Engagement for a Complex World,” discussed how old organizational frameworks with a centralized leadership and silos of responsibility, similar to the standard organization charts that everyone is familiar with, are no longer sufficiently functional and efficient in a changing world. He stated how the world is not just complicated, but complex, and the nature of complexity means that it cannot be predicted and a rapid, adaptive response is necessary.He highlighted his experiences in Iraq where a terrorist group, rather than using a hierarchical organization such as Al Queda, organically developed a highly adaptable and diffuse structure, which allowed them to have their leaders taken out without heavily impacting their ability to grow and rapidly respond. It wasn’t until the U.S. military under his leadership emulated such a diffuse response and geared up their efforts many-fold, that the anti-terrorism effort began to succeed.
The cascade through the chain of command just wasn’t fast enough.“We had entered an environment where we had to resynchronize the organization every 24 hours. The entire organization.” So he established a daily conference call not just among the leadership but, instead, “connected everybody, all at the same time. We started by ordering 400 people to be on it and in a very short period of time it became 7,500, and went from 30 minutes to 90 minutes a day,” he said. And despite the fact that some people would call this ‘crazy,’ he said. “I’ll tell you it’s the most efficient thing I’ve ever been a part of in my life. In those 90 minutes, everyone in the organization got shared contextual understanding of what we were doing, what we were trying to do, and what we could do.” Leaders need to create an environment for a new kind of organization to grow.
Monday’s Honored Guest Lecturer Gen. Stanley A. McChrystal, a retired four-star general, and former commander of U.S. and International Security Assistance Forces in Afghanistan, and of the Joint Special Operations Command, spoke on the transforming nature of leadership and teams.
His address, “Team of Teams – Rules of Engagement for a Complex World,” discussed how old organizational frameworks with a centralized leadership and silos of responsibility, similar to the standard organization charts that everyone is familiar with, are no longer sufficiently functional and efficient in a changing world. He stated how the world is not just complicated, but complex, and the nature of complexity means that it cannot be predicted and a rapid, adaptive response is necessary.He highlighted his experiences in Iraq where a terrorist group, rather than using a hierarchical organization such as Al Queda, organically developed a highly adaptable and diffuse structure, which allowed them to have their leaders taken out without heavily impacting their ability to grow and rapidly respond. It wasn’t until the U.S. military under his leadership emulated such a diffuse response and geared up their efforts many-fold, that the anti-terrorism effort began to succeed.
The cascade through the chain of command just wasn’t fast enough.“We had entered an environment where we had to resynchronize the organization every 24 hours. The entire organization.” So he established a daily conference call not just among the leadership but, instead, “connected everybody, all at the same time. We started by ordering 400 people to be on it and in a very short period of time it became 7,500, and went from 30 minutes to 90 minutes a day,” he said. And despite the fact that some people would call this ‘crazy,’ he said. “I’ll tell you it’s the most efficient thing I’ve ever been a part of in my life. In those 90 minutes, everyone in the organization got shared contextual understanding of what we were doing, what we were trying to do, and what we could do.” Leaders need to create an environment for a new kind of organization to grow.
Executive order aims to reform specialized visa program
A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.
The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.
In a statement, the White House said the order is intended to prevent companies from abusing the H-1B visa program by replacing American workers with lower-paid foreign workers. While the program is designed to bring in skilled workers, the majority of approved applications are for the two lowest wage levels allowed, according to a White House statement.
“This executive order targets the abusive use of waivers and exceptions that undermine ‘Buy American’ laws meant to promote taxpayer money going to American companies,” according to the statement. “President Trump is making sure the immigration system isn’t abused to displace hard-working American workers for cheaper foreign labor.”
But the executive order will have no immediate effect on the H-1B program or foreign physicians applying for such visas, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.
“[There is] no immediate impact on the H-1B at all, just a promise to look at the program and ‘crack down’ on the alleged abuse and fraud,” Ms. Minear said in an interview. “I view this as a way of scaring people and looking to sound tough while actually doing nothing to change the system.”
Many of the changes proposed by the Trump administration would require legislation or a lengthy rule-making process, according to Adam Cohen, a Memphis immigration attorney. Some of the proposed changes have included changing the H-1B lottery system, altering the way prevailing wages are calculated, and charging higher processing fees.
“[The executive order] reflects a desire to move toward H-1B reforms but does not signal any immediate or concrete change,” Mr. Cohen said in an interview.
It remains to be seen what the new toughness on potential fraud and abuse may look like, Ms. Minear said. Added enforcement could include additional hurdles during visa processing due to heightened suspicion and review of all H-1B applicants. Depending on the extent of enforcement, it’s possible the changes could end up before a court, she said.
“If the administration oversteps in terms of enforcements and inappropriate scrutinizing of the program, there will be litigation in a heartbeat,” she predicted.
Meanwhile, there is still no word whether U.S. Citizenship and Immigration Services (USCIS) may exempt physicians from the 
On April 3, USCIS temporarily suspended its expedited processing of H-1B visas, a program by which applicants could pay for expedited processing and a response within 15 days. Standard processing of H-1B applications takes 6-10 months. USCIS is terminating the expedited reviews for up to 6 months to address long-standing H-1B petitions and to reduce backlogs, according to a March announcement by the agency.
The International Medical Graduate Taskforce and a group of U.S. senators have urged USCIS to exempt physicians from the premium processing ban.
USCIS officials have not said whether the agency will exempt physicians. In an interview, a spokeswoman said the agency will be monitoring the situation during the coming months and will evaluate any time-sensitive impacts prior to the resumption of premium processing services.
[email protected]
On Twitter @legal_med
A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.
The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.
In a statement, the White House said the order is intended to prevent companies from abusing the H-1B visa program by replacing American workers with lower-paid foreign workers. While the program is designed to bring in skilled workers, the majority of approved applications are for the two lowest wage levels allowed, according to a White House statement.
“This executive order targets the abusive use of waivers and exceptions that undermine ‘Buy American’ laws meant to promote taxpayer money going to American companies,” according to the statement. “President Trump is making sure the immigration system isn’t abused to displace hard-working American workers for cheaper foreign labor.”
But the executive order will have no immediate effect on the H-1B program or foreign physicians applying for such visas, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.
“[There is] no immediate impact on the H-1B at all, just a promise to look at the program and ‘crack down’ on the alleged abuse and fraud,” Ms. Minear said in an interview. “I view this as a way of scaring people and looking to sound tough while actually doing nothing to change the system.”
Many of the changes proposed by the Trump administration would require legislation or a lengthy rule-making process, according to Adam Cohen, a Memphis immigration attorney. Some of the proposed changes have included changing the H-1B lottery system, altering the way prevailing wages are calculated, and charging higher processing fees.
“[The executive order] reflects a desire to move toward H-1B reforms but does not signal any immediate or concrete change,” Mr. Cohen said in an interview.
It remains to be seen what the new toughness on potential fraud and abuse may look like, Ms. Minear said. Added enforcement could include additional hurdles during visa processing due to heightened suspicion and review of all H-1B applicants. Depending on the extent of enforcement, it’s possible the changes could end up before a court, she said.
“If the administration oversteps in terms of enforcements and inappropriate scrutinizing of the program, there will be litigation in a heartbeat,” she predicted.
Meanwhile, there is still no word whether U.S. Citizenship and Immigration Services (USCIS) may exempt physicians from the
On April 3, USCIS temporarily suspended its expedited processing of H-1B visas, a program by which applicants could pay for expedited processing and a response within 15 days. Standard processing of H-1B applications takes 6-10 months. USCIS is terminating the expedited reviews for up to 6 months to address long-standing H-1B petitions and to reduce backlogs, according to a March announcement by the agency.
The International Medical Graduate Taskforce and a group of U.S. senators have urged USCIS to exempt physicians from the premium processing ban.
USCIS officials have not said whether the agency will exempt physicians. In an interview, a spokeswoman said the agency will be monitoring the situation during the coming months and will evaluate any time-sensitive impacts prior to the resumption of premium processing services.
[email protected]
On Twitter @legal_med
A recent executive order by President Trump that aims to overhaul a specialized visa program for foreign workers appears to have more bark than bite, immigration experts say.
The order, published April 21 in the Federal Register, calls upon federal agencies to propose new rules, guidance, and reforms to ensure that H-1B visas are granted only to fill the most highly skilled positions. The H-1B visa program allows U.S. employers to temporarily employ highly skilled foreign workers in specialty occupations; foreign physicians and medical students regularly use the program to practice and train in the United States.
In a statement, the White House said the order is intended to prevent companies from abusing the H-1B visa program by replacing American workers with lower-paid foreign workers. While the program is designed to bring in skilled workers, the majority of approved applications are for the two lowest wage levels allowed, according to a White House statement.
“This executive order targets the abusive use of waivers and exceptions that undermine ‘Buy American’ laws meant to promote taxpayer money going to American companies,” according to the statement. “President Trump is making sure the immigration system isn’t abused to displace hard-working American workers for cheaper foreign labor.”
But the executive order will have no immediate effect on the H-1B program or foreign physicians applying for such visas, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.
“[There is] no immediate impact on the H-1B at all, just a promise to look at the program and ‘crack down’ on the alleged abuse and fraud,” Ms. Minear said in an interview. “I view this as a way of scaring people and looking to sound tough while actually doing nothing to change the system.”
Many of the changes proposed by the Trump administration would require legislation or a lengthy rule-making process, according to Adam Cohen, a Memphis immigration attorney. Some of the proposed changes have included changing the H-1B lottery system, altering the way prevailing wages are calculated, and charging higher processing fees.
“[The executive order] reflects a desire to move toward H-1B reforms but does not signal any immediate or concrete change,” Mr. Cohen said in an interview.
It remains to be seen what the new toughness on potential fraud and abuse may look like, Ms. Minear said. Added enforcement could include additional hurdles during visa processing due to heightened suspicion and review of all H-1B applicants. Depending on the extent of enforcement, it’s possible the changes could end up before a court, she said.
“If the administration oversteps in terms of enforcements and inappropriate scrutinizing of the program, there will be litigation in a heartbeat,” she predicted.
Meanwhile, there is still no word whether U.S. Citizenship and Immigration Services (USCIS) may exempt physicians from the
On April 3, USCIS temporarily suspended its expedited processing of H-1B visas, a program by which applicants could pay for expedited processing and a response within 15 days. Standard processing of H-1B applications takes 6-10 months. USCIS is terminating the expedited reviews for up to 6 months to address long-standing H-1B petitions and to reduce backlogs, according to a March announcement by the agency.
The International Medical Graduate Taskforce and a group of U.S. senators have urged USCIS to exempt physicians from the premium processing ban.
USCIS officials have not said whether the agency will exempt physicians. In an interview, a spokeswoman said the agency will be monitoring the situation during the coming months and will evaluate any time-sensitive impacts prior to the resumption of premium processing services.
[email protected]
On Twitter @legal_med
Monday’s Lillehei Forum highlighted basic research
The Lillehei Forum is a series of presentations on basic research by residents in the field of cardiothoracic surgery.
A targeted near-infrared contrast agent specific for lung adenocarcinomas was assessed for effectiveness during intraoperative molecular imaging (IMI) in animal models. Use of the contrast agent proved significantly more effective at detecting positive margins than did surgery alone, according to a study presented by Jarrod D. Predina, MD.
Initial human experiences with IMI for NSCLC using a fluorescent contrast agent have been limited by technical hurdles including high background noise in inflammatory tissues and low signal output, according to Dr. Predina. As an alternative, he and his colleagues at the University of Pennsylvania hypothesized that a targeted near-infrared contrast agent specific for lung adenocarcinomas would improve sensitivity and specificity during surgery.
Using a mouse surgical model of non–small cell lung cancer (NSCLC) that recapitulates local and systemic post-operative recurrences, Dr. Predina and his colleagues at the University of Pennsylvania injected 140 mice intravenously prior to resection with a near-infrared imaging agent (OTL0038). This agent is specific for pulmonary adenocarcinomas due to its high affinity binding of the folate receptor alpha. Tumor-bearing mice were randomized to surgery with or without IMI. Suspicious residual disease was resected and analyzed by immunohistochemistry, flow cytometry, and immunofluorescence. Based on this data, OTL0038 was tested in a pilot study of five canines with spontaneously occurring lung cancer.
In a local recurrence model system, of 80 mice assessed, surgeons identified 10 positive margins in those randomized to imaging with IMI vs. three positive margins in mice undergoing surgery alone, a significant difference. In systemic recurrence models (60 mice), the mean number of pulmonary nodules located with IMI was 7.2 vs. 3.4 in controls, also a significant difference, according to Dr. Predina.
In five canines with a presumed diagnosis of NSCLC, no toxicity was observed. Four of five canines had fluorescent tumors; the non-fluorescing tumor was discovered to be a metastatic mammary tumor on final pathologic analysis. In one canine, an otherwise undetectable 8-mm pulmonary adenocarcinoma was discovered with IMI.
“Our data suggest that a targeted near-infrared contrast agent may improve IMI technology. Ultimately, this will enable accurate identification of residual disease that may otherwise be overlooked. These results are the basis of an ongoing phase I human trial,” concluded Dr. Predina.
The complexity of the lung has limited the prospects of bioengineering strategies utilizing stem cells and fully decellularized or bioartificial scaffolds, according to Brandon A. Guenthart, MD, of Columbia University.
Using standard protocols, Dr. Guenthart and his colleagues procured human lungs rejected for transplantation on the basis of standard clinical criteria. Lungs were placed on a custom-built EVLP system, ventilated and perfused. Utilizing video bronchoscopy, real-time transpleural imaging, and a custom designed micro-catheter delivery and occlusion system, the team delivered a decellularization solution into targeted lung regions that resulted in the selective removal of airway epithelium.
Human airway epithelial cells or human-derived alveolar progenitor cells were labeled (with a quantum dot or a near-infrared dye) and delivered into decellularized lung regions. Following delivery, EVLP was continued for 4-6 hours to allow for cell engraftment. Lung wedge samples were collected at each time point for histologic analysis.
Following decellularization, hematoxylin and eosin staining confirmed removal of pseudostratified and columnar epithelium in proximal airways and removal of type I and II pneumocytes in the distal lung. Delivered cells were retained in the lung after EVLP and fixation, and cellular morphology and distribution within the alveoli indicated early engraftment.
“Bioengineering human lungs utilizing advanced therapeutic interventions such as cell replacement may help combat the critical shortage of transplantable lungs,” said Dr. Guenthart. “Additionally, in the future, targeted intervention and patient-specific cell replacement strategies may have translational applications in vivo and eliminate the need for transplantation in select patients,” he concluded.
They used a previously validated porcine lung injury model of intravenous lipopolysaccharide (LPS) to induce a systemic inflammatory response and subsequent severe ARDS requiring ECMO support. A total of eight mature adult swine were administered LPS via the external jugular vein followed by sternotomy and central ECMO cannulation (right atrium to ascending aorta).
The left pulmonary artery (inflow) and left superior and inferior pulmonary veins (outflow) were dissected out and cannulated to isolate the left lung, which then underwent 4 hours normorthermic IVLP with Steen Solution followed by 4 hours of lung reperfusion after IVLP decannulation.
Dr. Mehaffey and his colleagues then compared the right (LPS control) and left lungs (LPS+IVLP) of the same animal.
All animals demonstrated a significant reduction in PaO2/FiO2 ratio and total lung compliance 2 hours after the start of LPS infusion. During IVLP, the left (treated) pulmonary vein oxygenation was superior to right (control) pulmonary vein oxygenation. After reperfusion and IVLP decannulation, six (75%) animals had improved lung function allowing for ECMO decannulation.
The left lung showed significant improvement of lung-specific oxygenation compared to the right control at 4 hours of reperfusion. Similarly, total lung compliance improved after targeted rehabilitation of the left lung, according to Dr. Mehaffey. In addition, the wet-to-dry ratio of lung tissue demonstrated significantly reduced edema in the rehabilitated left lungs compared to right controls.
Dr. Mehaffey and his colleagues concluded that IVLP may reduce the duration of ECMO and ventilator support resulting in major reduction in morbidity, mortality, and health care–related costs in patients with ARDS.
The Lillehei Forum is a series of presentations on basic research by residents in the field of cardiothoracic surgery.
A targeted near-infrared contrast agent specific for lung adenocarcinomas was assessed for effectiveness during intraoperative molecular imaging (IMI) in animal models. Use of the contrast agent proved significantly more effective at detecting positive margins than did surgery alone, according to a study presented by Jarrod D. Predina, MD.
Initial human experiences with IMI for NSCLC using a fluorescent contrast agent have been limited by technical hurdles including high background noise in inflammatory tissues and low signal output, according to Dr. Predina. As an alternative, he and his colleagues at the University of Pennsylvania hypothesized that a targeted near-infrared contrast agent specific for lung adenocarcinomas would improve sensitivity and specificity during surgery.
Using a mouse surgical model of non–small cell lung cancer (NSCLC) that recapitulates local and systemic post-operative recurrences, Dr. Predina and his colleagues at the University of Pennsylvania injected 140 mice intravenously prior to resection with a near-infrared imaging agent (OTL0038). This agent is specific for pulmonary adenocarcinomas due to its high affinity binding of the folate receptor alpha. Tumor-bearing mice were randomized to surgery with or without IMI. Suspicious residual disease was resected and analyzed by immunohistochemistry, flow cytometry, and immunofluorescence. Based on this data, OTL0038 was tested in a pilot study of five canines with spontaneously occurring lung cancer.
In a local recurrence model system, of 80 mice assessed, surgeons identified 10 positive margins in those randomized to imaging with IMI vs. three positive margins in mice undergoing surgery alone, a significant difference. In systemic recurrence models (60 mice), the mean number of pulmonary nodules located with IMI was 7.2 vs. 3.4 in controls, also a significant difference, according to Dr. Predina.
In five canines with a presumed diagnosis of NSCLC, no toxicity was observed. Four of five canines had fluorescent tumors; the non-fluorescing tumor was discovered to be a metastatic mammary tumor on final pathologic analysis. In one canine, an otherwise undetectable 8-mm pulmonary adenocarcinoma was discovered with IMI.
“Our data suggest that a targeted near-infrared contrast agent may improve IMI technology. Ultimately, this will enable accurate identification of residual disease that may otherwise be overlooked. These results are the basis of an ongoing phase I human trial,” concluded Dr. Predina.
The complexity of the lung has limited the prospects of bioengineering strategies utilizing stem cells and fully decellularized or bioartificial scaffolds, according to Brandon A. Guenthart, MD, of Columbia University.
Using standard protocols, Dr. Guenthart and his colleagues procured human lungs rejected for transplantation on the basis of standard clinical criteria. Lungs were placed on a custom-built EVLP system, ventilated and perfused. Utilizing video bronchoscopy, real-time transpleural imaging, and a custom designed micro-catheter delivery and occlusion system, the team delivered a decellularization solution into targeted lung regions that resulted in the selective removal of airway epithelium.
Human airway epithelial cells or human-derived alveolar progenitor cells were labeled (with a quantum dot or a near-infrared dye) and delivered into decellularized lung regions. Following delivery, EVLP was continued for 4-6 hours to allow for cell engraftment. Lung wedge samples were collected at each time point for histologic analysis.
Following decellularization, hematoxylin and eosin staining confirmed removal of pseudostratified and columnar epithelium in proximal airways and removal of type I and II pneumocytes in the distal lung. Delivered cells were retained in the lung after EVLP and fixation, and cellular morphology and distribution within the alveoli indicated early engraftment.
“Bioengineering human lungs utilizing advanced therapeutic interventions such as cell replacement may help combat the critical shortage of transplantable lungs,” said Dr. Guenthart. “Additionally, in the future, targeted intervention and patient-specific cell replacement strategies may have translational applications in vivo and eliminate the need for transplantation in select patients,” he concluded.
They used a previously validated porcine lung injury model of intravenous lipopolysaccharide (LPS) to induce a systemic inflammatory response and subsequent severe ARDS requiring ECMO support. A total of eight mature adult swine were administered LPS via the external jugular vein followed by sternotomy and central ECMO cannulation (right atrium to ascending aorta).
The left pulmonary artery (inflow) and left superior and inferior pulmonary veins (outflow) were dissected out and cannulated to isolate the left lung, which then underwent 4 hours normorthermic IVLP with Steen Solution followed by 4 hours of lung reperfusion after IVLP decannulation.
Dr. Mehaffey and his colleagues then compared the right (LPS control) and left lungs (LPS+IVLP) of the same animal.
All animals demonstrated a significant reduction in PaO2/FiO2 ratio and total lung compliance 2 hours after the start of LPS infusion. During IVLP, the left (treated) pulmonary vein oxygenation was superior to right (control) pulmonary vein oxygenation. After reperfusion and IVLP decannulation, six (75%) animals had improved lung function allowing for ECMO decannulation.
The left lung showed significant improvement of lung-specific oxygenation compared to the right control at 4 hours of reperfusion. Similarly, total lung compliance improved after targeted rehabilitation of the left lung, according to Dr. Mehaffey. In addition, the wet-to-dry ratio of lung tissue demonstrated significantly reduced edema in the rehabilitated left lungs compared to right controls.
Dr. Mehaffey and his colleagues concluded that IVLP may reduce the duration of ECMO and ventilator support resulting in major reduction in morbidity, mortality, and health care–related costs in patients with ARDS.
The Lillehei Forum is a series of presentations on basic research by residents in the field of cardiothoracic surgery.
A targeted near-infrared contrast agent specific for lung adenocarcinomas was assessed for effectiveness during intraoperative molecular imaging (IMI) in animal models. Use of the contrast agent proved significantly more effective at detecting positive margins than did surgery alone, according to a study presented by Jarrod D. Predina, MD.
Initial human experiences with IMI for NSCLC using a fluorescent contrast agent have been limited by technical hurdles including high background noise in inflammatory tissues and low signal output, according to Dr. Predina. As an alternative, he and his colleagues at the University of Pennsylvania hypothesized that a targeted near-infrared contrast agent specific for lung adenocarcinomas would improve sensitivity and specificity during surgery.
Using a mouse surgical model of non–small cell lung cancer (NSCLC) that recapitulates local and systemic post-operative recurrences, Dr. Predina and his colleagues at the University of Pennsylvania injected 140 mice intravenously prior to resection with a near-infrared imaging agent (OTL0038). This agent is specific for pulmonary adenocarcinomas due to its high affinity binding of the folate receptor alpha. Tumor-bearing mice were randomized to surgery with or without IMI. Suspicious residual disease was resected and analyzed by immunohistochemistry, flow cytometry, and immunofluorescence. Based on this data, OTL0038 was tested in a pilot study of five canines with spontaneously occurring lung cancer.
In a local recurrence model system, of 80 mice assessed, surgeons identified 10 positive margins in those randomized to imaging with IMI vs. three positive margins in mice undergoing surgery alone, a significant difference. In systemic recurrence models (60 mice), the mean number of pulmonary nodules located with IMI was 7.2 vs. 3.4 in controls, also a significant difference, according to Dr. Predina.
In five canines with a presumed diagnosis of NSCLC, no toxicity was observed. Four of five canines had fluorescent tumors; the non-fluorescing tumor was discovered to be a metastatic mammary tumor on final pathologic analysis. In one canine, an otherwise undetectable 8-mm pulmonary adenocarcinoma was discovered with IMI.
“Our data suggest that a targeted near-infrared contrast agent may improve IMI technology. Ultimately, this will enable accurate identification of residual disease that may otherwise be overlooked. These results are the basis of an ongoing phase I human trial,” concluded Dr. Predina.
The complexity of the lung has limited the prospects of bioengineering strategies utilizing stem cells and fully decellularized or bioartificial scaffolds, according to Brandon A. Guenthart, MD, of Columbia University.
Using standard protocols, Dr. Guenthart and his colleagues procured human lungs rejected for transplantation on the basis of standard clinical criteria. Lungs were placed on a custom-built EVLP system, ventilated and perfused. Utilizing video bronchoscopy, real-time transpleural imaging, and a custom designed micro-catheter delivery and occlusion system, the team delivered a decellularization solution into targeted lung regions that resulted in the selective removal of airway epithelium.
Human airway epithelial cells or human-derived alveolar progenitor cells were labeled (with a quantum dot or a near-infrared dye) and delivered into decellularized lung regions. Following delivery, EVLP was continued for 4-6 hours to allow for cell engraftment. Lung wedge samples were collected at each time point for histologic analysis.
Following decellularization, hematoxylin and eosin staining confirmed removal of pseudostratified and columnar epithelium in proximal airways and removal of type I and II pneumocytes in the distal lung. Delivered cells were retained in the lung after EVLP and fixation, and cellular morphology and distribution within the alveoli indicated early engraftment.
“Bioengineering human lungs utilizing advanced therapeutic interventions such as cell replacement may help combat the critical shortage of transplantable lungs,” said Dr. Guenthart. “Additionally, in the future, targeted intervention and patient-specific cell replacement strategies may have translational applications in vivo and eliminate the need for transplantation in select patients,” he concluded.
They used a previously validated porcine lung injury model of intravenous lipopolysaccharide (LPS) to induce a systemic inflammatory response and subsequent severe ARDS requiring ECMO support. A total of eight mature adult swine were administered LPS via the external jugular vein followed by sternotomy and central ECMO cannulation (right atrium to ascending aorta).
The left pulmonary artery (inflow) and left superior and inferior pulmonary veins (outflow) were dissected out and cannulated to isolate the left lung, which then underwent 4 hours normorthermic IVLP with Steen Solution followed by 4 hours of lung reperfusion after IVLP decannulation.
Dr. Mehaffey and his colleagues then compared the right (LPS control) and left lungs (LPS+IVLP) of the same animal.
All animals demonstrated a significant reduction in PaO2/FiO2 ratio and total lung compliance 2 hours after the start of LPS infusion. During IVLP, the left (treated) pulmonary vein oxygenation was superior to right (control) pulmonary vein oxygenation. After reperfusion and IVLP decannulation, six (75%) animals had improved lung function allowing for ECMO decannulation.
The left lung showed significant improvement of lung-specific oxygenation compared to the right control at 4 hours of reperfusion. Similarly, total lung compliance improved after targeted rehabilitation of the left lung, according to Dr. Mehaffey. In addition, the wet-to-dry ratio of lung tissue demonstrated significantly reduced edema in the rehabilitated left lungs compared to right controls.
Dr. Mehaffey and his colleagues concluded that IVLP may reduce the duration of ECMO and ventilator support resulting in major reduction in morbidity, mortality, and health care–related costs in patients with ARDS.
Monday’s Plenary tackled key issues
Presentations of the latest research in cardiothoracic surgery are the hallmark of the AATS Plenary session and this year’s session did not disappoint.
When repairing large paraesophageal hernias, transthoracic Belsey Mark IV fundoplication led to lower rates of leaks and reoperations than did the widely used laparoscopic Nissen fundoplication, according to a study presented by Danuel Laan, MD.
Dr. Laan, a resident at the Mayo Clinic in Rochester, Minn., and his colleagues compared outcomes after Belsey Mark IV fundoplication with those after laparoscopic Nissen fundoplication.
The researchers performed a retrospective review of prospectively collected data on all Mayo patients from 2002 to 2011 who underwent repair of a large paraesophageal hernia, defined as having more than 50% of the stomach within the chest. The analysis excluded patients who had already undergone a fundoplication.
Matching 118 Belsey fundoplication patients 1:1 with 118 Nissen fundoplication patients, the investigators compared the two groups for recurrence, need for reoperation, and perioperative outcomes. Nearly 30% of patients in the Belsey and Nissen groups were male. Mean age was 68.7 years and 69.8 years, respectively. Body mass index was 30.3 kg/m2 and 28.8 kg/m2, respectively.
Ten Belsey patients (8.4%) had a hernia recurrence, as did 19 Nissen patients (16.1%). Rates of leak and reoperation were greater in Nissen fundoplication patients than in Belsey patients. There were no leaks in the Belsey patients, compared with eight leaks (6.8%) in the Nissen patients, a statistically significant difference. Reoperation was necessary in 3 Belsey patients (2.5%), significantly fewer than the 11 Nissen patients (9.3%) who underwent reoperation.
Among 77 patients in each group followed for 5 years or less, there was no difference in symptoms. However, in 41 patients in each group followed for more than 5 years, symptoms were excellent or good in 85% of Belsey patients, compared with 56% of Nissen patients.
AATS: Surgical intervention relatively safe for AAOCA in youth
It’s relatively safe to surgically treat anomalous aortic origin of a coronary artery in children and adolescents, with essentially all patients cleared for full activity after 3 months, according to a study presented by Carlos M. Mery, MD.
Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden cardiac death (SCD) in young people, noted Dr. Mery of Texas Children’s Hospital.
He and his colleagues prospectively analyzed outcomes for 44 AAOCA patients who underwent surgical intervention as part of a standardized management program. The researchers included all AAOCA patients aged 2-18 years who underwent surgical intervention between December 2012 and April 2017 as part of the multidisciplinary Coronary Anomalies Program at Texas Children’s Hospital.
Surgical indications included an anomalous left coronary artery, ischemic symptoms, a positive nuclear perfusion test (NPT), or high-risk anatomy such as long intramural segment or ostial stenosis identified via CT angiography. Median patient age was 14 years.
Nine of the patients (20%) underwent surgery for an anomalous left coronary artery, with 32 patients (80%) receiving surgical intervention for an anomalous right coronary artery. A total of 34 surgical procedures (77%) were unroofing of intramural segments, 7 were coronary translocations (16%), and 2 were ostioplasties (4%).
There were no operative deaths. One patient required coronary artery bypass grafting after developing ischemia following a coronary translocation. Minor complications were seen in eight other patients (18%). One patient presented with a second episode of aborted sudden cardiac death 1 year after unroofing of an anomalous left coronary artery with a short intramural segment, and underwent successful coronary translocation and unroofing of a previously identified myocardial bridge.
At follow-up (median 2 years), 40 patients were asymptomatic (91%), while 4 patients had nonspecific chest pain (9%). Forty-one patients (93%) had returned to full activity, while 3 patients were waiting for their 3-month clearance to return to full activity.
Lobectomy can be done safely after concurrent chemotherapy and high-dose radiation in patients with resectable N2-positive stage IIIA non–small-cell lung cancer, according to study findings presented by Jessica S. Donington, MD.
Dr. Donington, of New York University, and her colleagues analyzed two prospective trials conducted by NRG Oncology, RTOG 0229 and RTOG 0839. Both trials’ primary endpoint was mediastinal node sterilization after concurrent chemotherapy and full-dose radiation and has been previously reported.
Dr. Donington and her fellow investigators specifically examined short-term surgical outcomes, given the significant controversy regarding the safety of resection after full-dose thoracic radiation.
In both trials, patients received weekly carboplatin and paclitaxel. Those in the 0229 trial underwent 61.2 Gy of radiation in 34 fractions, while patients in the 0839 trial underwent 60 Gy in 30 fractions. In addition, patients in the 0839 trial were randomized 2:1 to receive weekly panitumumab, an EGFR monoclonal antibody, with their induction therapy.
Surgical expertise was considered essential to this treatment strategy. Therefore, all surgeons were certified by RTOG prior to enrolling patients, and all patients were surgically evaluated before beginning induction therapy to determine resectability and appropriateness for trimodality therapy.
Of 125 eligible patients enrolled in the two trials, 93 patients (74%) underwent anatomic resection. A total of 77 patients underwent lobectomy, 8 underwent pneumonectomy, 6 underwent bilobectomy, and 2 patients had sleeve lobectomy. Medical contraindication and persistent nodal disease found during post-induction invasive staging were the most common reasons patients didn’t undergo resection.
Eighty-five of the 93 surgical patients had R0 resections (91%). Surgeons attempted 14 minimally invasive resections (15%), 2 of which uneventfully converted to open resection.
Just over one-quarter (28%) of patients suffered greater than Grade 3 adverse events (AEs) related to surgery, the majority of which were pulmonary in nature. The 30-day mortality rate was 4%, and all four deaths were linked to pulmonary AEs, including acute respiratory distress syndrome, bronchopleural fistula, pulmonary artery hemorrhage, and respiratory failure. Multivariable analysis for mortality identified the addition of panitumumab and use of an extended resection to be associated with an increased risk for operative mortality.
In the patients undergoing lobectomy, rates for greater than Grade 3 AEs and 30-day mortality were 26%, and 1.3%, respectively. Those rates are similar to rates reported for lobectomy without induction therapy in the National Inpatient Sample (NIS) and the STS General Thoracic Surgery Database over the same time period.
These two RTOG trials are the first to prospectively demonstrate that trimodality therapy with full-dose neoadjuvant radiation therapy is safe in a multi-institutional setting, Dr. Donington said.
Presentations of the latest research in cardiothoracic surgery are the hallmark of the AATS Plenary session and this year’s session did not disappoint.
When repairing large paraesophageal hernias, transthoracic Belsey Mark IV fundoplication led to lower rates of leaks and reoperations than did the widely used laparoscopic Nissen fundoplication, according to a study presented by Danuel Laan, MD.
Dr. Laan, a resident at the Mayo Clinic in Rochester, Minn., and his colleagues compared outcomes after Belsey Mark IV fundoplication with those after laparoscopic Nissen fundoplication.
The researchers performed a retrospective review of prospectively collected data on all Mayo patients from 2002 to 2011 who underwent repair of a large paraesophageal hernia, defined as having more than 50% of the stomach within the chest. The analysis excluded patients who had already undergone a fundoplication.
Matching 118 Belsey fundoplication patients 1:1 with 118 Nissen fundoplication patients, the investigators compared the two groups for recurrence, need for reoperation, and perioperative outcomes. Nearly 30% of patients in the Belsey and Nissen groups were male. Mean age was 68.7 years and 69.8 years, respectively. Body mass index was 30.3 kg/m2 and 28.8 kg/m2, respectively.
Ten Belsey patients (8.4%) had a hernia recurrence, as did 19 Nissen patients (16.1%). Rates of leak and reoperation were greater in Nissen fundoplication patients than in Belsey patients. There were no leaks in the Belsey patients, compared with eight leaks (6.8%) in the Nissen patients, a statistically significant difference. Reoperation was necessary in 3 Belsey patients (2.5%), significantly fewer than the 11 Nissen patients (9.3%) who underwent reoperation.
Among 77 patients in each group followed for 5 years or less, there was no difference in symptoms. However, in 41 patients in each group followed for more than 5 years, symptoms were excellent or good in 85% of Belsey patients, compared with 56% of Nissen patients.
AATS: Surgical intervention relatively safe for AAOCA in youth
It’s relatively safe to surgically treat anomalous aortic origin of a coronary artery in children and adolescents, with essentially all patients cleared for full activity after 3 months, according to a study presented by Carlos M. Mery, MD.
Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden cardiac death (SCD) in young people, noted Dr. Mery of Texas Children’s Hospital.
He and his colleagues prospectively analyzed outcomes for 44 AAOCA patients who underwent surgical intervention as part of a standardized management program. The researchers included all AAOCA patients aged 2-18 years who underwent surgical intervention between December 2012 and April 2017 as part of the multidisciplinary Coronary Anomalies Program at Texas Children’s Hospital.
Surgical indications included an anomalous left coronary artery, ischemic symptoms, a positive nuclear perfusion test (NPT), or high-risk anatomy such as long intramural segment or ostial stenosis identified via CT angiography. Median patient age was 14 years.
Nine of the patients (20%) underwent surgery for an anomalous left coronary artery, with 32 patients (80%) receiving surgical intervention for an anomalous right coronary artery. A total of 34 surgical procedures (77%) were unroofing of intramural segments, 7 were coronary translocations (16%), and 2 were ostioplasties (4%).
There were no operative deaths. One patient required coronary artery bypass grafting after developing ischemia following a coronary translocation. Minor complications were seen in eight other patients (18%). One patient presented with a second episode of aborted sudden cardiac death 1 year after unroofing of an anomalous left coronary artery with a short intramural segment, and underwent successful coronary translocation and unroofing of a previously identified myocardial bridge.
At follow-up (median 2 years), 40 patients were asymptomatic (91%), while 4 patients had nonspecific chest pain (9%). Forty-one patients (93%) had returned to full activity, while 3 patients were waiting for their 3-month clearance to return to full activity.
Lobectomy can be done safely after concurrent chemotherapy and high-dose radiation in patients with resectable N2-positive stage IIIA non–small-cell lung cancer, according to study findings presented by Jessica S. Donington, MD.
Dr. Donington, of New York University, and her colleagues analyzed two prospective trials conducted by NRG Oncology, RTOG 0229 and RTOG 0839. Both trials’ primary endpoint was mediastinal node sterilization after concurrent chemotherapy and full-dose radiation and has been previously reported.
Dr. Donington and her fellow investigators specifically examined short-term surgical outcomes, given the significant controversy regarding the safety of resection after full-dose thoracic radiation.
In both trials, patients received weekly carboplatin and paclitaxel. Those in the 0229 trial underwent 61.2 Gy of radiation in 34 fractions, while patients in the 0839 trial underwent 60 Gy in 30 fractions. In addition, patients in the 0839 trial were randomized 2:1 to receive weekly panitumumab, an EGFR monoclonal antibody, with their induction therapy.
Surgical expertise was considered essential to this treatment strategy. Therefore, all surgeons were certified by RTOG prior to enrolling patients, and all patients were surgically evaluated before beginning induction therapy to determine resectability and appropriateness for trimodality therapy.
Of 125 eligible patients enrolled in the two trials, 93 patients (74%) underwent anatomic resection. A total of 77 patients underwent lobectomy, 8 underwent pneumonectomy, 6 underwent bilobectomy, and 2 patients had sleeve lobectomy. Medical contraindication and persistent nodal disease found during post-induction invasive staging were the most common reasons patients didn’t undergo resection.
Eighty-five of the 93 surgical patients had R0 resections (91%). Surgeons attempted 14 minimally invasive resections (15%), 2 of which uneventfully converted to open resection.
Just over one-quarter (28%) of patients suffered greater than Grade 3 adverse events (AEs) related to surgery, the majority of which were pulmonary in nature. The 30-day mortality rate was 4%, and all four deaths were linked to pulmonary AEs, including acute respiratory distress syndrome, bronchopleural fistula, pulmonary artery hemorrhage, and respiratory failure. Multivariable analysis for mortality identified the addition of panitumumab and use of an extended resection to be associated with an increased risk for operative mortality.
In the patients undergoing lobectomy, rates for greater than Grade 3 AEs and 30-day mortality were 26%, and 1.3%, respectively. Those rates are similar to rates reported for lobectomy without induction therapy in the National Inpatient Sample (NIS) and the STS General Thoracic Surgery Database over the same time period.
These two RTOG trials are the first to prospectively demonstrate that trimodality therapy with full-dose neoadjuvant radiation therapy is safe in a multi-institutional setting, Dr. Donington said.
Presentations of the latest research in cardiothoracic surgery are the hallmark of the AATS Plenary session and this year’s session did not disappoint.
When repairing large paraesophageal hernias, transthoracic Belsey Mark IV fundoplication led to lower rates of leaks and reoperations than did the widely used laparoscopic Nissen fundoplication, according to a study presented by Danuel Laan, MD.
Dr. Laan, a resident at the Mayo Clinic in Rochester, Minn., and his colleagues compared outcomes after Belsey Mark IV fundoplication with those after laparoscopic Nissen fundoplication.
The researchers performed a retrospective review of prospectively collected data on all Mayo patients from 2002 to 2011 who underwent repair of a large paraesophageal hernia, defined as having more than 50% of the stomach within the chest. The analysis excluded patients who had already undergone a fundoplication.
Matching 118 Belsey fundoplication patients 1:1 with 118 Nissen fundoplication patients, the investigators compared the two groups for recurrence, need for reoperation, and perioperative outcomes. Nearly 30% of patients in the Belsey and Nissen groups were male. Mean age was 68.7 years and 69.8 years, respectively. Body mass index was 30.3 kg/m2 and 28.8 kg/m2, respectively.
Ten Belsey patients (8.4%) had a hernia recurrence, as did 19 Nissen patients (16.1%). Rates of leak and reoperation were greater in Nissen fundoplication patients than in Belsey patients. There were no leaks in the Belsey patients, compared with eight leaks (6.8%) in the Nissen patients, a statistically significant difference. Reoperation was necessary in 3 Belsey patients (2.5%), significantly fewer than the 11 Nissen patients (9.3%) who underwent reoperation.
Among 77 patients in each group followed for 5 years or less, there was no difference in symptoms. However, in 41 patients in each group followed for more than 5 years, symptoms were excellent or good in 85% of Belsey patients, compared with 56% of Nissen patients.
AATS: Surgical intervention relatively safe for AAOCA in youth
It’s relatively safe to surgically treat anomalous aortic origin of a coronary artery in children and adolescents, with essentially all patients cleared for full activity after 3 months, according to a study presented by Carlos M. Mery, MD.
Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden cardiac death (SCD) in young people, noted Dr. Mery of Texas Children’s Hospital.
He and his colleagues prospectively analyzed outcomes for 44 AAOCA patients who underwent surgical intervention as part of a standardized management program. The researchers included all AAOCA patients aged 2-18 years who underwent surgical intervention between December 2012 and April 2017 as part of the multidisciplinary Coronary Anomalies Program at Texas Children’s Hospital.
Surgical indications included an anomalous left coronary artery, ischemic symptoms, a positive nuclear perfusion test (NPT), or high-risk anatomy such as long intramural segment or ostial stenosis identified via CT angiography. Median patient age was 14 years.
Nine of the patients (20%) underwent surgery for an anomalous left coronary artery, with 32 patients (80%) receiving surgical intervention for an anomalous right coronary artery. A total of 34 surgical procedures (77%) were unroofing of intramural segments, 7 were coronary translocations (16%), and 2 were ostioplasties (4%).
There were no operative deaths. One patient required coronary artery bypass grafting after developing ischemia following a coronary translocation. Minor complications were seen in eight other patients (18%). One patient presented with a second episode of aborted sudden cardiac death 1 year after unroofing of an anomalous left coronary artery with a short intramural segment, and underwent successful coronary translocation and unroofing of a previously identified myocardial bridge.
At follow-up (median 2 years), 40 patients were asymptomatic (91%), while 4 patients had nonspecific chest pain (9%). Forty-one patients (93%) had returned to full activity, while 3 patients were waiting for their 3-month clearance to return to full activity.
Lobectomy can be done safely after concurrent chemotherapy and high-dose radiation in patients with resectable N2-positive stage IIIA non–small-cell lung cancer, according to study findings presented by Jessica S. Donington, MD.
Dr. Donington, of New York University, and her colleagues analyzed two prospective trials conducted by NRG Oncology, RTOG 0229 and RTOG 0839. Both trials’ primary endpoint was mediastinal node sterilization after concurrent chemotherapy and full-dose radiation and has been previously reported.
Dr. Donington and her fellow investigators specifically examined short-term surgical outcomes, given the significant controversy regarding the safety of resection after full-dose thoracic radiation.
In both trials, patients received weekly carboplatin and paclitaxel. Those in the 0229 trial underwent 61.2 Gy of radiation in 34 fractions, while patients in the 0839 trial underwent 60 Gy in 30 fractions. In addition, patients in the 0839 trial were randomized 2:1 to receive weekly panitumumab, an EGFR monoclonal antibody, with their induction therapy.
Surgical expertise was considered essential to this treatment strategy. Therefore, all surgeons were certified by RTOG prior to enrolling patients, and all patients were surgically evaluated before beginning induction therapy to determine resectability and appropriateness for trimodality therapy.
Of 125 eligible patients enrolled in the two trials, 93 patients (74%) underwent anatomic resection. A total of 77 patients underwent lobectomy, 8 underwent pneumonectomy, 6 underwent bilobectomy, and 2 patients had sleeve lobectomy. Medical contraindication and persistent nodal disease found during post-induction invasive staging were the most common reasons patients didn’t undergo resection.
Eighty-five of the 93 surgical patients had R0 resections (91%). Surgeons attempted 14 minimally invasive resections (15%), 2 of which uneventfully converted to open resection.
Just over one-quarter (28%) of patients suffered greater than Grade 3 adverse events (AEs) related to surgery, the majority of which were pulmonary in nature. The 30-day mortality rate was 4%, and all four deaths were linked to pulmonary AEs, including acute respiratory distress syndrome, bronchopleural fistula, pulmonary artery hemorrhage, and respiratory failure. Multivariable analysis for mortality identified the addition of panitumumab and use of an extended resection to be associated with an increased risk for operative mortality.
In the patients undergoing lobectomy, rates for greater than Grade 3 AEs and 30-day mortality were 26%, and 1.3%, respectively. Those rates are similar to rates reported for lobectomy without induction therapy in the National Inpatient Sample (NIS) and the STS General Thoracic Surgery Database over the same time period.
These two RTOG trials are the first to prospectively demonstrate that trimodality therapy with full-dose neoadjuvant radiation therapy is safe in a multi-institutional setting, Dr. Donington said.
Presidential address focused on learning and teams
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.
Spontaneous coronary artery dissection: New insights
Washington – Patients with spontaneous coronary artery dissection as their presentation of acute coronary syndrome have a markedly better long-term survival rate than do patients with ACS in its various other forms, Rahul Potluri, MD, reported at the annual meeting of the American College of Cardiology.
In his retrospective cohort study of 182 U.K. patients diagnosed with spontaneous coronary artery dissection (SCAD) as the cause of their ACS and 32,981 controls with ACS without SCAD, the 15-year all-cause mortality rate was 10.4% in the SCAD group vs. 32.1% in the controls.
Although SCAD was first described in 1931, half of the roughly 1,500 cases reported in the medical literature have been published within the past 5 years. That makes this series of 182 SCAD patients with 15-year outcome data unique in providing the longest follow-up to date reported in a sizable patient series, said Dr. Potluri of the University of Alberta, Edmonton, and Aston University in Birmingham, England.
SCAD is a rupture in a coronary artery wall not related to atherosclerotic heart disease, trauma, or iatrogenic causes. The dissection is thought to result from an intimal tear or medial hemorrhage from the vasa vasorum, with subsequent accumulation of blood in a false lumen.
It’s not entirely unexpected that patients with SCAD have a better long-term prognosis than do those with ACS without SCAD, Dr. Potluri said. After all, patients with SCAD tend to be considerably younger: In Dr. Potluri’s series, the average age was younger than 52 years, vs. 66 years in controls. Plus they had lower levels of cardiovascular risk factors, and by definition they were free of atherosclerotic heart disease. But SCAD often occurs in conjunction with fibromuscular dysplasia, and the long-term health implications of that combination have not been well studied.
In a multivariate logistic regression analysis adjusted for age, sex, ethnicity, and comorbid conditions, the likelihood of dying within 5 years was 89% greater in the non-SCAD group. During follow-up, the non-SCAD ACS group was 4.1-fold more likely to have another ACS and 32% more likely to be diagnosed with heart failure.
SCAD was typically managed conservatively in Dr. Potluri’s series: In the SCAD group, 11% underwent PCI and 2.7% had CABG, compared with 51% and 10.7%, respectively, of controls.
“Conservative treatment appears to be safe in the SCAD patient population,” he said.
The prevalence of SCAD in his series of more than 33,000 patients admitted for ACS to U.K. hospitals in 2000-2014 was 0.54%. Dr. Potluri said that low figure likely reflects considerable underreporting due to the fact that some data were from the early 2000s, when SCAD was still largely below physicians’ radar.
Dr. Potluri is an authority on big data analytics in medical research. He formed his 182-patient SCAD series using ACALM (Algorithm for Comorbidity, Associations, Length of Stay, and Mortality), an analytic tool he developed years ago as a medical student. At the time of his SCAD study, the ACALM registry included anonymous, deidentified data on 1.8 million U.K. patients. The ACALM methodology utilizes a form of artificial intelligence known as novel field derivation to analyze huge amalgamated data sets. This is made possible by the fact that all U.K. hospitals report patient data in an identical standardized way, which is not the case in the United States.
Dr. Potluri has previously applied the ACALM methodology to a variety of other health care issues, including studies of an association between hyperlipidemia and breast cancer, the relationship between cardiovascular disease and mental health, and the so-called weekend effect, whereby U.K. patients hospitalized for cardiovascular reasons on the weekend have higher mortality than do those admitted on weekdays.
THE ACALM registry now exceeds 4 million patients. Dr. Potluri said he plans to analyze this full group to develop a large, comprehensive SCAD patient registry. This will enable investigators to evaluate potential psychosocial risk factors for SCAD, the role of fibromuscular dysplasia and connective tissue diseases, and other practical questions.
He reported having no financial conflicts regarding his study.
Washington – Patients with spontaneous coronary artery dissection as their presentation of acute coronary syndrome have a markedly better long-term survival rate than do patients with ACS in its various other forms, Rahul Potluri, MD, reported at the annual meeting of the American College of Cardiology.
In his retrospective cohort study of 182 U.K. patients diagnosed with spontaneous coronary artery dissection (SCAD) as the cause of their ACS and 32,981 controls with ACS without SCAD, the 15-year all-cause mortality rate was 10.4% in the SCAD group vs. 32.1% in the controls.
Although SCAD was first described in 1931, half of the roughly 1,500 cases reported in the medical literature have been published within the past 5 years. That makes this series of 182 SCAD patients with 15-year outcome data unique in providing the longest follow-up to date reported in a sizable patient series, said Dr. Potluri of the University of Alberta, Edmonton, and Aston University in Birmingham, England.
SCAD is a rupture in a coronary artery wall not related to atherosclerotic heart disease, trauma, or iatrogenic causes. The dissection is thought to result from an intimal tear or medial hemorrhage from the vasa vasorum, with subsequent accumulation of blood in a false lumen.
It’s not entirely unexpected that patients with SCAD have a better long-term prognosis than do those with ACS without SCAD, Dr. Potluri said. After all, patients with SCAD tend to be considerably younger: In Dr. Potluri’s series, the average age was younger than 52 years, vs. 66 years in controls. Plus they had lower levels of cardiovascular risk factors, and by definition they were free of atherosclerotic heart disease. But SCAD often occurs in conjunction with fibromuscular dysplasia, and the long-term health implications of that combination have not been well studied.
In a multivariate logistic regression analysis adjusted for age, sex, ethnicity, and comorbid conditions, the likelihood of dying within 5 years was 89% greater in the non-SCAD group. During follow-up, the non-SCAD ACS group was 4.1-fold more likely to have another ACS and 32% more likely to be diagnosed with heart failure.
SCAD was typically managed conservatively in Dr. Potluri’s series: In the SCAD group, 11% underwent PCI and 2.7% had CABG, compared with 51% and 10.7%, respectively, of controls.
“Conservative treatment appears to be safe in the SCAD patient population,” he said.
The prevalence of SCAD in his series of more than 33,000 patients admitted for ACS to U.K. hospitals in 2000-2014 was 0.54%. Dr. Potluri said that low figure likely reflects considerable underreporting due to the fact that some data were from the early 2000s, when SCAD was still largely below physicians’ radar.
Dr. Potluri is an authority on big data analytics in medical research. He formed his 182-patient SCAD series using ACALM (Algorithm for Comorbidity, Associations, Length of Stay, and Mortality), an analytic tool he developed years ago as a medical student. At the time of his SCAD study, the ACALM registry included anonymous, deidentified data on 1.8 million U.K. patients. The ACALM methodology utilizes a form of artificial intelligence known as novel field derivation to analyze huge amalgamated data sets. This is made possible by the fact that all U.K. hospitals report patient data in an identical standardized way, which is not the case in the United States.
Dr. Potluri has previously applied the ACALM methodology to a variety of other health care issues, including studies of an association between hyperlipidemia and breast cancer, the relationship between cardiovascular disease and mental health, and the so-called weekend effect, whereby U.K. patients hospitalized for cardiovascular reasons on the weekend have higher mortality than do those admitted on weekdays.
THE ACALM registry now exceeds 4 million patients. Dr. Potluri said he plans to analyze this full group to develop a large, comprehensive SCAD patient registry. This will enable investigators to evaluate potential psychosocial risk factors for SCAD, the role of fibromuscular dysplasia and connective tissue diseases, and other practical questions.
He reported having no financial conflicts regarding his study.
Washington – Patients with spontaneous coronary artery dissection as their presentation of acute coronary syndrome have a markedly better long-term survival rate than do patients with ACS in its various other forms, Rahul Potluri, MD, reported at the annual meeting of the American College of Cardiology.
In his retrospective cohort study of 182 U.K. patients diagnosed with spontaneous coronary artery dissection (SCAD) as the cause of their ACS and 32,981 controls with ACS without SCAD, the 15-year all-cause mortality rate was 10.4% in the SCAD group vs. 32.1% in the controls.
Although SCAD was first described in 1931, half of the roughly 1,500 cases reported in the medical literature have been published within the past 5 years. That makes this series of 182 SCAD patients with 15-year outcome data unique in providing the longest follow-up to date reported in a sizable patient series, said Dr. Potluri of the University of Alberta, Edmonton, and Aston University in Birmingham, England.
SCAD is a rupture in a coronary artery wall not related to atherosclerotic heart disease, trauma, or iatrogenic causes. The dissection is thought to result from an intimal tear or medial hemorrhage from the vasa vasorum, with subsequent accumulation of blood in a false lumen.
It’s not entirely unexpected that patients with SCAD have a better long-term prognosis than do those with ACS without SCAD, Dr. Potluri said. After all, patients with SCAD tend to be considerably younger: In Dr. Potluri’s series, the average age was younger than 52 years, vs. 66 years in controls. Plus they had lower levels of cardiovascular risk factors, and by definition they were free of atherosclerotic heart disease. But SCAD often occurs in conjunction with fibromuscular dysplasia, and the long-term health implications of that combination have not been well studied.
In a multivariate logistic regression analysis adjusted for age, sex, ethnicity, and comorbid conditions, the likelihood of dying within 5 years was 89% greater in the non-SCAD group. During follow-up, the non-SCAD ACS group was 4.1-fold more likely to have another ACS and 32% more likely to be diagnosed with heart failure.
SCAD was typically managed conservatively in Dr. Potluri’s series: In the SCAD group, 11% underwent PCI and 2.7% had CABG, compared with 51% and 10.7%, respectively, of controls.
“Conservative treatment appears to be safe in the SCAD patient population,” he said.
The prevalence of SCAD in his series of more than 33,000 patients admitted for ACS to U.K. hospitals in 2000-2014 was 0.54%. Dr. Potluri said that low figure likely reflects considerable underreporting due to the fact that some data were from the early 2000s, when SCAD was still largely below physicians’ radar.
Dr. Potluri is an authority on big data analytics in medical research. He formed his 182-patient SCAD series using ACALM (Algorithm for Comorbidity, Associations, Length of Stay, and Mortality), an analytic tool he developed years ago as a medical student. At the time of his SCAD study, the ACALM registry included anonymous, deidentified data on 1.8 million U.K. patients. The ACALM methodology utilizes a form of artificial intelligence known as novel field derivation to analyze huge amalgamated data sets. This is made possible by the fact that all U.K. hospitals report patient data in an identical standardized way, which is not the case in the United States.
Dr. Potluri has previously applied the ACALM methodology to a variety of other health care issues, including studies of an association between hyperlipidemia and breast cancer, the relationship between cardiovascular disease and mental health, and the so-called weekend effect, whereby U.K. patients hospitalized for cardiovascular reasons on the weekend have higher mortality than do those admitted on weekdays.
THE ACALM registry now exceeds 4 million patients. Dr. Potluri said he plans to analyze this full group to develop a large, comprehensive SCAD patient registry. This will enable investigators to evaluate potential psychosocial risk factors for SCAD, the role of fibromuscular dysplasia and connective tissue diseases, and other practical questions.
He reported having no financial conflicts regarding his study.
At ACC 17
Key clinical point:
Major finding: The 15-year all-cause mortality rate was 10% in patients with spontaneous coronary artery dissection, compared with 32% in those with ACS without spontaneous coronary artery dissection.
Data source: A retrospective cohort study including 15-year outcomes for 182 patients with spontaneous coronary artery dissection and more than 32,000 controls with ACS without dissection.
Disclosures: The study presenter reported having no financial conflicts.
Noncardiovascular comorbidities spike in acute heart failure
PARIS – Patients hospitalized for heart failure increasingly present with a growing number of noncardiovascular comorbidities, according to registry data from more than 300 U.S. hospitals.
During the decade of 2005-2014, the percentage of patients hospitalized for heart failure diagnosed with three or more noncardiovascular comorbidities (NCCs) jumped from abut 17% of these patients in 2005 to about 28% in 2015, Abhinav Sharma, MD, said at a meeting held by the Heart Failure Association of the ESC. This increase occurred as the percentages of hospitalized heart failure patients with none or one NCC showed clear decreases.
U.S. patients hospitalized for heart failure “appear to now be sicker and more medically complex. Probably, a large number of the noncardiovascular comorbidities are not being recognized when the focus is on treating the patient’s heart failure,” he said in an interview. “If we can identify the noncardiovascular comorbidities and target appropriate treatment, it may potentially decrease the risk of readmissions.”
He included five NCCs in his analysis: chronic obstructive pulmonary disease, anemia, diabetes, chronic kidney disease, and obesity.
His analysis showed that a higher rate of readmissions, as well as increased mortality both in hospital and during the 30 days following discharge, are outcomes that all connect with increased numbers of NCCs. Patients with three or more NCCs at the time of their heart failure admission were about 50% more likely to die in hospital, about 65% more likely to die during the 30 days following admission, about 35% more likely to be readmitted, and about half as likely to be discharged home following hospitalization, when compared with patients with no NCC in multivariate analyses that adjusted for demographic and other clinical variables. Patients with three or more NCCs were also about 67% more likely to have an index hospitalization of at least 4 days, compared with patients with no NCC.
Dr. Sharma speculated that the increased prevalence of multiple NCCs in acute heart failure patients may result, in part, from secular trends in the rates of diabetes and obesity and the noncardiovascular comorbidities associated with these conditions. All five of the NCCs included in his analysis showed increased prevalence rates from 2005 to 2014 in the patients he studied. The biggest jump occurred in the prevalence of chronic obstructive pulmonary disease, which rose from about 27% in 2005 to about 35% in 2014.
His study used data collected in the Get With the Guidelines–Heart Failure Registry, which began in 2005, and included just under 208,000 total patients. He acknowledged that it is hard to know how representative these patients are of the entire population of U.S. patients hospitalized for heart failure during the study period, because the patients he studied came from a self-selected group of more than 300 hospitals that opted to participate in the registry. “We need to see if this can be extrapolated to all U.S. hospitals,” Dr. Sharma said.
[email protected]
On Twitter @mitchelzoler
PARIS – Patients hospitalized for heart failure increasingly present with a growing number of noncardiovascular comorbidities, according to registry data from more than 300 U.S. hospitals.
During the decade of 2005-2014, the percentage of patients hospitalized for heart failure diagnosed with three or more noncardiovascular comorbidities (NCCs) jumped from abut 17% of these patients in 2005 to about 28% in 2015, Abhinav Sharma, MD, said at a meeting held by the Heart Failure Association of the ESC. This increase occurred as the percentages of hospitalized heart failure patients with none or one NCC showed clear decreases.
U.S. patients hospitalized for heart failure “appear to now be sicker and more medically complex. Probably, a large number of the noncardiovascular comorbidities are not being recognized when the focus is on treating the patient’s heart failure,” he said in an interview. “If we can identify the noncardiovascular comorbidities and target appropriate treatment, it may potentially decrease the risk of readmissions.”
He included five NCCs in his analysis: chronic obstructive pulmonary disease, anemia, diabetes, chronic kidney disease, and obesity.
His analysis showed that a higher rate of readmissions, as well as increased mortality both in hospital and during the 30 days following discharge, are outcomes that all connect with increased numbers of NCCs. Patients with three or more NCCs at the time of their heart failure admission were about 50% more likely to die in hospital, about 65% more likely to die during the 30 days following admission, about 35% more likely to be readmitted, and about half as likely to be discharged home following hospitalization, when compared with patients with no NCC in multivariate analyses that adjusted for demographic and other clinical variables. Patients with three or more NCCs were also about 67% more likely to have an index hospitalization of at least 4 days, compared with patients with no NCC.
Dr. Sharma speculated that the increased prevalence of multiple NCCs in acute heart failure patients may result, in part, from secular trends in the rates of diabetes and obesity and the noncardiovascular comorbidities associated with these conditions. All five of the NCCs included in his analysis showed increased prevalence rates from 2005 to 2014 in the patients he studied. The biggest jump occurred in the prevalence of chronic obstructive pulmonary disease, which rose from about 27% in 2005 to about 35% in 2014.
His study used data collected in the Get With the Guidelines–Heart Failure Registry, which began in 2005, and included just under 208,000 total patients. He acknowledged that it is hard to know how representative these patients are of the entire population of U.S. patients hospitalized for heart failure during the study period, because the patients he studied came from a self-selected group of more than 300 hospitals that opted to participate in the registry. “We need to see if this can be extrapolated to all U.S. hospitals,” Dr. Sharma said.
[email protected]
On Twitter @mitchelzoler
PARIS – Patients hospitalized for heart failure increasingly present with a growing number of noncardiovascular comorbidities, according to registry data from more than 300 U.S. hospitals.
During the decade of 2005-2014, the percentage of patients hospitalized for heart failure diagnosed with three or more noncardiovascular comorbidities (NCCs) jumped from abut 17% of these patients in 2005 to about 28% in 2015, Abhinav Sharma, MD, said at a meeting held by the Heart Failure Association of the ESC. This increase occurred as the percentages of hospitalized heart failure patients with none or one NCC showed clear decreases.
U.S. patients hospitalized for heart failure “appear to now be sicker and more medically complex. Probably, a large number of the noncardiovascular comorbidities are not being recognized when the focus is on treating the patient’s heart failure,” he said in an interview. “If we can identify the noncardiovascular comorbidities and target appropriate treatment, it may potentially decrease the risk of readmissions.”
He included five NCCs in his analysis: chronic obstructive pulmonary disease, anemia, diabetes, chronic kidney disease, and obesity.
His analysis showed that a higher rate of readmissions, as well as increased mortality both in hospital and during the 30 days following discharge, are outcomes that all connect with increased numbers of NCCs. Patients with three or more NCCs at the time of their heart failure admission were about 50% more likely to die in hospital, about 65% more likely to die during the 30 days following admission, about 35% more likely to be readmitted, and about half as likely to be discharged home following hospitalization, when compared with patients with no NCC in multivariate analyses that adjusted for demographic and other clinical variables. Patients with three or more NCCs were also about 67% more likely to have an index hospitalization of at least 4 days, compared with patients with no NCC.
Dr. Sharma speculated that the increased prevalence of multiple NCCs in acute heart failure patients may result, in part, from secular trends in the rates of diabetes and obesity and the noncardiovascular comorbidities associated with these conditions. All five of the NCCs included in his analysis showed increased prevalence rates from 2005 to 2014 in the patients he studied. The biggest jump occurred in the prevalence of chronic obstructive pulmonary disease, which rose from about 27% in 2005 to about 35% in 2014.
His study used data collected in the Get With the Guidelines–Heart Failure Registry, which began in 2005, and included just under 208,000 total patients. He acknowledged that it is hard to know how representative these patients are of the entire population of U.S. patients hospitalized for heart failure during the study period, because the patients he studied came from a self-selected group of more than 300 hospitals that opted to participate in the registry. “We need to see if this can be extrapolated to all U.S. hospitals,” Dr. Sharma said.
[email protected]
On Twitter @mitchelzoler
AT HEART FAILURE 2017
Key clinical point:
Major finding: The prevalence of three or more noncardiovascular comorbidities jumped from about 17% in 2005 to about 28% in 2014.
Data source: Review of 207,984 U.S. hospitalized heart failure patients included in the Get With the Guidelines–Heart Failure Registry during 2005-2014.
Disclosures: Dr. Sharma has received research support from Roche Diagnostics and Takeda.
AATS Mitral Conclave Draws the Largest Crowd Ever
The fourth biennial the American Association for Thoracic Surgery (AATS) Mitral Conclave 2017 was attended by a large audience of cardiothoracic surgeons and other professionals from 67 countries on Thursday and Friday to hear the latest on repair and replacement of the mitral valve.
Conference chair David H. Adams, MD, of Mount Sinai Health System noted that this was the first time the AATS had directly managed the meeting. The conclave included more than 200 oral presentations and 207 e-posters.
The faculty included more than 70 international thought leaders in mitral valve repair, and the live sessions featured more than 200 lectures, abstracts, and video presentations. Twenty-two breakout sessions reported on more than 80 submitted abstracts.
Mastering videography skills also improves one’s minimally invasive skills, said Vinay Badhwar, MD, of West Virginia University. “To do mitral surgery robotically and do minimally invasive surgery, you have to become a videographer,” he said. The surgeon must also be engaged in carefully selecting his or her team, Dr. Badhwar added.
In seven different plenary sessions, international experts participated in panels that discussed management of complications and explored scenarios in which they would not intervene. A debate format modeled on the movie Thunderdome—“four men enter, one man leaves”—featured a spirited discussion on when to repair functional tricuspid regurgitation. Dr. Adams and Tirone E. David, MD, of Toronto General Hospital, took rather strident opposing views, with Dr. Adams advocating for repair. The goal, Dr. Adams said, is to provide normal tricuspid valve function for the long term. “We got aggressive because we were doing a lot of reoperations for tricuspid disease in patients who had mitral valve surgery,” Dr. Adams said.
One plenary roundtable tackled the subject of when to use mechanical valves instead of biological valves. “Has the pendulum swung too far away from mechanical valves and are there cases where mechanical valves should be the first choice?” Dr. Sundt, session chair, asked the panelists.
The panelists concurred that a patient’s individual needs would drive decision-making. Anelechi Anyanwu, MD, of Mount Sinai, said he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis.* In younger patients, namely teenagers, valve selection depends on the activity level they’d pursue after surgery, said Pedro J. del Nido, MD, of Children’s Hospital Boston.
At the plenary on transcatheter mitral therapy, John Laschinger, MD, of the Food and Drug Administration, reviewed the approval process for new mitral devices. “It comes down to the benefit-risk determination where we look at the standard-of-care surgery and look to see if the device is an acceptable alternative – that is, if it is safer and more effective,” Dr. Laschinger said.
James S. Gammie, MD, of the University of Maryland, also reported on an analysis of 87,214 mitral procedures from the Society for Thoracic Surgeons database over the past 5 years. Among the revelations from this analysis are that 96.1% of procedures for leaflet prolapse involved annuloplasty and that 75.8% receive a bioprosthetic valve.
The plenary and breakouts also included seven different video sessions ranging from managing leaflet prolapse to adult congenital surgery and complex scenarios.
Robert A. Dion, MD, Genk, Belgium, delivered the Conclave Honored Lecture and received the Mitral Conclave Achievement Award. He talked about the operative team as a geese flight. “The geese flight is always a unit of hierarchy,” Dr. Dion said. “The figure of the geese flight is V and the chief chooses the lead goose for the capacity to fly high enough and fast enough.”
In the Honored Cardiology Lecture, Robert O. Bonow, MD, of Northwestern Memorial Hospital, explored clinical guidelines for mitral valve repair and replacement and their application in the clinic. “Both sets of guidelines in Europe and the United States make the clear point that is obvious to all of you but less so to cardiologists, that there are two forms of mitral valve disease: degenerative or primary, and functional, which is secondary,” he said. He called for thoracic surgeons to collaborate with their cardiology colleagues. “You and I have lots of work to do, not only in caring for our patients but also in starting to devise appropriate quality metrics, hopefully working together in a team-based approach,” Dr. Bonow said. “This is what gives the best patient care but also gives us the best recommendations for our policy issues. And I look forward to further enhancements from your field and mine as well.”
The AATS Mitral Conclave skips a year in 2018. Instead, New York will host the biennial AATS Aortic Symposium April 26–28 next year.
* CORRECTION: Dr. Anyanwu's remarks were corrected read "he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis." 5/5/2017
The fourth biennial the American Association for Thoracic Surgery (AATS) Mitral Conclave 2017 was attended by a large audience of cardiothoracic surgeons and other professionals from 67 countries on Thursday and Friday to hear the latest on repair and replacement of the mitral valve.
Conference chair David H. Adams, MD, of Mount Sinai Health System noted that this was the first time the AATS had directly managed the meeting. The conclave included more than 200 oral presentations and 207 e-posters.
The faculty included more than 70 international thought leaders in mitral valve repair, and the live sessions featured more than 200 lectures, abstracts, and video presentations. Twenty-two breakout sessions reported on more than 80 submitted abstracts.
Mastering videography skills also improves one’s minimally invasive skills, said Vinay Badhwar, MD, of West Virginia University. “To do mitral surgery robotically and do minimally invasive surgery, you have to become a videographer,” he said. The surgeon must also be engaged in carefully selecting his or her team, Dr. Badhwar added.
In seven different plenary sessions, international experts participated in panels that discussed management of complications and explored scenarios in which they would not intervene. A debate format modeled on the movie Thunderdome—“four men enter, one man leaves”—featured a spirited discussion on when to repair functional tricuspid regurgitation. Dr. Adams and Tirone E. David, MD, of Toronto General Hospital, took rather strident opposing views, with Dr. Adams advocating for repair. The goal, Dr. Adams said, is to provide normal tricuspid valve function for the long term. “We got aggressive because we were doing a lot of reoperations for tricuspid disease in patients who had mitral valve surgery,” Dr. Adams said.
One plenary roundtable tackled the subject of when to use mechanical valves instead of biological valves. “Has the pendulum swung too far away from mechanical valves and are there cases where mechanical valves should be the first choice?” Dr. Sundt, session chair, asked the panelists.
The panelists concurred that a patient’s individual needs would drive decision-making. Anelechi Anyanwu, MD, of Mount Sinai, said he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis.* In younger patients, namely teenagers, valve selection depends on the activity level they’d pursue after surgery, said Pedro J. del Nido, MD, of Children’s Hospital Boston.
At the plenary on transcatheter mitral therapy, John Laschinger, MD, of the Food and Drug Administration, reviewed the approval process for new mitral devices. “It comes down to the benefit-risk determination where we look at the standard-of-care surgery and look to see if the device is an acceptable alternative – that is, if it is safer and more effective,” Dr. Laschinger said.
James S. Gammie, MD, of the University of Maryland, also reported on an analysis of 87,214 mitral procedures from the Society for Thoracic Surgeons database over the past 5 years. Among the revelations from this analysis are that 96.1% of procedures for leaflet prolapse involved annuloplasty and that 75.8% receive a bioprosthetic valve.
The plenary and breakouts also included seven different video sessions ranging from managing leaflet prolapse to adult congenital surgery and complex scenarios.
Robert A. Dion, MD, Genk, Belgium, delivered the Conclave Honored Lecture and received the Mitral Conclave Achievement Award. He talked about the operative team as a geese flight. “The geese flight is always a unit of hierarchy,” Dr. Dion said. “The figure of the geese flight is V and the chief chooses the lead goose for the capacity to fly high enough and fast enough.”
In the Honored Cardiology Lecture, Robert O. Bonow, MD, of Northwestern Memorial Hospital, explored clinical guidelines for mitral valve repair and replacement and their application in the clinic. “Both sets of guidelines in Europe and the United States make the clear point that is obvious to all of you but less so to cardiologists, that there are two forms of mitral valve disease: degenerative or primary, and functional, which is secondary,” he said. He called for thoracic surgeons to collaborate with their cardiology colleagues. “You and I have lots of work to do, not only in caring for our patients but also in starting to devise appropriate quality metrics, hopefully working together in a team-based approach,” Dr. Bonow said. “This is what gives the best patient care but also gives us the best recommendations for our policy issues. And I look forward to further enhancements from your field and mine as well.”
The AATS Mitral Conclave skips a year in 2018. Instead, New York will host the biennial AATS Aortic Symposium April 26–28 next year.
* CORRECTION: Dr. Anyanwu's remarks were corrected read "he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis." 5/5/2017
The fourth biennial the American Association for Thoracic Surgery (AATS) Mitral Conclave 2017 was attended by a large audience of cardiothoracic surgeons and other professionals from 67 countries on Thursday and Friday to hear the latest on repair and replacement of the mitral valve.
Conference chair David H. Adams, MD, of Mount Sinai Health System noted that this was the first time the AATS had directly managed the meeting. The conclave included more than 200 oral presentations and 207 e-posters.
The faculty included more than 70 international thought leaders in mitral valve repair, and the live sessions featured more than 200 lectures, abstracts, and video presentations. Twenty-two breakout sessions reported on more than 80 submitted abstracts.
Mastering videography skills also improves one’s minimally invasive skills, said Vinay Badhwar, MD, of West Virginia University. “To do mitral surgery robotically and do minimally invasive surgery, you have to become a videographer,” he said. The surgeon must also be engaged in carefully selecting his or her team, Dr. Badhwar added.
In seven different plenary sessions, international experts participated in panels that discussed management of complications and explored scenarios in which they would not intervene. A debate format modeled on the movie Thunderdome—“four men enter, one man leaves”—featured a spirited discussion on when to repair functional tricuspid regurgitation. Dr. Adams and Tirone E. David, MD, of Toronto General Hospital, took rather strident opposing views, with Dr. Adams advocating for repair. The goal, Dr. Adams said, is to provide normal tricuspid valve function for the long term. “We got aggressive because we were doing a lot of reoperations for tricuspid disease in patients who had mitral valve surgery,” Dr. Adams said.
One plenary roundtable tackled the subject of when to use mechanical valves instead of biological valves. “Has the pendulum swung too far away from mechanical valves and are there cases where mechanical valves should be the first choice?” Dr. Sundt, session chair, asked the panelists.
The panelists concurred that a patient’s individual needs would drive decision-making. Anelechi Anyanwu, MD, of Mount Sinai, said he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis.* In younger patients, namely teenagers, valve selection depends on the activity level they’d pursue after surgery, said Pedro J. del Nido, MD, of Children’s Hospital Boston.
At the plenary on transcatheter mitral therapy, John Laschinger, MD, of the Food and Drug Administration, reviewed the approval process for new mitral devices. “It comes down to the benefit-risk determination where we look at the standard-of-care surgery and look to see if the device is an acceptable alternative – that is, if it is safer and more effective,” Dr. Laschinger said.
James S. Gammie, MD, of the University of Maryland, also reported on an analysis of 87,214 mitral procedures from the Society for Thoracic Surgeons database over the past 5 years. Among the revelations from this analysis are that 96.1% of procedures for leaflet prolapse involved annuloplasty and that 75.8% receive a bioprosthetic valve.
The plenary and breakouts also included seven different video sessions ranging from managing leaflet prolapse to adult congenital surgery and complex scenarios.
Robert A. Dion, MD, Genk, Belgium, delivered the Conclave Honored Lecture and received the Mitral Conclave Achievement Award. He talked about the operative team as a geese flight. “The geese flight is always a unit of hierarchy,” Dr. Dion said. “The figure of the geese flight is V and the chief chooses the lead goose for the capacity to fly high enough and fast enough.”
In the Honored Cardiology Lecture, Robert O. Bonow, MD, of Northwestern Memorial Hospital, explored clinical guidelines for mitral valve repair and replacement and their application in the clinic. “Both sets of guidelines in Europe and the United States make the clear point that is obvious to all of you but less so to cardiologists, that there are two forms of mitral valve disease: degenerative or primary, and functional, which is secondary,” he said. He called for thoracic surgeons to collaborate with their cardiology colleagues. “You and I have lots of work to do, not only in caring for our patients but also in starting to devise appropriate quality metrics, hopefully working together in a team-based approach,” Dr. Bonow said. “This is what gives the best patient care but also gives us the best recommendations for our policy issues. And I look forward to further enhancements from your field and mine as well.”
The AATS Mitral Conclave skips a year in 2018. Instead, New York will host the biennial AATS Aortic Symposium April 26–28 next year.
* CORRECTION: Dr. Anyanwu's remarks were corrected read "he’d be inclined to use a mechanical valve in a 25-year-old man with rheumatic mitral stenosis." 5/5/2017
