pci vs. cabg: inside which is best for · and general surgery residency. he is now a thoracic track...

B Y M A RY A N N M O O N

Else vier Global Medical Ne ws

Survival after lung trans-plantation varies widely

across the 61 U.S. medical cen-ters where it is performed, ac-cording to a report in JAMA.

However, only 15% of thatvariation can be attributed tothe volume of proceduresdone at each center, said Dr.Gabriel Thabut of the depart-ment of health sciences re-search at the Mayo Clinic in

Rochester, Minn., and his as-sociates.

“We assessed the associationof center volume and survivalusing different time frames, dif-ferent definitions of volume,and different statistical meth-ods. All analytic frames showeda consistent and statistically sig-nificant positive association be-tween center volume andsurvival.” However, volumecontributed only a smallamount to mortality after lungtransplant, and several low-

and medium-volume centersachieved good outcomes,showing that “volume alonedoes not determine perfor-mance,” they noted.

The investigators undertooktheir study because researchhas suggested that outcomesvary greatly from one center tothe next. “For example, studiesfrom several large centers re-port 3-year survival ratesgreater than 70% and even

VOL. 6 • NO. 8 • SEPTEMBER 2010

PCI vs. CABG:Which Is Best for

Complex CAD?

B Y R I C H A R D M .

K I R K N E R


N E W Y O R K — Coronaryartery bypass grafting may re-main the standard treatmentfor left main coronary arteryand complex multivessel dis-ease, but results achieved usingpercutaneous coronary inter-vention with drug-elutingstents have come close to thoseseen with coronary bypass.

Dr. Upendra Kaul of FortisEscorts Heart Institute in NewDelhi and Dr. Alfredo Ro-driguez, head of the cardiacunit at Otamendi Hospital inBuenos Aires, debated themerits of the two interven-tional approaches at the Mt.Sinai Symposium of ComplexCoronary and Vascular Cases.

“The difference between by-pass surgery and angioplasty incomplex and left main arterydisease has always been one of

higher reintervention rates;and, as we know, restenosis isnot a benign entity,” Dr. Kaulsaid. He acknowledged that re-cent clinical trials have shownthat drug-eluting stents (DES)have substantially lower ratesof reintervention than do bare-metal stents, but he painted adifferent picture when com-paring either stenting modali-ty with coronary artery bypassgrafting (CABG) in complexand left main artery stenosis.

“The rates of repeat vascu-larization very clearly favor by-pass surgery,” he said, citing a2008 trial (N. Engl. J. Med.2008;358:331-41). Among pa-tients with two-vessel disease,CABG had slightly better out-comes than did DES: 96% vs.94.6% for adjusted survival rate,and 94.5% vs. 92.5% for my-ocardial infarction-free survival.

Dr. Rodriguez countered

Resident ‘Boot Camp’Introduces Techniques

B Y M A R K S. L E S N E Y


Ensuring that cardiothoracicsurgery residents receiveappropriate training in

core CT-surgical techniques is acritical issue in a world of rapid-ly changing technology and ed-ucational demands. Innovativetraining methods are required,and the Thoracic Surgery Di-rectors Association has been atthe forefront of efforts to im-prove the learning experiencefor today’s residents.

A prime example of these ef-forts is the TSDA Cardiotho-racic Surgery Resident BootCamp. The annual Boot Campwas held on July 8-11, 2010 atthe William and Ida Friday Cen-ter of the University of NorthCarolina, Chapel Hill, N.C. Theprogram was developed andhosted by the Thoracic SurgeryDirectors Association and wasfunded in part through a grantfrom the Joint Council on Tho-racic Surgical Education, Inc.

Now in its third year, the BootCamp uses cardiothoracic sim-ulator-based training to give res-

idents some of the basic skillsets necessary to enhance theirresidency educational experi-ence, especially in the operatingroom.

More than 30 highly experi-enced cardiothoracic surgeryeducators and guests fromaround the country donatedtheir time and expertise to leadthe resident courses in thoracicendoscopy (Dr. Alberto deHoyos, course director), car-diopulmonary bypass (Dr.James Gangemi, course direc-tor), open lobectomy (Dr.Daniel Miller, course director),and vascular anastomosis (Dr.James Fann, course director).Each course used recently-de-veloped cardiothoracic-specificsimulators, including the Ram-phal Cardiac Surgery Simulator,the Carolina Lung Surgery Sim-ulator, the Heart Case Platform,and Mediastinoscopy Man.

“Over the last three years, wehave learned a tremendousamount about resident educa-tion and especially how effectivesimulator-based training can

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Dr. Mark Iannettoni (R) guides residents Dr. Dawn Hui and Dr.Elan Burton through a simulated open lobectomy.

Lung Transplant Survival Varies by Center

See Debate • page 5

See Education • page 3

Outcomes gap may be narrowing.

Presorted StandardU.S. Postage

PAIDPermit No. 384Lebanon Jct. KY

THORACICSURGERYNEWSCHANGE SERVICE REQUESTED60 Columbia Rd.,Bldg. B, 2

ndflr.

Morristown, NJ 07960

See Center • page 13

Residents’ Corner

ReachingResidents

TSN launches its new

section for residents

featuring info on education,

training, and other issues of

interest to residents and their

educators. • 2

General Thoracic

Living LongerPalliative care not only

improves quality of life for

metastatic lung cancer

patients, it prolongs it. • 6

Adult Cardiac

‘Six of One . . .’Little difference seen between

transapical or transfemoral

aortic valve implantation in

high risk patients. • 1 1

I N S I D E

T H O R AC I C S U RG E RY

N E W S O N L I N E !

Visit our new interactive editions.

See our new ‘Residents’ Corner’

section on pages 2-3 for details.

01_3_4_5_13ts10_9.qxp 8/24/2010 3:59 PM

2 RESIDENTS’ CORNER S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

B Y D R . YO L O N D A C O L S O N

Medical Editor

Hard to believe we are alreadyinto fall. Hope all of you hadtime for some relaxation and re-

flection over the summer, mixed witha little fun and adventure with friendsand family. It is times like these thatmake us truly appreciate what we doeveryday—we strive tomake such memories pos-sible for our patients byrestoring their health andgiving them a new leaseon life.

As we begin a new acad-emic year, THORACIC

SURGERY NEWS has manynew initiatives to bringnew life into our world aswell. The mission of theAATS has always been fo-cused on the promotion and fosteringof education and research in the fieldof cardiothoracic surgery.

As academic cardiothoracic surgeonswe are a small, close community witha strong commitment to the educationand development of the next genera-tion of surgeons. Although anoverused cliche, we really do recognizethat the next generation is our futureand our legacy, building the future isour responsibility.

Our community is too small and ourexpertise too important to not cultivatethe talent among us and make the nextgeneration even greater than ourselves.This challenge and responsibility has al-ways been accepted by CT surgeonswith great pride and enthusiasm.

It is with this focus of welcomingour residents and fellows into theAATS, building bridges among the ea-ger to learn and the eager to teach, andthe desire to pass along our rich her-itage to the next generation that weproudly introduce our two new resi-dent associate editors and the launch

of a resident-centered section in theTSN newspaper and website. In orderto get this initiative started with lots offace-to-face brainstorming time, wehave been fortunate to recruit two tal-ented cardiothoracic residents repre-senting cardiac and thoraciceducational interests.

In alphabetical order, Stephanie Mickis a cardiac surgery resident at Brigham

and Women's Hospital,Boston, raised in Dayton,Ohio and moved to NewYork, New York for collegeat Columbia. She attendedCornell Medical Schooland completed her Gener-al Surgery Residency atNew York PresbyterianHospital, Cornell.

Christian Peyre was bornand raised in Los Angelesand completed his under-

graduate degree at UC Berkeley beforegoing to USC for both medical schooland general surgery residency. He isnow a thoracic track cardiothoracicsurgery resident also at BWH.

Together, they have worked with TSNto establish a Residents’ Corner, a“Training Table” if you will, where res-idents can come any time of day ornight for a few minutes and drink insome sustenance in the field of cardio-thoracic surgery.

In coming issues, we will start a“case of the month” column with im-ages to learn from on bread and buttertopics (no pun intended but it works),expert commentary, review of classiccardiothoracic papers, updates on JointCouncil on Thoracic Surgery Educa-tion ( JCTSE) initiatives and other ed-ucational news, articles aboutcardiothoracic pioneers and our histo-ry, and mentoring advice on how tostart your career or at least things wewished we had know when we were inyour shoes.

It will be a place to find information

about the events and deadlines that areimportant to cardiothoracic residentsand fellows, here and abroad, and itwill serve to highlight the commit-ment to education that AATS alreadyexemplifies through the AATS Travel-ing Fellowship and Scholarship Pro-grams, the Summer InternshipProgram, the C. Walton Lillehei Resi-dent Forum, and our joint support ofThoracic Surgery Foundation for Re-search and Education (TSFRE) andJCTSE programs.

We will draw on great mentoring re-sources like the AATS Academy, Devel-oping the Academic SurgeonSymposium, the Grantsmanship Courseand the wisdom of experience that theAATS membership already possesses,but we will also draw on other resourcesincluding our recent collaboration withThoracic Surgery Residents Association(TSRA). AATS has always been a strongsupporter of resident education and re-search, with resident resources availableon their web page (www.aats.org/TSR/index.html), but we have not had anongoing forum to interact, teach, andlearn from the residents.

Through resident editors, TSN willbe able to provide a window for theTSRA to let us know how we can bet-ter help residents become the best part-ners and cardiothoracic surgeonspossible and we will be able to get im-portant AATS opportunities and TSRAinformation to the sometimes “missing-in-action” CT resident through an al-ways available website.

I invite all of you, resident and attend-ings alike, to take a look at the new sec-tion, send new ideas, volunteer to addexpert commentary and help us makeTSN the best place for a “quick bite”ofCT surgery news and education.

Feel free to contact as at aats.prri.com.And to see the latest edition of TSN on our redesigned website please visit www.aats.org/Association/Thoracic_Surgery_News.html. ■

Welcome to Our Residents’ Section

DR. YOLONDA COLSON

Making theMatch in

2010B Y M A R K S. L E S N E Y

Senior Editor

This year’s Thoracic Surgery FellowshipMatch Day was held June 9 and the

trend of comparatively few applicantsper position continued. A total of 99 cer-tified applicants applied for 113 positionsin 80 certified thoracic surgery programs.

In part, because there were fewer ap-plicants compared with the number of fel-lowships, only 88 of these positions werefilled (78%). A total of 95% of 65 certifiedU.S. graduate applicants from U.S. pro-grams were matched, compared with72% of 18 certified foreign applicants. U.S.applicants trained at foreign institutionsdid not fare as well as their U.S.-trainedpeers, with only 75% of 8 certified can-didates being matched (www.nrmp.org/fel-low/match_name/thoracic/stats.html).

Registration for the 2010 Match beganJan. 6, 2010, for the appointment year2011. The Thoracic Surgery FellowshipMatch is conducted by the National Res-ident Matching Program. Low numbersof applicants are traditionally consid-ered less than ideal for a profession forthe obvious reasons that employers arebest served by larger number of appli-cants, which ensures that there will be alarger pool of above-average individualsto choose from and that all positions willbe fillable from the pool. Unmatched po-sitions usually indicate a competition forcandidates and lack of acceptable appli-cants from which to select. This year 25(22%) positions went unfilled.

Conversely, having less competition isideal for those who are actually applyingfor positions. In this case, overall 89% ofthe 99 applicants matched.

Further information on the match sta-tistics and the National Resident MatchingProgram is available at www.nrmp.org. ■

THORACIC SURGERY NEWS

AMERICAN ASSOCIATION FOR THORACIC SURGERY

Editor Yolonda L. Colson, M.D., Ph.D.

Associate Editor, General Thoracic

Michael J. Liptay, M.D.

Associate Editor, Adult Cardiac John G. Byrne, M.D.

Associate Editor, Cardiopulmonary Transplant

Richard N. (Robin) Pierson III, M.D.

Associate Editor, Congenital Heart William G. Williams, M.D.

Executive Director Elizabeth Dooley Crane, CAE, CMP

Associate Executive Director Cindy VerColen

Editorial Associate Lisl K. Jones

Resident Editor Stephanie Mick, M.D.

Resident Editor Christopher Peyre, M.D.

THORACIC SURGERY NEWS is the official newspaper of the American Association

for Thoracic Surgery and provides the thoracic surgeon with timely and

relevant news and commentary about clinical developments and about

the impact of health care policy on the profession and on surgical practice

today. Content for THORACIC SURGERY NEWS is provided by International

Medical News Group and Elsevier Global Medical News. Content for the

News From the Association is provided by the American Association for

Thoracic Surgery.

The ideas and opinions expressed in THORACIC SURGERY NEWS do not

necessarily reflect those of the Association or the Publisher. The

American Association for Thoracic Surgery and Elsevier Inc., will not

assume responsibility for damages, loss, or claims of any kind arising

from or related to the information contained in this publication,

including any claims related to the products, drugs, or services

mentioned herein.

POSTMASTER: Send changes of address (with old mailing label) to

Circulation, THORACIC SURGERY NEWS, 60 B Columbia Rd., 2nd flr.,

Morristown, NJ 07960.

The American Association for Thoracic Surgery headquarters is

located at 900 Cummings Center, Suite 221-U, Beverly, MA

01915.

THORACIC SURGERY NEWS (ISSN 1558-0156) is published bimonthly for

the American Association for Thoracic Surgery by Elsevier Inc., 60

B Columbia Rd., 2nd flr., Morristown, NJ 07960, 973-290-8200,

fax 973-290-8250.

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©Copyright 2010, by the American Association for Thoracic Surgery

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02ts10_9.qxp 8/24/2010 4:03 PM

be,” said Dr. Richard Feins who, alongwith Dr. George Hicks and Dr. JamesFann, served as a Boot Camp III Director.

“In addition, the residents get a veryclear message that their education is ofparamount importance to our special-ty. We are hopeful that the ‘boot camp’concept will be expanded in the yearsahead and that simulator-based trainingwill become a part of every cardiotho-racic residency program,” Dr. Feinsadded.

Feedback from the residents indicat-ed that Boot Camp III was a resound-ing success. Evaluation comments

included, “The CPB emergency simu-lation was fantastic;” “Excellentcourse;” “Thank you for this amazingopportunity;” and “I loved everyminute.”

Residents also expressed gratitude tothe “very helpful” faculty who volun-teered their time for this “fantastic andvery rewarding event.” And, as one res-ident noted, “It would be wonderful if allresidents could participate.”

In addition to the 8 hours of trainingresidents received each day, keynoteaddresses delivered during group mealsprovided additional didactic education

on relevant topics.Ron Maness, formerchief pilot for con-tract simulator train-ing at USAirways,spoke on simulation-based training in avi-ation and itsimplications for car-diothoracic surgerytraining.

Dr. K. Anders Eric-sson, noted authorand researcher atFlorida State Univer-sity, discussed hiswork on achievingtechnical expertisethrough deliberatepractice.

Dr. G. Alec Patter-son, past president ofthe American Asso-ciation for ThoracicSurgery, presentedhighlights from hisrecent AATS presi-dential address onhow proper leader-ship translates intoaccomplishment.

Finally, Dr. Paul

Sergeant, past president of the Euro-pean Association of Cardio-ThoracicSurgery and currently the editor ofCTSNet, presented his insights on lead-ership, hierarchy, and surgical educa-tion.

“I am very proud of the work theTSDA is doing to make cardiothoracicsurgery resident training innovative, rel-evant, and effective,” said Dr. Hicks,president of the TSDA. “The great suc-cess of Boot Camp is just the beginning,and we expect the years ahead to be veryexciting for everyone involved in residenteducation,” he added.

Information about future Boot Campevents will be posted on www.TSDA.orgwhen available.

Powerpoints of these educational ses-sion presentations are available at theTSDA website as well (www.tsda.org/sec-tions/meetings/2010%20Boot%20Camp/index.html.)

Along with funding by the JCTSE,the residents’ boot camp was support-ed by the University of North Carolina,Chapel Hill, division of cardiothoracicsurgery, and in-kind support from a va-riety of health care and medical devicecompanies. ■

S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S RESIDENTS' CORNER 3

AATS Resident Resources: www.aats.org/TSR/index.htmlCTSNET Residents Section: www.ctsnet.org/sections/residentsThoracic Surgery Directors Association: www.tsda.orgThoracic Surgery News: www.aats.org/Association/Thoracic_Surgery_News.htmlThoracic Surgery Residents Association: www.tsranet.orgThoracic Surgery Foundation for Research and Education: www.tsfre.org

Some Online Resources ofInterest

‘Boot Camp’Education • from page 1

The Boot Camp faculty used a simulator heart case to educate residents duringthe large/small vessel anastomosis session.

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L to R: Dr. Cameron Wright assists resident, Dr. SagarDamle. Mannequins and scopes were utilized during thebronchoscopy/mediastinoscopy session.

B Y R E B E C C A J. M A R K

JCTSE, Administration and

Education Manager

The Joint Council on Tho-racic Surgery Education,Inc. held its first Educate the

Educator symposium on July 9,10, and 11, 2010 in Chapel Hill,North Carolina. The course wasdeveloped based on the specificneeds of cardiothoracic sur-geons and ran in conjunctionwith the Thoracic Surgery Di-rectors Association 2010 BootCamp III, which was supportedin part by JCTSE (see accompa-nying story).

According to JCTSE SurgicalDirector of Education, Dr. Ed-ward Verrier, “One of the ad-vantages of running theseprograms side-by-side was tocapitalize on the presence of

the cardiothoracic surgicaltrainees. This provided a uniqueopportunity for faculty to ob-serve and improve teachingskills—an opportunity thatis not currently availablewith other faculty develop-ment programs.”

The goals and objectivesof this course were de-rived from national sur-veys of US cardiothoracicsurgery faculty and resi-dents. The findings fromthese surveys guided Educatethe Educator Course Co-Di-rectors, Dr. Stephen C. Yang,and Dr. Ara Vaporciyan, inplanning a program that fo-cused on effective delivery ofskills-based education (simula-tion and intra-operative teach-ing) and methods to converteducational efforts into career

advancement (grants and pro-motion). The 2½ day coursewas created in collaborationwith nationally respected ex-

perts in surgical education.Content areas for the programincluded adult learning theory,how to teach in the operatingroom, curriculum develop-ment and implementation,how to improve assessmentskills, and how to use the sci-ence of education as a facultyadvancement tool.

“The purpose of this pro-gram was to enhance the teach-ing skills of cardiothoracicsurgical faculty, while promot-

ing the concept of careeradvancement through ed-ucation. While othercourses such as this exist(most notable being theweek-long Surgeons asEducators program runby the American Collegeof Surgeons), interest inthese programs by car-

diothoracic surgeons has beenlimited both because of thetime commitment required andthe broad focus of the curricu-lum,” stated Dr. Yang.

“This endeavor was donewith the hope of generating an‘army of educators’ who willlead the new wave of educationfor the next generation of CT

surgeons, thereby, elevating tho-racic surgery education in pri-ority, quality, and reward,” Dr.Vaporciyan added.

As a result of this program,attendees are now better pre-pared to enhance educationalefforts at their home institu-tion. This enhancement maycome in the form of initiatinga skills laboratory with a com-plete curriculum or develop-ing a separate program toaddress a specific educationalneed. JCTSE intends to remainconnected to those who at-tended this outstanding pro-gram to help guide attendeesas they make inroads into im-proved cardiothoracic surgeryeducation in the future. In ad-dition, plans are already un-derway to offer this programagain in 2011. ■

‘Educating the Educator’ Symposium Held

THIS ENDEAVOR WAS DONE IN HOPE

OF GENERATING AN ‘ARMY OF

EDUCATORS’ WHO WILL LEAD THE

NEW WAVE OF CT EDUCATION.

01_3_4_5_13ts10_9.qxp 8/24/2010 4:00 PM

4 NEWS S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

B Y A L I C I A A U LT


The Accreditation Council for Graduate MedicalEducation revisited its standards for resident dutyhours and determined that modifications should

be made, mostly for first-year residents. All other resi-dents should still be subject to an 80-hour work weekand up to 24 hours of continuous duty, according to anonline article in the New England Journal of Medicine.

The ACGME task force that wrote the standards willreview public comments and make any modificationsconsidered necessary before July 2011, when the newstandards will go into effect.

The ACGME standards, estab-lished in 2003, have been contro-versial, with opinions differingover whether they have been toorestrictive or too loose to proper-ly protect patients and ensure agood quality of life for residents.

According to the latest report,written by Dr. Thomas J. Nasca andcolleagues on behalf of theACGME task force, the 2003 standards had the follow-ing three “problematic” elements, as identified by the ed-ucational community and the public: P The limits on duty hours may have created a shiftmentality among residents, which tends to conflictwith the duty to serve patients.P Many programs began focusing on meeting the dutyhour restrictions, perhaps at the expense of education. P The 80-hour work week, with up to 24 hours of con-tinuous duty, was seen as compromising patient safety.

In 2008, the Institute of Medicine looked at theACGME standards and, recommended that no residentsshould exceed 16 hours of continuous duty. TheACGME convened the task force to consider the IOMrecommendations. One of the biggest challenges was to

reconcile the IOM’s suggestion for an across-the-boardrestriction with the plea from academic programs thatduty hours needed to be tailored to each specialty (N.Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]).

The ACGME panel also weighed whether there wassufficient evidence to show that working more than16 hours or up to 30 hours continuously led to moremedical errors, as suggested by many critics of theduty hour standards. According to the panel, the datathus far indicate only that first-year residents are moreprone to mistakes as a result of sleep deprivation. There-fore, they urged a new paradigm for first year residents,whereby they can’t be on duty longer than 16 hours con-

tinuously with 10 hours off and 8hours free of duty between sched-uled duty periods. They are alsonot allowed to moonlight, andmust have direct, in-house, attend-ing-level supervision. All residentsare allowed to work up to 4 morehours to facilitate patient hand-offs—an area of concern for pa-tient safety. The panel decidednot to tailor hours to specialties.

The IOM also criticized the ACGME for not enforc-ing the duty hours. The task force said that enforcementis an “inherent” challenge, partly because there aresome 9,000 accredited programs. However, the ACGMEis now undertaking annual site visits and analyzingwhether institutions can comply. Eventually, the ACGMEwill give each institution a report on its compliance sta-tus and recommendations for resolving problems.

Wake Up Doctor, a coalition of public interest andpatient safety groups pushing the ACGME to furtherrestrict resident hours, said that the new standards don’tgo far enough. The group gave the ACGME an “F” forfailing to comply with the IOM recommendation thatcontinuous duty be restricted to 16 hours for all resi-dents. However, the recommendation for greater su-

pervision of first-year residents got higher marks. On August 9, The Society of Thoracic Surgeons, the

AATS, the American Board of Thoracic Surgery, the Tho-racic Surgery Directors Association, and the ThoracicSurgery Foundation for Research and Education, and oth-er representatives of the thoracic surgery community,sent a letter to the ACGME responding the proposedchange. They identfied difficulties with the proposedmaximum duty length of 16 hours for first year residents.

“Of necessity, at least two shifts (a day and a nightshift, and probably an overlapping third shift) of tho-racic surgical residents will be required to cover any 24-hour period. The thoracic surgical resident workforceto provide such shift work simply does not exist,” theywarned. With the structure of thoracic surgery residenteducation changing from independent to integratedprograms “the resident component for each of thesesix-year programs is typically only one resident peryear.” The proposed changes would “have a devastat-ing effect” and “will lead to program closures.”

The letter pointed out that “the proposed change inwork hours will be detrimental to resident education,”with night shifts having no access to didactic conferencesor clinical teaching, and providing only minimal interac-tion with faculty and senior residents. This would “stuntthe growth of professionalism and limit the acquisitionof medical knowledge among first-year residents” and“preclude responsiveness to patient and family needs.”

Since the implementation of the 2003 ACGME workhour regulations, the clinical and operative experiencehas significantly decreased for thoracic surgical resi-dents, an outcome coinciding with a near doubling ofthe failure rate among thoracic surgery residency pro-gram graduates on the American Board of ThoracicSurgery certifiying examination.

“In summary, the ACGME proposed changes inwork hours will compromise patient care and residenteducation….We strongly urge the ACGME to with-draw this proposal,” their letter concluded. ■

ACGME: Reduce Resident Duty Hours in First Year

The following articles are featured inthe September 2010 issue of the

Journal of Thoracic and CardiovascularSurgery.

Presidential AddressNon Solus—A Leadership ChallengeG. Alexander Patterson

Expert ReviewEpithelial to mesenchymal transition:The doorway to metastasis in hu-man lung cancersChadrick E. Denlinger, John S. Ikonomidis,Carolyn E. Reed, and Francis G. SpinaleLung cancers metastasize through areversible process involving epithelialto mesenchymal transition in whichmalignant cells lose intracellular ad-hesions and become mobile. Subse-quent reversion to an epithelialphenotype allows metastatic growth.Ongoing clinical and basic sciencestudies will identify ways to exploitthis process for clinical benefits.

Congenital Heart DiseaseAtrioventricular valve repair in pa-tients with functional single ventricleTomohiro Nakata, Yoshifumi Fujimoto,Keiichi Hirose, et al.Our 10-year experience with 65 con-

secutive patients with functional sin-gle ventricle undergoing atrioventric-ular valve repair suggests the midtermresults were favorable and cardiacfunction was maintained effectively.However, young and small patients,especially those with hypoplastic leftheart syndrome, still had poor out-comes. Therefore, more efforts shouldbe made.

General ThoracicNational Emphysema Treatment Tri-al redux: Accentuating the positivePablo Gerardo Sanchez, John CharlesKucharczuk, Stacey Su, Larry RobertKaiser, and Joel David CooperFor patients in the NETT trial with het-erogeneously distributed, upper lobepredominant emphysema, LVRS pro-vided significant long-term survival andfunctional benefit compared with sim-ilar patients randomized to medicaltherapy alone.

Acquired Cardiovascular DiseaseFunctional mitral stenosis after sur-gical annuloplasty for ischemic mi-tral regurgitation: Importance ofsubvalvular tethering in the mecha-nism and dynamic deterioration dur-ing exertion

Kayoko Kubota, Yutaka Otsuji, TetsuyaUeno, et al.In patients with annuloplasty for is-chemic mitral regurgitation, diastolicmitral valve area was frequently lessthan 1.5 cm2 (functional mitral stenosis)and significantly correlated with re-stricted leaflet opening, left ventriculardilatation, and New York Heart Asso-ciation class. Leaflet tethering in thepresence of surgical annuloplasty in is-chemic mitral regurgitation frequentlycauses functional mitral stenosis.

Perioperative ManagementSimulation-based training delivereddirectly to the pediatric cardiac in-tensive care unit engenders pre-paredness, comfort, and decreasedanxiety among multidisciplinary re-suscitation teamsCatherine K. Allan, Ravi R. Thiagarajan,Dorothy Beke, et al.Successful resuscitation of pediatriccardiac patients requires advancedtechnical skills and multidisciplinarycollaboration. A Crisis Resource Man-agement Training Program was de-veloped to address specific technicaland teamwork training needs ofteams caring for this unique patientpopulation. Participants reported in-

creased comfort and confidence par-ticipating in code events after courseparticipation.

Cardiothoracic TransplantationStandard versus bicaval techniquesfor orthotopic heart transplantation:An analysis of the United Networkfor Organ Sharing databaseRyan R. Davies, Mark J. Russo, Jeffrey A.Morgan, Robert A. Sorabella, YoshifumiNaka, and Jonathan M. ChenA review of 20,999 heart transplanta-tions from 1997 to 2007 demonstratesthat those performed with biatrialanastomoses require postoperativepermanent pacemaker implantationat higher frequency (odds ratio, 2.6;95% confidence intervals, 2.2–3.1) andhave a small but significant disadvan-tage in survival (hazard ratio, 1.11;95% confidence intervals, 1.04–1.19)compared with bicaval anastomoses.

Brief Technique ReportBridge to lung transplantation usingshort-term ambulatory extracorpo-real membrane oxygenationAbeel A. Mangi, David P. Mason, James J.Yun, Sudish C. Murthy, and Gosta B. Pet-tersson

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S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S NEWS 5

that Debateer trials have shown moreequivocal comparisons, particularly innon-diabetic populations, even withbare-metal stents (Circulation 2009;120:S967). “We got almost identical survivalbetween bare-metal stents and CABG inmultivessel coronary artery disease, andalmost identical incidents of death, MI,and stroke at 5 years’ follow-up,” hesaid.

“The difference in event-free survivalhas been shrinking,” Dr. Kaul said. He cit-ed the Arterial Revascularization Thera-pies Study II (ARTS II, J. Am. Coll.Cardiol. 2010;55:1093-1101), whichshowed that patients with multivesseldisease who had sirolimus-eluting stentshad a rate of major adverse cardiac and

cerebrovascular events (MACCE) of27.5% at 5 years compared with 21.1% inthe earlier ARTS I CABG trial. But theSYNTAX trial (N. Engl. J. Med.2009;360:961-72) still showed significant-ly higher rates for MI, repeat vascular-ization, and MACCE across the board forstenting compared with CABG, Dr. Kaulsaid. The variations among diabetic pa-tients were even wider.

“Of course, the big difference is in thediabetic population,” Dr. Rodriguez ac-knowledged, and the Bypass Angioplas-ty and Revascularization Investigation 2Diabetes (BARI 2D) (Circulation2009;120:2529-40) recognizes this, hesaid. However, the BARI trial itselfshowed almost identical survival out-comes in non-diabetics who had eitherPCI or CABG, he added.

Furthermore, much of the evidenceagainst stenting in multivessel diseasewas gathered in “the pre-drug-elutingstent era” Dr. Rodriguez said. “These in-vestigators found no significant interac-tion between the number of diseasedvessels and treatment assignment. Thus,the conclusion is that only diabetics arepredictable of poor outcomes in multi-vessel coronary artery disease withCABG.” The predilection of poor out-comes in diabetics carried into the DESera, “The only advantage of CABG wasin diabetic patients.”

However, among study cohorts in theSYNTAX trial, the rates of MACCEamong patients who had PCI continuedto increase between 1 and 2 years post-procedure, Dr. Kaul said. “So at the lim-ited duration follow-up of 2 years, therewas a survival advantage with CABG foralmost 80% of patients with three-vesseldisease and a SYNTAX score greater than32, and 65% of similar patients with leftmain coronary artery disease,” he said.

The ERACI II trial (Circulation2008;118:1146-54) included a cohort of

patients with left main artery disease,but this population was too small tostand alone in a published report, Dr.Rodriguez said. However, that cohortshowed little variation in clinical eventsbetween CABG and either bare-metal ordrug-eluting stents. “The only differ-ence was in total vessel revascularizationrates.”

“Extension of coronary artery diseasedoes not predict better survival with

CABG in any randomized study in thepost-DES era,” Dr. Rodriguez said. Infact, he argued, first-generation DES incomplex coronary artery diseaseachieved better safety and efficacy atmid-term than did CABG, althoughlong-term outcomes remain unknown.

“Left main stenting can be safely at-tempted and appears to be—for me atleast—first choice in selective cases,” Dr.Rodriguez said.

Dr. Kaul wasn’t so sure, but he addedthat a way to improve outcomes is to usea multidisciplinary heart team and pre-operative planning. “It should not be de-

cided on the table by a doctor in the cathlab,” he said. “Avoid ad hoc PCI in selec-tive patients with multivessel disease.”

For Dr. Kaul, the clinical trials stillpoint to CABG in patients with complexCAD. “If you look at the results from theSYNTAX study, you can see the conclu-sion was that CABG remains the stan-dard of care for patients with three-vesseldisease or left main coronary artery dis-ease, because it results in lower rates ofthe combined end point of major adversecardiac and cerebrovascular events.”

Neither Dr. Rodriquez nor Dr. Kaulhad any relevant conflicts to disclose. ■

PCI vs. CABGDebate • from page 1

The predilectionof poor [PCI]outcomes indiabetics has carried into the DES era.

DR. RODRIGUEZ

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6 GENERAL THORACIC S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

B Y J A N E S A L O D O F M A C N E I L


C H I C A G O — Selenium supplementa-tion does not prevent second cancers insurvivors of early stage lung cancer—and may even make these patients morevulnerable to new tumors.

Indeed, although the differences didnot reach statistical significance, patientswho used supplements developed moresecond cancers, including lung tumors,than those who did not take selenium ina randomized controlled phase IIIchemoprevention trial that was stoppedearly for futility.

“We can say for sure that the seleniumwas not beneficial,” Dr. Daniel Karp saidat the annual meeting of the AmericanSociety of Clinical Oncology, where hepresented data on 1,522 patients, whohad been randomized from October2000 to November 2009 and followed fora median of more than 4 years.

As of August 2009, the trial populationhad developed 216 second primary tu-mors, including 84 new lung cancers in83 patients (one patient developed twonew lung tumors). The incidence of sec-ond primary tumors was 1.91 per 100

person-years followed in the seleniumgroup vs. 1.36 per 100 person-years in theplacebo group. Overall, the incidence ofsecond primary tumors of any type after1 year was 4.11% in the selenium cohortand 3.66% among those who were notgiven supplementation,

The progression-free survival rate at 5years was also slightly better in the place-bo group (78% vs. 72%), as was overallsurvival at 3 years (90% vs. 85%) and 5years (80% and 75%).

The Eastern Cooperative OncologyGroup (ECOG) started the intergrouptrial after a study failed to show seleni-um could prevent skin cancers sug-gested that it could reduce theincidence of lung, colorectal, andprostate cancers by as much as 30%( JAMA 1996;276:1957-63).

The ECOG trial enrolled patients 6-36 months after complete resection ofstage 1 non–small cell lung cancer. Allhad no sign of disease as evidenced bya negative mediastinal node biopsy.

Randomization was 3:1 to 200 micro-grams daily of selenium yeast for 4 yearsor placebo yeast. Dr. Karp, a professor ofthoracic/head and neck medical oncol-ogy at the University of Texas M.D. An-

derson Cancer Center in Houston, saidthat most patients had normal seleniumlevels when they entered the trial.

Particularly concerning, he noted,was that the amount of selenium in thesupplement used in the trial is compa-rable to the amount in most daily mul-tivitamins. “We need to find peoplewho are deficient and make sure they

have a normal amount,” he said, ques-tioning the wisdom of a one-size-fits-allapproach that gives supplements toeveryone.

While he stopped short of saying peo-ple should be dissuaded from taking sup-plements, Dr. Karp said he emphasizes tohis patients that they should eat a healthydiet and stop smoking.

Also noteworthy was that active smok-

ers had a 30% chance of developing lungcancer at 5 years vs. 24% for formersmokers and 20% for never smokers. Asubgroup of 94 never smokers had aslight trend toward benefit from seleni-um, he said.

One possibility Dr. Karp suggested ina press briefing is that antioxidants mighthave a harmful effect in the presence ofcarcinogens such as tobacco. Anotherstudy found worse outcomes—higherincidence of lung cancer and risk ofdeath from the disease—in people whotook beta carotene (N. Engl. J. Med.1996; 334:1150-5).

For Dr. Mark G. Kris, chief of the tho-racic oncology service at MemorialSloan-Kettering Cancer Center in NewYork City, an important message fromthe new trial was the high rate of sur-vival in these early-stage patients. Theprimary focus of efforts to prevent sec-ond tumors, as well as lung cancer itself,should be getting people not to smoke,Dr. Kris said at the press briefing, whichhe moderated.

Dr. Karp disclosed research fundingfrom Pfizer Inc., and Dr. Kris disclosedconsulting or advisory roles with sevendrug companies. ■

Selenium Fails to Prevent Second Lung Cancers

‘We need to findpeople who are[selenium]deficient andmake sure theyhave a normalamount.’

DR. KARP

B Y J A N E S A L O D O F M A C N E I L


C H I C A G O — Patients who began receiving palliativecare when diagnosed with metastatic lung cancer livedlonger, were less depressed, and had better quality oflife than their counterparts who received only standardcare in a randomized phase III clinical trial.

The survival improvement was unexpected, as sur-vival was not an end point of the study, which chal-lenged the traditional paradigm by which palliative careis offered only after treatment options are exhausted.Moreover, it occurred despite less-aggressive end-of-lifecare and longer hospice stays inthe intervention arm of the trial.

Patients randomized to earlypalliative care lived a median of11.6 months vs. 8.9 months in thecontrol group (P = .02), Dr. Jen-nifer Temel reported at the annu-al meeting of the AmericanSociety of Clinical Oncology. Af-ter controlling for age, sex, andECOG performance status, theadjusted hazard ratio was .59 (P = .01).

“It clearly shows that palliative care and active can-cer therapy can go hand in hand,” said Dr. Raffit Has-san, a senior investigator at the National CancerInstitute, Bethesda, Md., in an invited discussion of thetrial. He noted that it was the first randomized studyof early palliative care in newly diagnosed lung cancerand called for more randomized studies with survivalas a primary end point.

Patients were eligible for the trial within 8 weeks ofdiagnosis with metastatic lung cancer, if they had anECOG performance status of 0-2, could read and an-swer questions in English, and planned to receive careat the tertiary care institution where the study was con-ducted. From June 2006 to July 2009, 283 patients werescreened, but 59 declined to participate, 60 were not in-vited to participate, 9 were excluded, and the studyclosed while 4 others were eligible.

That left 151 patients who were randomized 77 toearly palliative care and 74 to standard care. Bothgroups had a median age of 65 years and were similarwith respect to sex, race, and marital status. In responseto an audience question, Dr. Temel said the lines ofchemotherapy were also identical.

The protocol called for patients in the interventionarm to meet with the palliative care team within 3weeks of consenting to the trial and at least once amonth thereafter; patients in the control arm alsocould receive palliative care, but by request of the pa-tient, family members, or oncology clinician. Whilemost standard care patients did not see the palliative

care team within 12 weeks of en-tering the trial, 88% of the pallia-tive arm had at least three visits bythat time point.

Dr. Temel of Harvard MedicalSchool and Massachusetts Gener-al Hospital in Boston emphasizedthat “the nature of palliative carevisits were not scripted or pre-scribed.” The team addressed ed-ucation about lung cancer

treatment, symptom management, stress, decisionmaking, and coping, as needed.

By the 12-week benchmark when psychological dis-tress was measured, 27 patients had died—10 in the stan-dard care arm and 17 given palliative care. In addition 10standard care and 7 palliative care patients did not com-plete the trial. All were followed until death. Dr. Temelsaid only 10 were still alive at the time of presentation.

She reported depression was significantly less at 12weeks whether measured by Hospital Anxiety and De-pression Scale (38% vs. 16%, P = .01) or the more rig-orous Diagnostic and Statistical Manual of MentalDisorders criteria for major depressive disorder (17% vs.3.5%, P = .04). Anxiety was not significantly different.

Quality of life also was better in the early palliativecare cohort as measured by the FACT-Lung (91.5 vs.98.0, P = .03) and FACT Trial Outcomes Index (59.0 vs.53.0, P = .01) at 12 weeks. Indeed, both measures im-

proved from baseline in the intervention arm, while de-clining among patients who received standard care.

More than half (54%) of patients in the standard carearm but only a third of the early palliative care groupreceived aggressive end-of-life care (P = .05). The stan-dard care patients were more likely to be admitted toa hospital or emergency room within 14 days of death(55% vs. 39%), spent fewer days in hospice (a medianof 4 vs. 11), and were less likely to have documentationof their resuscitation preferences (28% vs. 53%).

Dr. Temel suggested the better quality of life and re-duced depression could be caused by better symptommanagement (along with illness acceptance further re-ducing depression). As for the gains in survival, she saidthe investigators hypothesized that it might be relatedto “earlier recognition and management of medical is-sues, improved quality of life and mood, less chemother-apy at the end of life, [and] longer hospice admissions.”

Dr. Hassan noted and Dr. Temel acknowledged thatthe trial had a number of limitations, including the largeproportion of patients who chose not to participate, avery small proportion with an ECOG performance sta-tus of 2, and lack of ethnic and racial diversity. “Whatcomponent of palliative care intervention resulted inbeneficial effect is unclear,” Dr. Hassan said.

The investigators are planning another study to ad-dress many of the questions raised, such as which ser-vices were most used and contributed to the improvedsurvival. “We didn’t know what we were going to find,so did not collect all the information needed,” Dr.Temel said in an interview.

The current trial was supported by an ASCO YoungInvestigator Award and the palliative care visits coveredby the patients insurance, according to Dr. Temel.“We didn’t have reimbursement issues; there may bestate-to-state issues,” she said.

Asked what prompted her interest in early palliativecare, Dr. Temel explained, “The reason I chose to dolung cancer after my fellowship was I wanted to takecare of ill patients and dying patients, and it didn’t takedoing it very long to realize we weren’t doing a verygood job of it.” ■

Early Palliative Care Boosts Lung Cancer Survival

‘I WANTED TO TAKE CARE OF ILL

PATIENTS AND DYING PATIENTS,

AND IT DIDN’T TAKE DOING IT VERY

LONG TO REALIZE WE WEREN’T

DOING A VERY GOOD JOB OF IT.’

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S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S GENERAL THORACIC 7

We Model Excellence

AMERICAN ASSOCIATION

FOR THORACIC SURGERY

CALL FOR ABSTRACTS

Submission Deadline

Monday, October 4, 2010

Visit http://aats2011.abstractcentral.com to submit an abstract

Email [email protected] for more information

May 7–11, 2011 Philadelphia, PA, USA

Pennsylvania Convention Center

A ATS 91S T

A N N U A L M E E T I N G

www.aats.org



“

Too many” patients with earlystage non–small cell lung cancerforgo potentially curative resec-

tion, and the leading risk factor for miss-ing this life-saving opportunity is beingblack, according to a report in JAMA.

“Patients who do not undergo appro-priate surgery face a median survival ofless than 1 year and the sequelae of pro-gressive cancer and then death, whilethose who undergo appropriate surgeryhave a median survival of more than 4years” and good quality of life after thesurgery, said Dr. Samuel Cykert of theUniversity of North Carolina, ChapelHill, and his associates.

They examined a cohort of 386 patientswho had received a clinical diagnosis ofprobable stage I or II non–small cell lungcancer but had not yet decided on a treat-ment plan. The patients were members offive health care systems in North Caroli-na and South Carolina, which served ur-ban and rural populations in bothuniversity and community settings.

More than 90% of the study subjectshad health insurance, so access to carewas not a major factor in their treatmentdecisions. Twenty-nine percent wereblack and the remainder were white.

These patients were being treated byprimary care physicians (24%), pulmo-nologists (40%), thoracic surgeons (20%),or medical oncologists (16%).

The primary outcome of the prospec-tive study was surgical resection within4 months of diagnosis. Only 241 patients(62%) underwent such resection. Therate was 66% among white patients,compared with only 55% among blackpatients. However, black patients weresignificantly younger and therefore bet-ter surgical candidates than the whiteswere and thus likely to benefit morefrom treatment, wrote the investigators.

When the analysis was restricted toonly the 257 patients whose cancers wereconfirmed by biopsy, the gap betweenwhites and blacks again emerged: 75% ofwhite patients underwent resection,compared with only 63% of black pa-tients, Dr. Cykert and his colleagues said( JAMA 2010;303:2368-76).

Black race was the primary factor as-sociated with the decision to forgo re-section. However, a black patient was nomore likely than a white patient to refuseresection if it were recommended by aphysician. Therefore, it appears that“physicians’ surgical recommendationsmay have been framed in less favorableterms” when they were addressing blackpatients, the researchers said.

In particular, black patients who hadtwo or more comorbidities “had a verylow chance of surgery, while the samesituation in white patients was not asso-ciated with a limited rate” of resection.Reports in the literature indicate thateven for patients with severe comorbidi-ties, average survival after resection is 3years, the investigators noted.

Similarly, black patients who lacked aregular source of health care were morelikely to forgo resection, whereas whitepatients in this category were not.

A patient’s perception of poor com-munication with physicians also loweredthe chance that he or she would choosesurgical resection, regardless of race.This problem probably was more preva-lent among black than among white pa-tients, since previous reports havedocumented that communication withblack patients is characterized by “limit-ed questioning, less dialogue, and fewerexplanations,” Dr. Cykert and his asso-ciates said.

Other factors associated with the de-cision to forgo resection, among bothgroups, were patient age of 73 years orolder, the belief that prayer or faith alonecould cure cancer, the belief that the can-cer diagnosis might be incorrect, andthe feeling that overall quality of lifewould be worse after resection than

without resection. These findings “suggest the need for

preoperative discussions that pay closeattention to the prognosis for function-al and pulmonary recovery after surgery,compared with expected cancer pro-gression without intervention,” the re-searchers said.

“Given the consequences of lung can-cer surgery decision making and the lim-ited time to reverse course, decisionsagainst surgery should be subject to real-time tracking, be consistently flagged,and systematically readdressed,” theyadded.

Since physicians in practice are subjectto time constraints and are unlikely to beable “to meet all communication needs,”the researchers suggested that a cancer ed-ucator who is trained in active listening,patient-centered communication, andteach-back methods might be helpful.

“This supernavigator could serve as aphysician communication extender whoaddresses unmet needs beyond the lim-its of clinical visits [and who] could iden-tify misperceptions of process, surgicalrisk, and long-term prognosis while pro-viding a forum to vent concerns and re-solve them,” they said.

The study was funded by the AmericanCancer Society. Dr. Cykert and his asso-ciates reported no financial conflicts. ■

Blacks More Likely to Opt Out of Lung Resection

06_7ts10_9.qxp 8/24/2010 4:05 PM

8 NEWS FROM THE AATS S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

2010 Heart Valve Summit:Medical, Surgical and Inter-ventional Decision-MakingOctober 7 - 9, 2010Chicago Marriott DowntownMagnificent MileChicago, Illinois, USA

The American College of Car-diology Foundation (ACCF)and the American Associationfor Thoracic Surgery (AATS)have once again joined togeth-er to develop a unified pro-gram, the 2010 Heart ValveSummit, that will provide astimulating and in-depth lookat valvular heart disease fromboth a cardiology and surgicalpoint-of-view.

Using an integrative ap-proach to managing medical,surgical, and interventional

challenges in valvular heartdisease, world renowned car-diologists and cardiac sur-geons will provide clinicallyrelevant data on the currentand future directions in valvu-lar heart disease. Geared to-wards practicing cliniciansacross multiple disciplines,this unique program will in-clude real world interactivecase-based patient manage-ment discussions, review ofcurrent practice guidelinesand focused breakout sessions.

Program Directors: David H. Adams, M.D., F.A.C.C.Steven F. Bolling, M.D.,F.A.C.C.O.Robert O. Bonow, M.D., M.A.C.C.Howard C. Herrmann, M.D.,F.A.C.C., F.S.C.A.I.

Honored Lectures:Denton Cooley, M.D.Valentin Fuster, M.D., F.A.C.C.

2009 Testimonials“Excellent meeting. I alwayscome back intellectually chal-lenged and picking up newtricks, tips and pointers.”

“This was one of the bestmeetings I have attended inmy entire career. Putting sur-geons together with cardiolo-gists to discuss controversialtopics is a superb format.”

REGISTRATIONSpace is limited, register todayat www.acc.org/HVS2010.Please note that if you are amember of AATS, ASE, SCAIor STS, you must submit your

registration form through faxor mail to receive the mem-ber rate.

ACCREDITATIONPhysicians:The American College of Car-diology is accredited by theAccreditation Council for Con-tinuing Medical Education toprovide continuing medicaleducation for physicians.

The ACCF designates thiseducational activity for a max-imum of 18.25 AMA PRACategory 1 Credits™. Physi-cians should only claim cred-its commensurate with theextent of their participation inthe activity.

Nurses:The American College of Car-

diology Foundation is accredit-ed as a provider of continuingnursing education by theAmerican Nurses Credential-ing Center’s Commission onAccreditation.

The ACCF designates thiseducational activity for a max-imum of 18.25 continuing ed-ucation hours. Requirementsfor successful completion areattendance in a session in itsentirety and completing theevaluation tool.

Each attendee should onlyclaim credits commensuratewith the extent of their par-ticipation in the activity.

While offering credits notedabove, the program is not in-tended to provide extensivetraining or certification in thefield. ■

Attend the 2010 Heart Valve Summit

NCI: Clinical Proteomic Technologiesfor Cancer Initiative (CPTC): Pro-teome Characterization Centers (U24)In an effort to build upon the proteom-ic standards, technologies, standard op-erating procedures, workflows, andreproducibility of protein identificationand quantification developed throughthe Clinical Proteomic Technologiesfor Cancer initiative (CPTC); the NIHis soliciting grant applications to builda multidisciplinary collaborative teamof Proteome Characterization Centers(PCCs). These PCCs are expected toadvance multi-institutional and trans-disciplinary interactions using data andselected biospecimens from cancer ge-nomics programs to systematically de-fine the functional cancer proteomethat derives from alterations in cancergenomes, discover and verify protein(and peptide) biomarkers, and in doingso, drive the development of proteom-ic technologies. Application ReceiptDate: September 29, 2010

For more information or to apply:http://grants.nih.gov/grants/guide/rfa-files/RFA-CA-10-016.html

NHLBI: New Strategies for Growing3D Tissues (R01 and R21)Two Funding Opportunity Announce-ments have been issued that seek toimprove the understanding of howcells respond to their environment andto develop accurate assays and meth-ods to understand how organogenesismay instruct the creation of functional3D engineered cellular aggregates.This program will require collabora-tions of scientists from two or moredisciplines such as developmental biol-ogy, computational science and sys-tems biology, cell biology, tissueengineering, chemistry, physics, or or-gan physiology. Use of the multiple PImechanism is strongly encouraged.

For more information on R01:http://grants.nih.gov/grants/guide/rfa-

files/RFA-HL-11-025.htmlFor more information on R21:

http://grants.nih.gov/grants/guide/rfa-files/RFA-HL-11-026.html

NHLBI Request for Information:Ideas for improvements in a researchnetwork to advance the treatmentscience of critically ill patients withAcute Lung InjuryThis Notice is a Request for Informa-tion (RFI) for ideas to update and im-prove the structure of NHLBI-support-ed clinical research network of pul-monary and critical care investigatorsand to seek research ideas that have themost promise to improve outcomes inthe intensive care unit.

NHLBI requests input on new ap-proaches to clinical trials that might beincorporated into a network, opinionson whether the scope of research ques-tions previously addressed by ARDSnetshould change, how input from thecommunity and basic science might befed into a network, and identificationof the most important research ques-tions that can improve patient out-comes in the intensive care unit.

To respond by September 10, 2010,please complete and submit the formon line at: www.surveymonkey.com/s/TRF6CRN

NHLBI announces Pediatric HeartNetwork Clinical Centers & DataCoordinating Center Funding OpportunitiesThe NHLBI has issued two FundingOpportunity Announcements to sup-port the Clinical Center and Data Co-ordinating Center for the PediatricHeart Network. The mission of theNetwork is to improve the health andquality of life for children, adolescents,and young adults with congenital andacquired heart disease through multi-center collaborative clinical research.The Network provides an infrastruc-

ture to permit multicenter evaluationof medical, interventional, and surgicaltherapies; to serve as a training plat-form for fellows, junior faculty, andnurses; and to disseminate results ofstudies to improve the scientific basisfor the care of affected individuals

NHLBI requests applications to par-ticipate as a Clinical Center or DataCoordinating Center in the Network, acooperative network of pediatric car-diovascular clinical research centers.The goal of the Network is to evaluatetherapeutic and management strate-gies for children and adults with con-genital heart defects and for childrenwith inflammatory heart disease, heartmuscle disease, and arrhythmiasthrough multicenter clinical research.

Letters of Intent Receipt Date: Sep-tember 29, 2010

Application Receipt Date(s): October29, 2010

For more information, please visit:http://grants.nih.gov/grants/guide/rfa-files/RFA-HL-11-010.html for ClinicalCenter or http://grants.nih.gov/grants/guide/rfa-files/RFA-HL-11-027.html forData Coordinating Center.

NIH R01 Award Announcement toSupport Bioengineering ResearchPartnerships The NHLBI and NCI invite applica-tions for R01 awards to support Bio-engineering Research Partnerships forbasic, applied, and translational multi-disciplinary research that addresses im-portant biological, clinical, or bio-medical research problems. In the con-text of this program, a partnership is amulti-disciplinary research team, thatapplies an integrative, systems ap-proach to develop knowledge and/ormethods to prevent, detect, diagnose,or treat disease or to understand healthand behavior. The Partnership mustoperate according to a clear leadershipplan and include appropriate bioengi-

neering or allied quantitative sciencesin combination with biomedicaland/or clinical components. Partner-ships may propose, within a 12-page re-search strategy section,design-directed, developmental, discov-ery-driven, or hypothesis-driven re-search at universities, nationallaboratories, medical schools, large orsmall businesses, or other public andprivate entities or combinations ofthese entities, and will be evaluatedagainst expanded review criteria. It isexpected that a Partnership will have awell-defined goal or deliverable thatwill be achieved in a 5-10 year timeframe based on objective milestonesspecified in the initial application. Formore information, please visit:http://grants.nih.gov/grants/guide/pa-files/PAR-10-234.html. ■

Cardiothoracic Surgery Funding and Grants

Online AATSMembershipApplications

Applications for membership inthe Association are now avail-

able online at www.aats.org. In-terested applicants are encou-raged to review the membershiprequirements and guidelines onthe AATS Website.

To apply for membership acurrent member of the Associa-tion must act as the primarysponsor by initiating the applica-tion process in the MembersOnly area of the AATS Website.Applications must be receivedby November 30, 2010 for con-sideration. All applications re-ceived after that deadline will beautomatically deferred until No-vember 2011.

08_9ts10_9.qxp 8/24/2010 4:06 PM

S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S NEWS FROM THE AATS 9

New – 2011 Mitral Conclave,Call for Abstracts & Videos

The Abstract and Video SubmissionDeadline for the 2011 Mitral Con-clave is January 7, 2011. Visit

www.aats.org/mitral to submit.

Program Director: David H. Adams, M.D.Mount Sinai School of MedicineNew York, New YorkProgram Committee:Ottavio R. Alfieri, M.D.Milan, ItalyW. Randolph Chitwood, Jr., M.D.Greenville, North CarolinaRobert A. Dion, M.D.Genk, BelgiumA. Marc Gillinov, M.D.Cleveland, OhioFriedrich W. Mohr, M.D.Leipzig, Germany

The 2011 MITRAL CONCLAVE willbring the world’s leading figures in mi-tral valve disease together for two daysof inciteful discussion. Faculty presenta-tions of the latest available data, tech-niques, and state of the art reviews willbe supplemented by abstract and videopresentations selected by the programcommittee from submitted originalwork. Selected manuscripts from accept-ed presentations will be considered forpublication in a supplement to The Jour-nal of Thoracic and Cardiovascular Surgery.

Authors submitting abstracts andvideos for 2011 MITRAL CONCLAVEmust use electronic submission ONLY.Abstracts are limited to 400 words. Youmay use ONE image OR ONE tablewithin your abstract which will NOTdeduct from the word count.

Accepting Abstracts and Videos inthe following categories:P Degenerative Valve DiseaseP Mitral Regurgitation in Heart FailureP Novel Repair TechniquesP Other Mitral Valve DiseaseP Outcomes Following Mitral ValveSurgeryP Tricuspid Valve Disease

Video Submissions:All video submissions must be accom-panied by an abstract with a maximumof 400 words submitted via the ab-stract submission site. Two copies ofthe video must be mailed to the Asso-ciation offices by the January 7 dead-line and may not exceed 5 minutes inlength. Complete submission guide-lines can be found online atwww.aats.org/mitral.

Log on to the 2011 MITRAL CON-CLAVE Website at www.aats.org/mitraland select the Abstract and Video Sub-mission Link. Specific instructions forabstract and video submissions are lo-cated on the website, including how tosubmit images or tables.

Abstracts and videos must be re-ceived by Friday, January 7, 2011 by11:59 p.m. Eastern Standard Time.

Accreditation:The American Association for ThoracicSurgery is accredited by the Accredita-tion Council for Continuing MedicalEducation to provide continuing med-ical education for physicians.

This activity has been approved forAMA PRA Category 1 Credits™.

May 7 – 11, 2011Pennsylvania Convention CenterPhiladelphia, PAJoin us in Philadelphia from May 7–11, 2011 for the American Associationfor Thoracic Surgery’s 91st AnnualMeeting. This robust, high-qualityfive-day program, chaired by Irving L.Kron, M.D., of the University of Vir-ginia, is designed with a primary focuson delivering cutting-edge educationto improve cardiothoracic surgicalpractice. Gather with the world’s lead-ing scientists and medical professionalsin the specialty at this premier contin-uing medical education event.

Target AudienceThe AATS Annual Meeting is specifi-cally designed to meet the education-al needs of:P Cardiothoracic SurgeonsP Physicians in related specialties in-cluding Cardiothoracic Anesthesia,Cardiology, Critical Care, Pulmonolo-gy, Radiology, Gastroenterology, andThoracic OncologyP Fellows and Residents in Cardio-thoracic and General Surgical train-ing programsP Allied Health Professionals involvedin the care of cardiothoracic surgicalpatients including Nurses, PhysicianAssistants, Perfusionists, and AlliedHealth Professionals involved in thecare of cardiothoracic surgical patientsP Medical students with an interestin cardiothoracic surgery

AATS Annual Meeting AccreditationThe American Association for Tho-racic Surgery is accredited by the Ac-creditation Council for ContinuingMedical Education to provide contin-uing medical education for physicians.

This activity has been approved forAMA PRA Category 1 Credit(s)™.

CALL FOR ABSTRACTS:Authors submitting abstracts must useelectronic submission ONLY. Pleasevisit http://aats2011.abstractcentral.comto submit an abstract. Specific instruc-tions for abstract submission are locat-ed on the website, including how tosubmit graphics and charts. Manu-scripts are due in advance of the meet-ing for all accepted abstracts. Pleasenote: Videos and PowerPoints are notaccepted as part of abstract submis-sions for the 2011 AATS Annual Meet-ing. For the first time in 2011, theAAATS encourages submissions inEndovascular/Transcatheter Valve.

Presentation Types include:P Regular SessionP Laboratory Research ForumP Emerging Technologies ForumP C. Walton Lillehei Resident Forum

Abstracts may be submitted for thefollowing categories:P Adult CardiacP CongenitalP Endovascular TranscatheterValve—NEW IN 2011!P General Thoracic

Lillehei Resident ForumResidents are encouraged to submitabstracts, based on basic science, forthe 14th Annual C. Walton LilleheiResident Forum which will consist ofpresentations of original work byNorth American thoracic surgical resi-dents and/or residents in general sur-gical training programs who areworking in a cardiothoracic surgicallaboratory or clinical rotation. The pre-sentations are selected by the AATSCardiothoracic Residents’ Committee.

For further info on submitting ab-stracts please visit www.aats.org.

Save the Date for the 91stAATS Annual Meeting

September 21- 25, 2010TCT for Surgeons*Walter E. Washington Convention CenterWashington, DC

September 30 - October 2, 2010Cardiovascular - Thoracic (CVT)Critical Care 2010***Omni Shoreham HotelWashington, DC

October 7 - 9, 2010Heart Valve Summit 2010Chicago MarriottDowntown Magnificent MileChicago, Illinois

October 21 - 22, 201021st Century Treatment of HeartFailure 2010*The InterContinental Hotel and Bank of

America Conference CenterCleveland, Ohio

December 9 - 11, 2010Dallas Leipzig International Valve*Westin Galleria HotelDallas, Texas

December 9 - 11, 2010Multidisciplinary Symposium in Thoracic Oncology**Hilton ChicagoChicago, Illinois

February 10 - 13, 201111th Annual International Sympo-sium on Congenital Heart Disease*Renaissance Vinoy ResortSt. Petersburg, Florida

March 5, 2011Grant Writing Workshop

Bethesda MarriottBethesda, Maryland

May 5 - 6, 2011Mitral Conclave Sheraton New York Hotel and TowersNew York, NY

May 7 - 11, 2011AATS 91st Annual MeetingPennsylvania Convention CenterPhiladelphia, PA

May 26, 2011AATS/ASCVTS PostgraduateCourse*Hilton Phuket Arcadia Resort & SpaPhuket, Thailand

* Co-Sponsored by AATS** Content provided by AATS *** Jointly sponsored by AATS

2010/2011 AATS Meetings & Sponsored Events AATS 2010-2011Council

PresidentIrving L. Kron, M.D. Charlottesville, Virginia

President-ElectCraig R. Smith, M.D. New York, New York

Vice PresidentHartzell V. Schaff,M.D.Rochester, Minnesota

SecretaryThoralf M. Sundt,III, M.D.Rochester, Minnesota

TreasurerDavid J. Sugarbaker, M.D.Boston, Massachusetts

EditorLawrence H. Cohn, M.D.Boston, Massachusetts

Councilors R. Morton Bolman, M.D.Boston, Massachusetts

Joseph S. Coselli, M.D.Houston, Texas

Hiroshi Date, M.D.Kyoto, Japan

Bartley P. Griffith, M.D.Baltimore, Maryland

John D. Puskas, M.D.Atlanta, Georgia

Shaf Keshavjee, M.D.Toronto, Ontario

Alec Patterson, M.D. St. Louis, Missouri

Vaughn A. Starnes, M.D.Los Angeles, California

08_9ts10_9.qxp 8/24/2010 4:07 PM

In cooperation with

Cleveland Clinic Kaufman Center for Heart Failure

and the American Association for Thoracic Surgery

This activity has been approved for AMA PRACategory 1 Credit™

21st Century Treatment of

Heart Failure:Synchronizing Surgical and Medical Therapies for Better Outcomes

October 21-22, 2010InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio

www.ccfcme.org/heartfailure10

Abstract submission deadline: September 20, 2010

For exhibit information or questions, please contactJamie Belkin Events at 216.932.3448or email [email protected]

R e s e a r c h | E d u c a t i o n | Pa t i e n t C a r e

10 ADULT CARDIAC S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

B Y R I C H A R D M . K I R K N E R


N E W Y O R K — Percutaneous aorticvalve repair may be the preferred proce-dure in high-risk patients with aorticstenosis, according to Dr. Jeffrey Popmaof Beth Israel Deaconess Medical Center,Boston. He and Dr. Satyavan Sharma de-bated the merits of surgical aortic valverepair (AVR) vs. percutaneous repair inhigh-risk patients at the Mt. Sinai Sym-posium of Complex Coronary and Vas-cular Cases. Dr. Sharma is professor ofcardiology at Bombay Hospital and Med-ical Research Center in Mumbai.

The high-risk patient profile was com-posed of people aged 80 years and older,and those with a host of comorbiditiessuch as chronic occlusive pulmonary dis-ease, renal failure, peripheral vasculardisease, coronary artery disease, historyof stroke, or previous cardiac surgery. Dr.Sharma noted the “impressive results” ofone trial involving octogenarians whohad surgical AVR: a 30-day mortality of9% and 5-year survival of 56%.

Dr. Sharma pointed to the limitations ofEuroscore, a widely used scoring systemto predict the mortality of surgical AVRand select patients for percutaneous AVR.Several publications have emphasized thatEuroscore overestimates the surgical mor-

tality and is not an ideal scoring system forselecting patients for percutaneous AVR.It is likely that some patients eligible forsurgical AVR are denied the procedure be-cause of assumptions of high mortality byEuroscore, he said.

Dr. Popma noted that an 80-year-oldpatient has a mortality risk of 2.9% in theSociety for Thoracic Surgery database“with no other comorbidity risk factors.”These patients are often otherwise“healthy” when going into surgery, henoted. “But the question is, are all symp-tomatic patients with aortic valve steno-sis now being treated with surgical AVR?The answer is no,” Dr. Popma said. “Asa matter of fact, about 50% of patientswith aortic stenosis are deemed not suit-able operative candidates by cardiologistsor primary care providers.”

A recent abstract from the EuroPCRmeeting reported on patients with aor-tic valve disease who had either surgery,percutaneous AVR, or no intervention.The latter group “did awfully,” Dr. Pop-ma said, with significant mortality ratesat 2 years. “There is clearly an unmetneed, and these are the patients who arenot necessarily nonoperable but are sim-ply high risk,” he added.

Percutaneous AVR carries with it anumber of challenges, Dr. Sharma said.No calcified valves, particularly bicuspid

valves, are suitable for percutaneousAVR, he said. Noncircular stent deploy-ment is common in bicuspid valves andcan lead to premature failure of the valve.

“The procedure looked very simple tous when there was a demonstration from

a highly technically efficient center, butthere are all sorts of complications thatcan occur from transcatheter AVR—ac-cess and delivery site complications, com-plications in positioning and deployment,and a very high incidence of completeheart block,” Dr. Sharma said. Further, hecalled the need for permanent pacing inthe core valve “disturbingly high”—inthe range of 10%-25%.

Patients with peripheral vascular dis-ease and access site tortuosity are notsuitable for percutaneous AVR, he said.The transapical approach requires sur-gical assistance and left ventricular punc-ture. Still, the overall success rate of

percutaneous valve implants is 85%-90%in most experienced centers, althoughfailure rates can be high early in a sur-geon’s experience, he added.

Dr. Popma acknowledged the ItalianTAVI (transcatheter aortic valve implan-tation) registry showed that 50% of treat-ed patients died of noncardiac causes 30days after the procedure out to 2 yearswith conservatively defined stroke rates of9.6% in the initial series. However, resultsare improving with better case selection.“Fortunately and more to the question ofembolic protection, the stroke rate ismuch lower in those now treated in re-cent concurrent registries,” he said.

“Surgical AVR is a time-honored tech-nique and remains supreme,” Dr. Sharmaconcluded. “We do need to define certainissues better: an accurate definition of thepatient ineligible for surgical AVR, a bet-ter definition for successful treatmentand clinical follow-up, and durability ofthe prosthetic valve.”

He anticipates that trials in the UnitedStates and Europe, including the PART-NER (Placement of Aortic TranscatheterValve) now underway, should yield someanswers.

Dr. Popma disclosed relationships withAbbott Pharmaceuticals, Boston Scien-tific, Cordis, and Medtronic. Dr. Sharmahas no relevant disclosures. ■

Percutaneous or Surgical AVR for High-Risk Patients?

About 50% ofpatients withaortic stenosisare deemed notsuitableoperativecandidates.

DR. POPMA

10_11ts10_9.qxp 8/24/2010 4:13 PM

S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S ADULT CARDIAC 11



Highly concentrated supplemental oxygen given af-ter cardiac arrest often led to arterial hyperoxia,which in turn raised the risk of in-hospital mor-

tality, according to an observational study. Ironically, mortality rates after exposure to too much

oxygen were greater than mortality rates after oxygendeprivation—the very indication for which supple-mental oxygen is given, said Dr. J. Hope Kilgannon ofthe department of emergency medicine at CooperUniversity Hospital, Camden, N.J., and her associates( JAMA 2010;303:2165-71).

“This is the first large multicenter study document-ing the association between [post-resuscitation] hyper-oxia and poor clinical outcome,” the researchers noted.“These data support the hypothesis that high oxygendelivery in the post–cardiac arrest setting may have ad-verse effects.”

Current American Heart Association guidelines forcardiopulmonary resuscitation advocate the use of100% oxygen to maximize the chance of restoring spon-taneous circulation. “However, after circulation is suc-cessfully restored, clinicians frequently maintain[supplemental oxygen] for variable periods,” the inves-tigators said.

Controversy has arisen recently regarding that routinepractice, because it is feared that too much oxygen maytrigger neuronal injury and apoptosis. However, therehas been a lack of clinical data on the issue, they added.

Dr. Kilgannon and her colleagues used data from anetwork of adult intensive-care units across the Unit-ed States to study the question. The database includedmedical, surgical, and multidisciplinary ICUs from a va-riety of community, academic, private, public, urban,suburban, and rural hospitals.

They assessed 6,326 adults who received CPR afternontraumatic cardiac arrest and were admitted to a par-ticipating ICU in 2001-2005. Hyperoxia was defined asan arterial partial pressure of oxygen (PaO2) of 300 mmHg or greater on the first arterial blood gas obtainedon admission.

Hyperoxia was common, affecting 18% of patients.Approximately half of those patients had a PaO2 of 400mm Hg or greater. Most patients (63%) developed hy-poxia, defined as a PaO2 of less than 60 mm Hg, and theremaining 19% maintained normal blood oxygen levels.

In-hospital mortality was greatest in the group withhyperoxia, at 63%, compared with 57% in the hypoxiagroup and 45% in the normoxia group, Dr. Kilgannonand her associates said. A further analysis of the datarevealed that hyperoxia was an independent and strongpredictor of in-hospital death (732 of 1,156 patients).

Moreover, patients with hyperoxia who survived tohospital discharge were significantly more likely tohave poor functional outcomes (38%) than those withnormoxia (29%).

“Analogous to the concept that hyperoxia exposuremay be associated with harm in the resuscitation ofneonates, the ongoing oxidant stress with hyperoxicreperfusion may be capable of worsening anoxic brain

injury in adult patients with post-cardiac arrest syn-drome,” the researchers said.

The observational study could not determine causal-ity, but its findings “provide scientific rationale for clin-ical trials of controlled reoxygenation during thepostresuscitation period,” they added.

The true incidence of hyperoxia is probably muchhigher than 18%, given that the investigators used “arather conservative definition” of the disorder, notedDr. Patrick M. Kochanek and Dr. Hülya Bayir of theUniversity of Pittsburgh in an editorial comment ac-companying the report.

They concurred that a large clinical trial of the issueis warranted to resolve whether clinicians should bemore meticulous about titrating oxygenation after car-diac arrest, “and whether an alarm threshold should beset for arterial saturation ...after return of spontaneouscirculation” ( JAMA 2010;303:2190-1).

In addition, “unconventional resuscitation strategiesthat [have been] considered but heretofore unproven(such as intermittent, controlled, or even delayed reper-fusion)” are now being investigated, they said.

The study was supported by the Emergency Medi-cine Foundation, the National Institutes of Health, theNational Institute of General Medical Sciences, and theNational Heart, Lung, and Blood Institute.

Dr. Kilgannon had no financial disclosures. One ofDr. Kilgannon’s associates reported receiving supportfrom Ikaria Inc. and Spectral Diagnostics Inc. Dr.Kochanek reported being a co–patent holder on Emer-gency, Preservation, and Resuscitation. ■

Hyperoxia After Resuscitation Raised Mortality

B Y M I T C H E L L . Z O L E R


T O R O N T O — Using a transapical ap-proach for aortic valve implantation pro-duced safety and efficacy outcomes asgood as those from trans-femoral aortic valve replace-ment in a series of 299patients treated at the Uni-versity of Leipzig, Germany,the largest series of transapi-cal aortic valve replacementscollected to date.

“There is no evidence for a ‘trans-femoral first’ approach. I would go50:50,” Dr. Thomas Walther said at themeeting.

“There are some clear indications” foreach approach. Transapical works betterfor patients with poor peripheral vessels,while transfemoral hold the edge for pa-tients with poor lung function because itdoesn’t require intubation. “But other-wise you can do either, and you shoulddo a 50:50 split,” said Dr. Walther, for-merly with the Leipzig group and nowmedical director of thoracic and cardio-vascular surgery at the Kerckhoff Clinicin Bad Nauheim, Germany.

“Transapical is slightly better [thantransfemoral] because it uses an ante-grade approach so you can better directand more precisely implant the valve,”he said in an interview. The antegradeapproach also makes wire adjustmentseasier, and the stepwise inflation thattransapical makes possible is another ad-vantage.

But transcatheter valve replacementcurrently sits on procedural turf that’s

split between cardiologists and cardio-thoracic surgeons. Cardiologists gener-ally favor the transfemoral approach,and it’s diplomatic to let them do rough-ly half the cases, while surgeons handlethe rest, usually with the transapical ap-

proach, Dr. Walther said.Deciding whether to per-

form aortic valve replace-ment by a transcatheterapproach or by open surgeryraises another issue that re-quires careful judgment. Dr.Walther and his former col-

leagues in Leipzig adhere to the 2008 rec-ommendations of the European Societyof Cardiology and the European Asso-ciation of Cardio-Thoracic Surgery,which favored transcatheter valve re-placement over open surgery only for el-derly, high-risk patients or those withcontraindications for open surgery (Eur.Heart J. 2008;29:1463-70). The recom-mendations said that clinical judgementshould be the main determinant ofwhich patients had high risk, along withquantitative scoring methods such as thelogistic EuroScore and the Society ofThoracic Surgeons (STS) predicted riskof mortality score.

These limitations for transcathetervalve replacement continue to makesense because open surgical repair has avery low mortality rate of 1%. “Whatcould do better than that?” he said. Openreplacement “gives good hemodynamicfunction and has proven long-term dura-bility. With the transcatheter approachyou always have the risk of a paravalvu-lar leak, which may pose problems es-pecially in younger patients who

exercise. Plus, new procedures [such astranscatheter valve replacement] havesome inherent risks. To match a mortal-ity rate of 1% is very difficult.”

Transcatheter valve implantation hasnot yet received U.S. marketing approvalfrom the Food and Drug Administration.

The Leipzig group performed 299transapical aortic valve implantationssince it started in 2006 through the be-ginning of 2010, as well as a roughlyequal number of transfemoral implan-tations. The average age of the transapi-cal patients was 82, and 70% werewomen. Their average logistic Eu-roScore was 31%, and their average STSscore was 12%. Ninety percent of theprocedures occurred off pump. Thirty-day mortality in the patients was 8.7%.A total of 28% died during an averagefollow-up of about 16 months (thelongest follow-up was 4 years). Cardiacmortality predominated, followed by res-piratory causes of death.

Thirty-two patients had a periproce-dural complication, such as need for asecond valve, conversion to opensurgery, or need for cardiopulmonarybypass. Thirty-day mortality in this sub-group was 31%. In the remaining 267 pa-tients, 30-day mortality was 6%.

The logistic EuroScore provided agood indication of how likely patientswere to die following valve implantation.The series included 80 patients with aEuroScore of less than 20%; their aver-age EuroScore was 15%, and their aver-age STS score was 9%. Their 30-daymortality was 5%, and total mortalityduring complete follow-up was 22%.

A second subgroup of 142 patients

had a EuroScore of 20%-40%, with anaverage score of 29% and an average STSscore of 12%. Their 30-day mortalitywas 10%, with 25% overall mortalityduring complete follow-up. The remain-ing 77 patients had a EuroScore of morethan 40%, with an average EuroScore of53% and an average STS score of 17%.In this sickest group, 30-day mortalitywas also 10%, but a total of 39% diedduring complete follow-up.

Two patients had a stroke within thefirst 30 days following their procedure,with one additional stroke occurring dur-ing full follow-up. One patients developedendocarditis. Two patients required reop-eration for aortic insufficiency within thefirst 6 weeks, and 15% of patients neededtemporary renal replacement therapy.

Using echocardiography, the surgeonsfound mild aortic insufficiency in 37% ofpatients immediately after surgery, and in54% after 1 year. During longer follow-up the prevalence remained at aboutthis same level. Moderate aortic insuffi-ciency appeared in 4% right after surgery,and held at a level of 4%-5% during upto 3 years of follow-up.

Follow-up telephone interview of 80patients an average of 1.7 years aftertheir procedure showed that on averagethese long-term survivors had a qualityof life that closely matched historicaloctogenarian controls who had not un-dergone aortic valve implantation.

Overall, the findings show thattransapical aortic valve implantation is areasonable, minimally invasive optionfor high-risk patients, he concluded.

Dr. Walther said that he has receivedhonoraria from Edwards Lifesciences. ■

Transapical Implants Match Transfemoral Outcomes

FROM THE ANNUAL MEETING

OF THE AMERICAN ASSOCIATION


10_11ts10_9.qxp 8/24/2010 4:14 PM

12 CONGENITAL HEART S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

B Y M A R K S. L E S N E Y


T O R O N T O — The double-switch oper-ation for congenitally corrected transpo-sition of the great arteriesprevents long-term systolicdysfunction of the systemicventricle. The Senning andMustard procedures for sim-ple transposition havedemonstrated significantlong-term morbidity, specifi-cally related to sinus node dysfunctionand superior vena cava baffle obstruction,according to Dr. Sunil P. Malhotra of theUniversity of Florida and his colleagues.

At the meeting, they discussed the useof a modified atrial switch, consisting ofa Hemi-Mustard to baffle inferior venacava return to the tricuspid valve in con-junction with a bidirectional Glenn(BDG), to avoid such complications.They postulated that right ventricle (RV)unloading may lessen the impact of RVdysfunction, prolong the life of the RV-pulmonary artery (PA) conduit, and de-crease tricuspid regurgitation.

In addition, simplifying atrial baffle mayreduce sinus node dysfunction and atrialdysrhythmias as well as systemic and pul-monary venous pathway obstruction, andit might be helpful with positional anom-alies such as situs solitus with dextrocar-dia, mesocardia, and situs inversus.

Their study involved 56 patients withcongenitally corrected transposition ofthe great arteries (cc-TGA) who weremanaged surgically between January1993 and September 2009. Prerecon-struction pulmonary banding was per-formed using a strict protocol wherebyall patients except for the younger pa-tients are banded for at least a year. “Wethen restudy them looking at ECHO,CATH, and MRI characteristics, lookingat appropriate LV function and increaseof LV mass,” said Dr. Malhotra.

The subsequent anatomic repair wasachieved in 48 of the 56 patients (86%).The other eight patients also received pul-monary banding in preparation for even-tual reconstruction; of those, fiveappeared to be progressing but had not yet

reached appropriate LV mass and functionat the time of the study, and three ap-peared unlikely to achieve appropriatefunction, according to Dr. Malhotra. Forthose three, medical management would

be the choice since they donot meet the requirementsfor transplantation, he added.

There were positionalanomalies in 17 of the 48 re-construction patients (35%).The median age of these pa-tients was 3.0 years (range 3.9

months to 24 years).The Rastelli and atrial switch (RAS)

was performed in 25 patients, 22 withpulmonary atresia and 3 with severe sub-pulmonary stenosis. An arterial/atrialswitch (AAS) was performed in 23 pa-tients, 17 of whom required a pul-monary artery bypass (PAB). AHemi-Mustard was the atrial switch for33 of 48 anatomic repairs (69%). TheHemi-Mustard patch used was always asimple circle that bent appropriatelyaround the tricuspid valve annulus andinferior vena cava orifice. The conven-tional atrial baffle procedure was per-formed in the other 15 patients whenBDG was contraindicated.

There was one in-hospital death (2.1%)following anatomic repair, and therehave been no late deaths to date. Noneof the patients have required cardiactransplantation. Postoperative extracor-poreal membrane oxygenation supportwas required in 2 patients, and postop-erative heart block occurred in 10 of 48patients (21%).

At a median follow-up of 59.3 months(range 3 months to 14.2 years), 43 of 47survivors were in New York Heart Asso-ciation class I status. Normal left ventric-ular systolic function was demonstratedby follow-up echocardiography in 41 of47 patients (87%). All patients were acyan-otic. There have been no baffle-related re-operations. Tricuspid regurgitationdecreased significantly from a mean grade2.3 to 1.2 after repair.

The Hemi-Mustard results comparedfavorably with those reported for thestandard Senning-Mustard procedure,according to Dr. Malhotra. Among the

33 patients with the Hemi-Mustard pro-cedure, there was no baffle obstructionor sinus node dysfunction. According tothe literature, 5%-15% of Senning-Mus-tard patients had baffle obstruction, and35%-46% had sinus node dysfunction.Similarly, there was just one atrial tach-yarrhythmia requiring ablation with theHemi-Mustard procedure vs. a rate of8%-15% in Senning-Mustard patients.

The two BDG complications that oc-curred in infants under 4 months ofage led Dr. Malhotra to conclude thatthe Hemi-Mustard procedure should beavoided in the youngest patients whoare at highest risk of elevated pul-

monary vascular resistance.Dr. David Barron, the designated

discussant, asked about the necessityof epicardial pacing and repeat surgeryresulting from heart block in patientswith a BDG. “It is one of the draw-backs of this approach that it limits theaccess for pacing procedures. But wethink the benefits certainly outweighthe downsides of that,” Dr. Malhotrastated.

In answer to Dr. Barron’s question re-garding the functional difference be-tween this type of procedure and a fullbiventricular repair, Dr. Malhotra saidthat, based on follow-up, he felt therewas no evidence that functional resultswere unacceptable.

“A 15-year experience with anatomicrepair for cc-TGA using a modified atri-al switch has shown favorable midtermresults. Cardiac transplantation wasavoided in all cases, and excellent func-tional status was observed at follow-up,”Dr. Malhotra concluded.

Dr. Malhotra reported that he had noconflicts of interest in this study. ■

Changes to Senning and Mustard Lowered Morbidity

FROM THE ANNUAL MEETING

OF THE AMERICAN ASSOCIATION


B Y R I C H A R D M .

K I R K N E R


N E W Y O R K — Observationis an acceptable alternative tosurgical management of as-cending aortic dilatation inadult patients with congenitalheart disease, judging by a se-ries of 81 patients with long-term follow-up.

Thoracic surgeons have longdisagreed over the need for re-pairing a dilated ascending aor-ta during aortic valve repair insuch patients. The controversysurrounding the need for per-

forming prophylactic surgeryof the moderately dilated as-cending aorta during aorticvalve repair centers on howlarge the dilatation should bebefore starting a repair, andwhat types of patients shouldhave the preventative opera-tion, Dr. John M. Stulak said atthe American Association forThoracic Surgeons Aortic Sym-posium 2010.

To assess the risk of progres-sive ascending aortic dilatation ordissection in patients with con-genital heart failure, Dr. Stulakand his colleagues at the MayoClinic in Rochester, Minn., ana-

lyzed data on 81 patients withcongenital heart failure whowere followed over 35 years; 53had isolated aortic valve repairand 9 had combined valve and as-cending root repair (7 had aorticroot replacement, and 2 hadaneurysm repair). Patientsranged in age from 18 to 59 years.Four patients in the entire seriesrequired reoperation during amedian follow-up of 3.8 years.

After the initial operation,96% of the patients in the studyremained free from reoperationon the ascending aorta or aorticvalve at 5 years and 90% at 8years. Indications for subse-

quent operations were leakageof the prosthetic valve, severeaortic regurgitation after inten-sive aortic valve repair, and aor-tic root replacement caused byaneurysm.

“Moderate aortic enlarge-ment is common in patientswith conotruncal abnormali-ties,” said Dr. Stulak, notingthat these patients often re-quire multiple procedures andthe pathologies of their as-cending aortas are frequentlyabnormal. “However, late aor-tic events—that is, dissectionor aortic reoperation—arerare,” he added. “The moder-

ately dilated aorta in the set-ting of a conotruncal abnor-mality, especially in patientsundergoing isolated aorticvalve replacement, may be ob-served.

“Importantly, there have beenno late reoperations on the as-cending aorta either after re-duction ascending aortoplastyor supracoronary replacementof the ascending aorta,” Dr. Stu-lak said. “In addition, to datethere are no known late as-cending aortic dissections inthese patients.”

Dr. Stulak had no disclosuresrelevant to his presentation. ■

Observation May Suffice After Ascending Aorta Procedure

Don’t Dismiss Senning?

This study showed a 20% inci-dence of heart block across the

series. This is not unusual; it is partof the underlying condition and isalso a recognized high incidenceafter this sort of surgery. But whatconcerns me is that if you have abidirectional Glenn, that really lim-its your options for pacing now andpacing in the future. And this iscommitting those patients to epi-cardial systems and repeated surg-eries. It thus seems to me that theheart block is more of a concernthan sinus node dysfunction. In ad-dition, in defense of the Senning, itappears that the problems occurfrom the Mustard, rather than fromthe Senning. The arrhythmia com-plications are much more likelyfrom the full Mustard than the fullSenning. There is also quite good

evidence, I think, that the func-tional capacity of the physiology ofthis type of 1 and 1/2 repair com-pared to a true biventricular repairis significantly different. And eventhough this is shown to be a verysafe operation, with outstandingresults, my feeling is that we shouldnot dismiss the Senning. This studyshowed they actually got excellentresults with the Senning, and cer-tainly I believe you get a betterfunctional result with the full Sen-ning.

DR. DAVID J. BARRON, F.R.C.S., is aconsultant cardiac surgeon atBirmingham (England) Children’sHospital. He was the designateddiscussant at the meeting, andreported that he had nothing todisclose with regard to his remarks.

CO

MM

EN

TA

RY

WITH THE HEMI-MUSTARD

PROCEDURE, NO BAFFLE

OBSTRUCTION OR SINUS

NODE DYSFUNCTION

WAS SEEN.

12ts10_9.qxp 8/24/2010 4:22 PM

2010 Heart Valve SummitMedical, Surgical and Interventional Decision-Making

October 7 – 9, 2010Chicago Marriott

Downtown Magnificent Mile

Register today at www.acc.org/HVS2010

Program Directors

David H. Adams, M.D., F.A.C.C.

Steven F. Bolling, M.D., F.A.C.C.

Robert O. Bonow, M.D., M.A.C.C.

Howard C. Herrmann, M.D., F.A.C.C., F.S.C.A.I.

Co-sponsored by:

American Associationfor Thoracic Surgery

©2010 American College of Cardiology H10119

S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S TRANSPLANT 13

75%—rates that far exceed the average3-year survival of 64%” reported na-tionally, they noted.

Data from the United Network for Or-gan Sharing was used. UNOS is a registrythat includes all lung transplant casessince the first procedure was performedin 1987. They examined outcomes for15,642 procedures. Approximately 13%were done in centers that performedfewer than 10 lung transplants annually,39% in centers that performed 10-25 an-nually, 41% in centers that performed 25-50 annually, and 7% in centers thatperformed more than 50 annually.

Thus, transplant centers varied by asmuch as tenfold in the number of pro-cedures they performed each year, theresearchers noted.

Overall, median 1-month survival was93%, 1-year survival was 80%, 3-year sur-vival was 63%, and 5-year survival was50%. Survival varied markedly amongthe different centers: In all, 1-month sur-vival was 89%-95%, 1-year survival was68%-85%, 3-year survival was 45%-72%,and 5-year survival was 30%-61%.

This variation in survival persisted af-ter the data were adjusted to control fordifferences among transplant centers indonor selection, recipient selection, andsurgical approaches. This finding “sug-

gests that centers may exhibit true dif-ferences in the quality of care providedduring or following transplantation,” Dr.Thabut and his associates said ( JAMA2010;304:53-60).

“That our central results remainedunchanged through a series of sensitiv-ity analyses testing these and other po-tential influences therefore strengthensconsiderably the conclusions that canbe drawn. Specifically, our results suggestthat the influence of center on survivalafter transplantation is large and... maybe of comparable magnitude to the in-fluence of recipient age,” they noted.

In general, survival correlated with thevolume of procedures performed, withhigh-volume centers showing better pa-tient survival than did medium- or low-volume centers. However, volumeaccounted for only 15% of the variabili-ty among centers, and that variability re-mained strongly significant after thevolume of procedures was controlled for.

Survival rates were most varied duringthe first year after transplant, then tend-ed to become similar across transplantcenters. This suggests that “there may beundue variability in centers’ periopera-tive and early postoperative practices.” Italso indicates that “differences in surgi-cal expertise might contribute to center

variability,” the researchers said.Unfortunately, the UNOS data were

not sufficient to distinguish between a“center effect” and a “surgeon effect” onsurvival, because the registry does not in-clude surgeon identities or practice char-acteristics that would indicate thesurgeon’s level of expertise.

The study findings suggest that itmight be possible to identify specificpractices that favor survival at high-per-forming centers, so that low-performingcenters can adopt those practices and im-prove their outcomes. “The fact thatsome low-volume centers achieve goodoutcomes... suggests that excellence inlung transplantation is not merely a‘practice makes perfect’ phenomenon,”Dr. Thabut and his colleagues said.

In the meantime, clinicians may wantto provide patients with center-specificoutcome data so they can make more in-formed decisions as to which transplantcenter to attend. This information couldbe particularly important to patientswho have conditions that benefit onlymodestly from lung transplantation,such as chronic obstructive pulmonarydisease. “For such patients, the choice tobe listed for transplantation or not couldbe sensitive to even moderate differencesin the expected outcomes among localcenters,” they noted.

Dr. Thabut was supported by As-traZeneca and the Public AssistanceHospital of Paris, and an associate was

supported by the U.S. Agency forHealthcare Research and Quality.Text.In an accompanying editorial ( JAMA2010;304:95-7) Dr. Edward H. Liv-ingston, of the University of TexasSouthwestern Medical Center, Dallas,and contributing to editor to JAMA andJing Cao, Ph.D., at Southern MethodistUniversity, Dallas stated: The volume oflung transplant procedures was found tobe significantly related to survival, suchthat centers that performed more trans-plants had better survival outcomes. Yetonly 15% of the variance in survivalamong lung transplant centers could beattributed to annual procedural volume.How could such a small effect be statis-tically significant?

“The overall significance of center vol-ume in the model was mainly influencedby the 15 very-high-volume centers. Thisdemonstrates how the results of a fewhospitals can disproportionately influ-ence a statistical analysis and result in sig-nificant findings when the actual effect ofvolume on outcomes is small.

“Most published studies that have foundan association between a higher volumeof procedures and better survival out-comes have been methodologically flawedand have not accounted for this effect. Thisstudy demonstrates how researchersshould quantify the degree to which vol-ume contributes to outcomes.”

Dr. Livingston and Dr. Cao reportedno disclosures. ■

Lung Transplant SurvivalCenter • from page 1

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The UPMC Department of Cardiothoracic Surgery offers the following one-year

fellowships:

• Advanced General Thoracic and Minimally Invasive Surgery

• Adult Advanced Cardiac Surgery

• Cardiopulmonary Transplantation and Cardiac Assist Device

• Pediatric Cardiac Surgery

Each fellowship offers a position at the instructor level, with a competitive salary, and is

designed for board certified or board eligible cardiothoracic surgeons or those with

comparable training or experience. Fellows are encouraged to participate in clinical

research efforts and present at national and international meetings.

________________________________________________________

The Advanced General Thoracic & Minimally Invasive Surgery Fellowship is

designed to offer experience in minimally invasive surgical techniques of the lung,

esophagus and mediastinum. The individuals will gain significant expertise in

minimally invasive esophagectomy, laparoscopic anti-reflux surgery, thoracoscopic

lobectomy, CT-guided chest interventions, endoscopic therapy and many other

advanced minimally invasive procedures of the chest and foregut.

Program Director: James D. Luketich, MD; Chief, Division of Thoracic and Foregut

Surgery; Chair, Department of Cardiothoracic Surgery

The Adult Advanced Cardiac Surgery Fellowship is designed to provide advanced,

concentrated training in adult cardiac surgery to refine and advance the fellows’ surgical

skills required to treat adult and acquired cardiac disease. Candidate must have

completed a two-year cardiothoracic surgery residency accredited by the ACGME or

comparable training and experience in a non-accredited program.

Program Director: James D. Luketich, MD; Chair, Dept. of Cardiothoracic Surgery

The Cardiopulmonary Transplantation and Cardiac Assist Device Fellowship

provides extensive exposure in the disciplines of heart transplantation, lung

transplantation, mechanical cardiac assistance and other aspects of surgical therapy for

end-stage heart failure. It is anticipated that fellows will meet UNOS requirements for

heart and lung transplantation during the fellowship.

Program Director: Yoshiya Toyoda, MD; Director, Cardiopulmonary Transplantation;

Surgical Director, Pediatric Lung and Heart-Lung Transplantation

The Pediatric Cardiac Surgery Fellowship offers an investigational year in

ventricular mechanical support and a clinical year that will provide extensive exposure

in the management of simple and complex congenital heart lesions, including

cardiopulmonary transplantation and assist devices.

Program Director: Victor O. Morell, MD, Chief, Pediatric Cardiac Surgery

________________________________________________________Applicants should submit letter of fellowship preference/interest, current curriculum vitae, 3

reference letters, USMLE & ECFMG status, and current Visa status (if applicable) to:

Christine Regan Carey, Fellowship Coordinator

UPMC Presbyterian, Suite C-700

200 Lothrop Street

Pittsburgh, PA 15213

(412) 648-6359 or [email protected]

FELLOWSHIPS

DisclaimerTHORACIC SURGERY NEWS assumes the statements made in classified advertisements are ac-curate, but cannot investigate the statements and assumes no responsibility or liability con-cerning their content. The Publisher reserves the right to decline, withdraw, or editadvertisements. Every effort will be made to avoid mistakes, but responsibility cannot beaccepted for clerical or printer errors.

CLASSIFIED DEADLINESAND INFORMATION:

Contact: Robert Zwick(973) 290-8226

Email ad to:[email protected]

R

Put your moneywhere your heart is.

AmericanHeartAssociation

WE’RE FIGHTING FOR YOUR LIFE

14 S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S

C L A S S I F I E D SA l s o a v a i l a b l e a t w w w. i m n g m e d j o b s . c o m

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S E P T E M B E R 2 0 1 0 • T H O R A C I C S U R G E R Y N E W S DEVICES, DRUGS & TRIALS 15

2011

decision making

OUTCOMES

surgical video sessions

mitralconclave

MAY 5-6, 2011Sheraton Hotel & Towers

New York, New York, USA

American Associationfor Thoracic Surgery

PROGRAM DIRECTOR

David H. Adams, MD

PROGRAM committee

Ottavio R. Alfieri, MD

W. Randolph Chitwood, Jr., MD

Robert A. Dion, MD

A. Marc Gillinov, MD

Friedrich W. Mohr, MDAbstract Deadline: Friday, January 7, 2011Abstract Submission: www.aats.org/mitral

Call

for

Abs

trac

tsA

NDV

IDEO

SACC/AHA Stress Judgment onClopidogrel’s ‘Boxed Warning’



The clinician’s judgment is thekey to interpreting the Foodand Drug Administration’s

March announcement of a “boxedwarning” concerning clopidogrel’sreduced effectiveness in certain pa-tients, according to a Clinical Alert is-sued June 28 by the AmericanCollege of Cardiology and theAmerican Heart Association.

“Adhering to existing ACC/AHAguidelines for the use of antiplatelettherapy should remain the founda-tion” of treatment. However, carefulclinical judgment also is essential inlight of the FDA’s warning that clopi-dogrel (Plavix) is ineffective in an esti-mated 2%-14% of the population whoare poor metabolizers of the drug, be-cause they carry variations in the genecoding for CYP liver enzymes.

The role of genetic testing ineveryday practice is not yet clear,and the FDA only informs physi-cians and patients that genetic test-ing is available to determinewhether patients carry the variants.

“It neither mandates, requires, norrecommends genetic testing, there-by allowing for flexibility in clinicaldecisions,” according to the Alert,which also was endorsed by the So-ciety of Thoracic Surgeons and theSociety for Cardiovascular Angiog-raphy and Interventions.

The American College of Physi-cians also participated in reviewingthe FDA announcement to formu-late this Clinical Alert.

The Alert notes that the CYP2C19polymorphism accounts for only12% of the variability in platelet re-sponse to clopidogrel, and that thepositive predictive value of genetictesting is estimated to be only 12%-20% among patients with acutecoronary syndromes undergoingpercutaneous coronary intervention(PCI). And it remains unknownwhether other genetic polymor-phisms contribute to drug response,or whether the risk from a given ge-netic profile changes depending onthe clinical scenario--for example,whether the patient has acute coro-nary syndrome vs. stable angina, isundergoing PCI vs. medical therapy,

has small-vessel vs. large-vessel dis-ease, or is undergoing carotid stent-ing vs. medical therapy.

In short, “the evidence base is in-sufficient to recommend either rou-tine genetic or platelet functiontesting at the present time.” Similar-ly, the data are not available regard-ing different dosing regimens forclopidogrel, the substitution of new-er antiplatelet drugs such as prasug-rel or ticagrelor (which have not yetbeen FDA approved), or the additionof agents such as cilostazol to stan-dard clopidogrel regimens, the state-ment said ( J. Am. Coll. Cardiol. 2010[doi:10.1016/jacc.2010.05.013]).

The 15-page Clinical Alert also in-cludes a review of the available evi-dence on clopidogrel response, thecurrent status of CYP genotyping as-says, the data on alternative dosingregimens and alternative treatments,and ongoing clinical trials related tothis issue. The Alert will be pub-lished in the July 20 issue of Circu-lation and is now available online atthe ACC Web site (cardiosource.com)and also at the AHA Web site (my.americanheart.org). ■

The CT Surgery Network reached an importantbenchmark on June 30th. The 100th patient

was randomized in a trial to evaluate the effective-ness and safety of mitral valve repair vs. replace-ment in patients with severe ischemic mitralregurgitation. Enrollment is expected to completein spring 2011. CTSN investigators are also study-ing the preferred approach to moderate, ischemicMR (MMR) and have randomized nearly 90 patientsin the MMR trial to evaluate the effectiveness andsafety of mitral valve repair with CABG comparedwith CABG alone. Another area of focus for theNetwork has been atrial fibrillation (AF), one of thetop priorities according to the IOM for comparativeeffectiveness research. The Network recently initi-ated a trial of surgical ablation with left atrial ap-pendage (LAA) closure versus LAA closure alone inpatients with persistent AF undergoing mitral valvesurgery. Nested within this trial, is a further ran-domized comparison of 2 different lesions sets(pulmonary vein isolation and full Maze lesionset). Currently, 28 patients have been randomized.Finally, the Network is completing a prospective co-hort study to better understand management prac-tices (e.g., line and ventilator management) that putpatients at risk for infections post-surgery, the mainnon-cardiac complication after heart surgery. Morethan 3,800 patients have been enrolled to date. Formore information, visit www.ctsurgerynet.org.

—From Staff Reports

Progress in the CTSurgery Network

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pci vs. cabg: inside which is best for · and general surgery residency. he is now a thoracic track...

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