Highlighting the Plenary Sessions at AATS 2018

The 98^th Annual Meeting of the American Association for Thoracic Surgery (AATS) was held recently in San Diego, California, where more than 2,600 professional attendees gathered to discuss a variety of topics in cardiothoracic surgery. This summary focuses on the scientific presentations and special lectures in the Plenary Sessions to give readers a taste of the research presented and the topics discussed.

Scientific Sessions

Monday’s Plenary Session began with presentations of cardiac, thoracic, and congenital research. Joanna Chikwe of Mount Sinai Medical Center in New York presented an analysis of 10-year outcomes for over 22,000 patients who underwent coronary artery bypass grafting (CABG) either off-pump or on-pump, concluding that on-pump revascularization remains a gold standard for most patients. Marcelo Cypel of Toronto General Hospital in Canada discussed his center’s six-year experience implementing ex vivo lung perfusion to evaluate and treat donor lungs for transplantation, which allowed for an expansion of the program’s annual lung transplantation activity. Luca Vricella of The Johns Hopkins Hospital in Baltimore, Maryland, presented outcomes of 100 consecutive pediatric valve-sparing root replacements, wherein he and his colleagues found the procedure to be an effective option, with reimplantation being the generally preferred approach. Next, Tirone David of Toronto General Hospital discussed the Ross procedure results at 15 and 20 years in a cohort of over 200 patients. Dr David concluded that long-term outcomes for the Ross procedure were excellent despite it not necessarily providing a lifelong repair.

The session continued as Christopher Mascio of the Children’s Hospital of Philadelphia in Pennsylvania presented outcomes for patients with hypoplastic left heart syndrome who underwent a Norwood procedure during a 30-year period. Despite improvements in patient care and surgical techniques, improvements in survival have plateaued in recent years, although Dr Mascio felt that research efforts will likely advance on risk factors that are currently considered not to be modifiable. A late breaking clinical trial abstract was presented by Mario Gaudino of Cornell Medicine in New York. This patient-level combined analysis of data from randomized controlled trials compared radial artery to saphenous vein grafts for CABG. The study was published simultaneously in the New England Journal of Medicine. In the final scientific presentation of Monday, David Shahian of Massachusetts General Hospital in Boston discussed mandatory reporting of CABG outcomes in the state of Massachusetts, showing that both observed and expected mortality rates were lower in Massachusetts than nationwide. Although the data cannot distinguish between different explanations for this difference, the presentation evoked a spirited discussion about potential causes, with a focus on the potential for mandatory public reporting to influence risk aversion, “teaching aversion,” and “innovation aversion.” Closing comments noted that risk aversion and risk awareness are similar yet distinct, and that public reporting can improve matching of high-risk patients to high-level centers.

Tuesday’s Plenary Session began with presentations of thoracic and cardiac research. Nasser Altorki of New York-Presbyterian Weill Cornell Medical Center in New York presented a multicenter international randomized trial suggesting no morbidity or mortality difference between lobar and sublobar resection for early stage non-small cell lung cancer. Siva Raja of the Cleveland Clinic in Ohio presented his center’s experience performing 120 per oral endoscopic myectomy (POEM) procedures as an alternative to Heller myotomy or pneumatic dilation for the palliation of patients with achalasia. He concluded that POEM is a particularly good option for frail patients given the short recovery time, though the rate of postoperative reflux calls for continued study to determine the long-term effects. Anusha Jegatheeswaran of the Hospital for Sick Children in Toronto, Canada, discussed the anatomic characterization of 560 patients with anomalous aortic origin of a coronary artery, a study that sought to clarify the association between different morphologic features of the pathology and negative outcomes. Although features such as an anomalous left coronary artery, an intramural course, and a high or slit-like orifice were more likely to be associated with ischemia than not, anomalous right coronary arteries were not benign, further highlighting the complexity of determining appropriate treatment based on morphology. A late breaking clinical trial presented by Douglas Johnston of the Cleveland Clinic evaluated the three-year outcomes after aortic valve replacement with the Inspiris Resilia bioprosthesis from Edwards Lifesciences, a valve designed for improved long-term durability, which will be tested in longer follow-up.

Continuing Tuesday’s session, Joseph Coselli of Baylor College of Medicine in Houston, Texas, presented an analysis of spinal cord deficit after extensive thoracoabdominal aortic aneurysm repair, finding that several factors contributed to the development of persistent paraplegia or paraparesis (PPP) and nearly half of all incidences of PPP were delayed. Brendon Stiles of Weill Cornell Medical Center in New York discussed an analysis of complications for patients undergoing surgical treatment from the National Lung Screening Trial, which suggested that the previous report likely overestimates the harm of screening to detect early stage lung cancer. Finally, Dawn Hui of Saint Louis University in Missouri presented responses to an anonymous online survey from board-certified practicing cardiothoracic surgeons in North America that asked about junior surgeons’ operative independence at the beginning of their independent careers. Survey responses showed a discrepancy between junior surgeons’ confidence in their own operative independence and senior surgeons’ confidence in their junior colleagues’ independence. Additionally, junior respondents reported only moderate confidence in their initial independence for basic thoracic and complex cardiac procedures. Dr Hui’s presentation prompted vigorous discussion on the importance of ensuring that training programs adequately prepare residents to transition to an independent career. It was noted that competence and confidence do not necessarily track together, but there was agreement that the survey data underscored the importance of ensuring that residents master the skills necessary for clinical quality during their training.

Invited Lectures

The invited guest speaker on Monday, Martin Elliott of the Great Ormond Street Hospital for Children in London, UK, gave a lecture entitled “Maximize the Data, Minimize the Fraud: A Plea to Change the Way We Publish.” He discussed examples of fraud in science and medical research, including Andrew Wakefield in vaccine research and Paolo Macchiarini in regenerative medicine, and he emphasized the harm that falsified data bring upon other research and medical advancements in the same field. Stating that trust is the basis of a surgeon’s work, both with their patients and with their colleagues, Mr Elliott proposed changes to publishing in surgical science that could improve the trustworthiness of published data. Items at the core of his proposed changes included peer review of protocols before a paper is finished, the open-platform maintenance of datasets by an “honest broker” who was not involved in the research, provision of raw data to the research community for in-depth review and further exploration, and the submission of papers to preprint servers like those in use in the physical and biological sciences. In closing, he challenged the surgical research community to facilitate career progression based on collaboration, transparency, and the quality of one’s data, rather than on the weight of one’s CV.

The invited guest speaker on Tuesday, Edward Tufte, Professor Emeritus of Political Science, Statistics, and Computer Science at Yale University in New Haven, Connecticut, discussed analytical thinking, the relationship between observation and conclusion, and useful displays and data presentation in a lecture entitled “The Thinking Eye in the OR and Elsewhere.” Focusing on visual presentations of data, he emphasized that there is no fundamental relationship between the complexity of information presented and the difficulty of viewing that information, but that in many cases information is presented poorly, which obscures the relevant data, the signal, in the noise of presentation. Professor Tufte discussed several situations where visual noise interferes with relevant information. One example he gave was the brightness of lights in the operating room, which illuminate everything in the room equally rather than highlighting the relevant activities of the room, and cause glare and reflections that obscure visualization of screens and cabinet contents. He showed echocardiograms and graphically displayed data, pointing out cases where data presentation was easy to understand and situations where information was hard to glean, contrasting this with the large amount of easy to understand information in a Google Maps view of San Diego. Professor Tufte commented that information can often be presented to convey specific points rather than providing a true picture of what a set of data say. In closing, Professor Tufte challenged the audience to ask themselves “How do I know what I know?” and to maintain self-awareness about what they hear and see, remembering the ways in which information is presented and how that can cause bias or affect the conclusion.

Presidential Address

Monday’s Plenary Session was closed by outgoing AATS President Duke Cameron of Massachusetts General Hospital, with a Presidential Address entitled “Gentle Handling.” Dr Cameron focused on the surgical maxim of gentle handling of tissues, one of William Stewart Halsted’s principles for surgical technique. He posited that gentleness is a general surgical concept to be applied to all aspects of the profession: in interacting with patients, in training young surgeons, in collaborating with colleagues, and in performing surgical procedures. Dr Cameron discussed his own mentors, who he said were “gentle people, to both hearts and people,” and he asked the audience to consider the kind of person they would want to train them, to train their daughter, or to operate on their mother. In closing, Dr Cameron reiterated that competence and compassion are not incompatible, and encouraged those in attendance to immerse themselves in their craft and to love the work that they do.

Conclusion

For more detail on individual sessions, lectures, interviews, and press releases from the 2018 AATS Annual Meeting, please see the AATS Week Recap. Upcoming AATS meetings can be viewed on the meetings page of the AATS website.