PROM Score Predicts Long- Term Survival - Thoracic Surgery News

Dr. Rochus K. Voeller presented the J. Maxwell Chamberlain 

Memorial Paper for Congenital Heart Surgery at the STS meeting. 

Changing Indications 

In Pediatric Transplants 

BY MARK S. LESNEY 

Elsevier Global Medical News 

SAN DIEGO – Over the past 

24 years, the prevalence of indications 

for pediatric heart 

transplantation resulting from 

congenital heart disease has 

changed. Transplantation for 

failed SV palliation, including 

failed Fontan procedure, has 

now become the predominant 

indication, according to the observations 

of a single-center experience 

reported in the J. 

Maxwell Chamberlain Memorial 

Paper for Congenital Heart 

Surgery at the annual meeting 

of the Society of Thoracic Surgeons. 

Heart transplantation is the 

only viable treatment for children 

with end-stage heart failure 

resulting from either 

congenital heart disease (CHD) 

or cardiomyopathy. The purpose 

of this study by Dr. 

Rochus K. Voeller and his colleagues 

at Washington University 

in St. Louis was to review 

the trends in the indications for 

transplant and survival following 

transplant, using a retro- 

Presorted Standard 

U.S. Postage 

PAID 

Permit No. 384 

Lebanon Jct. KY 

spective review of all 307 orthotopic 

heart transplants performed 

at St. Louis Children’s 

Hospital from January 1986 to 

December 2009. Combined 

heart-lung transplants were excluded 

from the study. 

The indications for transplantation 

in 1986-2009 were 39% 

cardiomyopathy, 57% CHD, and 

4% retransplant. Of the 174 patients 

with CHD, 80% had single-ventricle 

anomalies (SV). In 

the CHD group, transplantation 

for failed SV palliation, including 

the failed Fontan 

procedure, became the predominant 

indication in the latest 

8-year interval of their program 

(increasing from 11% in the 

1984-1993 period to 60% in the 

2002-2009 period). The rate of 

retransplantation remained low 

and unchanged across the various 

time periods, according to 

Dr. Voeller. 

The mean recipient age was 

6.1 years, with 41% of the recipients 

aged younger than 1 

year at the time of transplantation. 

Nearly one-third of all pa- 

See Indications • page 9 

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©MARTIN ALLRED 

PROM Score 

Predicts Long- 

Term Survival 

Predicts up to 12 yrs after cardiac surgery 



SAN DIEGO – The Society 

of Thoracic Surgeons Predicted 

Risk of Mortality score is a 

well-validated predictor of 

mortality during the first 30 

days after cardiac surgery. The 

PROM score’s role in predicting 

longer-term survival, however, 

has not been investigated, 

according to Dr. John D. 

Puskas at the annual meeting 

of the Society of Thoracic Surgeons. 

To fill this void, Dr. Puskas 

and his colleagues from 

Emory University, Atlanta, undertook 

a study to statistically 

validate PROM at 1, 3, 5, and 

10 years after cardiac surgery. 

He presented the study’s results 

at the meeting. 

The investigators found that 

the STS PROM algorithm accurately 

predicted mortality 

both at 30 days and during 12 

BY NASEEM S. MILLER 


It’s a simple idea, but it could 

help save millions of lives: a 

Web site helping hospitals and 

surgeons worldwide improve 

surgical outcomes by making a 

commitment to implement 

proven protocols in their operating 

rooms, to share ideas, and 

to receive feedback on what 

works best. 

Called ORReady, the grass 

roots project is the brainchild 

years of follow-up with almost 

equally strong discriminatory 

power. “This may have profound 

implications for informed 

consent as well as for 

longitudinal comparative effectiveness 

studies,” Dr. 

Puskas said in an interview. 

“The STS Predicted Risk of 

Mortality models are probably 

underutilized and underappreciated 

in their power to predict 

short and long-term 

outcomes for our patients. 

The STS provides this service 

free of charge, and it is available 

online 24/7. I am hopeful 

that this newfound ability to 

predict longer-term survival 

after cardiac surgery will find 

utility in comparative effectiveness 

research and ultimately 

in shaping health 

policy,” he added. 

Dr. Puskas and his colleagues 

evaluated the survival 

See Long-Term • page 5 

of Dr. Paul Alan Wetter, 

founder and chairman of the 

Society of Laparoendoscopic 

Surgeons. Inspired by the humble 

beginnings of Facebook, 

and the power of collaboration 

in the Human Genome 

Project, Dr. Wetter decided 

that his idea – a global effort to 

improve surgical outcomes – 

would be just as feasible because 

“smart doctors around 

the world can get together and 

do it.” No bureaucracy. No big 

dollar budget. 

VOL. 7 • NO. 3 • MARCH 2011 

I N S I D E 

Adult Cardiac 

Educating RITA? 

Surgeons do not use RITA 

often enough in CABG. • 4 

General Thoracic 

Desirable Debris? 

Tissue on staplers may be a 

useful cytological tool for 

identifying surgical margins 

in NSCLC. • 6 

Dangerous 

Invasions 

Microvascular invasion 

indicates poor prognosis in 

NSCLC • 8 

Congenital Heart 

Of CABGs 

and CHD 

Late outcomes are good with 

CABG plus CHD repair. • 9 

Web Site Seeks to Improve OR Safety 

Launched in early 2010, the 

project is still in its infancy, and 

the Web site (www.orready.com) 

is still maturing. But the power 

of it all, he said in an interview, 

lies in the number of people 

who know about it and use it. 

“There are many examples 

of people who have really improved 

outcomes in surgery 

with increased use of safety 

measures,” said Dr. Wetter, 

who is an ob.gyn. in South Mi- 

See Web Site • page 2 

THORACIC SURGERY 

NEWS ONLINE! 

Visit our new interactive 

editions at www.aats.org/TSN.

2 NEWS MARCH 2011 • THORACIC SURGERY NEWS 

Online to OR Safety 

Web Site • from page 1 

ami, Fla., and an internationally recognized 

leader in the field of minimally invasive 

surgery. 

He hopes that by sharing OR safety 

information, there will be at least a 2%- 

3% improvement in outcomes. That’s 

six million lives saved worldwide each 

year. He hopes that hospitals, medical 

societies, and surgical centers worldwide 

sign onto this effort within the 

coming years. 

He admits that it’s a lofty goal. But he 

also believes that the increasing emphasis 

on improving patient safety will 

[Hopefully] there 

will be at least a 

2%-3% improvement 

in outcomes. 

That’s six million 

lives saved worldwide 

each year. 

DR. WETTER 

help the initiative take off. Add to that 

the power of technology and collaboration: 

“[The] world is becoming a small 

place and information is disseminated 

quickly,” said Dr. Wetter, who is also 

clinical professor emeritus at the University 

of Miami. 

ORReady is a nonprofit project run 

by members and institutions that have 

volunteered their time and resources. 

The Web site follows the Creative Commons 

guidelines. “We encourage you to 

copy and use any materials that will 

help improve surgical outcome and create 

Centers of Merit in Surgery and MIS 

[minimally invasive surgery].” It encourages 

hospitals and departments to 

download and sign an “Outcome Commitment 

Letter”; to choose from a set 

of protocols on the Web site that suit 

their operating rooms; and register as 

an ORReady Center of Merit. 

The guidelines suggest three main 

steps for surgeons and their teams: 

AMERICAN ASSOCIATION FOR THORACIC SURGERY 

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

Associate Editor, General Thoracic 

Michael J. Liptay, M.D. 

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

Associate Editor, Cardiopulmonary Transplant 

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

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

Executive Director Elizabeth Dooley Crane, CAE, CMP 

Associate Executive Director Cindy VerColen 

Editorial Associate Lisl K. Jones 

Resident Editor Stephanie Mick, M.D. 

Resident Editor Christian Peyre, M.D. 

THORACIC SURGERY NEWS is the official newspaper of the American Association 

for Thoracic Surgery and provides the thoracic surgeon with timely and 

relevant news and commentary about clinical developments and about 

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

today. Content for THORACIC SURGERY NEWS is provided by International 

Medical News Group 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. 

“Slow Down for Warm Up and Check 

Lists; Stop for Time Out before you 

Go.” A stoplight on the site sums up the 

message. 

Soon, participants can register with 

an open-access database that can be 

used for research to improve outcomes 

and to provide feedback. The school of 

biological and health systems engineering 

at Arizona State University, 

Tempe, has offered to help create the 

database. Dr. Wetter said that with 

the rapidly changing technology and 

arrival of new procedures, ORReady 

can be the tool through which surgeons 

and institutions can quickly 

share their data and receive feedback 

on what works best. 

Dr. Wetter said that so far he has approached 

a handful of institutions in the 

United States and abroad and has received 

a unanimously positive response. 

The project also recently won its first 

award. The Society of Laparoendoscopic 

Surgeons won the 2011 Alliance 

for Continuing Medical Education 

Great Idea Award in the Medical Specialty 

Societies Member section for introducing 

ORReady as a way to 

encourage surgical facilities to improve 

CME for improved surgical outcomes. 

“We’re looking for things that are 

best practices, are innovative, and that 

other people may want to replicate, 

adapt, [and] consider using,” Jann 

Balmer, Ph.D., president of the Alliance, 

said in an interview. 

“It’s very exciting to do this and see 

this great enthusiasm,” said Dr. Wetter. 

“For almost any doctor, the main concern 

is the safety of their patients.” 

Dr. Wetter is now focusing on spreading 

the word and making more surgeons 

and hospitals aware of and 

involved in ORReady. “The more people 

that know about this, the more successful 

it’s going to be.” 

He hopes to see his project make an 

impact within the next few years. ■ 

THORACIC SURGERY NEWS 

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Simple Protocol Improved 

Handwashing in the ICU 

BY DOUG BRUNK 


SAN DIEGO – Adding a simple question 

to the daily ICU checklist about 

handwashing before touching patients 

significantly improved handwashing 

compliance and was associated with a 

decreased rate of central line–associated 

bloodstream infections in a surgical 

intensive care unit over the course of 6 

months, according to a presentation at 

the annual congress of the Society of 

Critical Care Medicine. 

“If you look at how people address 

hand hygiene compliance overall, most 

of the time it’s with fairly elaborate and 

expensive educational and marketing 

campaigns,” Dr. Jeremy Pamplin said in 

an interview after the study was presented 

during a poster session at the 

congress. “Inevitably, you improve 

hand hygiene compliance for a while. 

Then the campaign goes away and you 

start to have fading of the compliance.” 

As part of a process improvement 

project, Dr. Pamplin, medical codirector 

of the 20-bed surgical/trauma ICU at 

Brooke Army Medical Center, Fort Sam 

Houston, Tex., and his associates added 

the following question to their daily ICU 

checklist: “Has anyone seen anyone else 

touch the patient without washing their 

hands in the past 24 hours?” The question 

was asked during multidisciplinary ICU 

rounds for every patient, and only “yes” 

or “no” answers were allowed. 

If respondents answered “yes,” they 

were asked to provide the name of the 

offender, which was recorded. Compliance 

was measured by a third-party observer 

and was defined as washing 

hands or using hand sanitizer prior to 

touching a patient or the patient’s immediate 

surroundings. 

Dr. Pamplin and his associates collected 

data for 3 months before and 3 

ELSEVIER SOCIETY NEWS GROUP, A DIVISION OF 

INTERNATIONAL MEDICAL NEWS GROUP 

President, IMNG Alan J. Imhoff 

Director, ESNG Mark Branca 

Editor in Chief Mary Jo M. Dales 

Executive Editors Denise Fulton, Kathy Scarbeck 

Managing Editor Mark S. Lesney 

Circulation Analyst Barbara Cavallaro, 973-290-8253, 

b.cavallaro@elsevier.com 

Executive Director, Operations Jim Chicca 

Director, Production and Manufacturing Yvonne Evans Struss 

Production Manager Judi Sheffer 

Creative Director Louise A. Koenig 

months after this question was added to 

the ICU checklist. Over that period, the 

rate of handwashing compliance significantly 

increased from 69% to 89%, 

while the rate of central line–associated 

bloodstream infections decreased from 

13.7/1,000 central line days to 2.7/1,000 

central line days, an improvement that 

did not reach statistical significance. 

“Before we introduced this question to 

our checklist, it was very rare for a 

provider to tell another provider, ‘Hey, I 

didn’t see you wash your hands,’ ” Dr. 

Pamplin said. “After we introduced this 

question, people started doing it because 

we gave leadership and emphasis to it.” 

With the new 

protocol, handwashingcompliance 

in the 

ICU significantly 

increased from 

69% to 89%. 

DR. PAMPLIN 

This resulted in a change of culture, 

he continued, “so if nurses, residents, 

or technicians saw someone walk into 

the room without washing their hands, 

they would stop them and say, ‘Hang 

on a second; you didn’t wash your 

hands.’ Everyone knows that hand hygiene 

is an important part of infection 

control. The hard part is remembering 

to do it. It’s a rare circumstance that 

someone gets upset by another health 

care provider who says, ‘Hey, you forgot 

to wash your hands.’ Because we 

have talked about hand hygiene compliance 

on rounds as a team, it has elevated 

that component of infection 

control so that everyone recognizes it 

as being important.” 

Dr. Pamplin said that he had no relevant 

financial disclosures to make. ■ 

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©Copyright 2011, by the American Association for Thoracic Surgery

MARCH 2011 • THORACIC SURGERY NEWS RESIDENTS’ CORNER 3 

Perspectives From Cross-Trained Cardiac Surgeons 

I n 

Part II gives the views of ‘early adopters’ on 

the risks and benefits of cross-training. 

BY STEPHANIE MICK, M.D. 

Resident Associate Medical Editor 

the second part of a discussion of 

the potential integration of Cardiac 

Surgery and Interventional Cardiology, 

two “early adopters” – Mathew 

Williams at New York Presbyterian 

Hospital–Columbia and Michael Davidson 

at the Brigham and Women’s Hospital 

– continue their personal 

perspective on potential problems and 

training challenges such integration 

might entail. 

Dr. Davidson notes there are some 

downsides to this new type of practice. 

“The issues that all of us face that do this 

… the ‘ugly underbelly,’ if you will … revolve 

around competition and turf. It 

plays out differently in every institution 

due to differences in reimbursement at 

each institution, etc. 

“But even if reimbursement is not the 

issue, there are also issues of identity. 

There is a little element of being in “no 

man’s land” … you are set aside from 

your cardiac surgery colleagues because 

you do things that they don’t. And on the 

flipside you have the cardiologists, who 

are largely supportive, but there is always 

a little worry about encroachment on 

turf that you have to be very careful 

about. I don’t think anyone has the ideal 

solution to this.” 

Looking to the future and the idea of 

the integration of cardiac surgery and interventional 

cardiology, both focused on 

potential changes in training programs. 

As a first point, they both noted that a 

significant amount time is required to 

master catheter-based skills. “We need to 

accept that it takes more than three 

months to learn,” Dr. Williams said. 

Dr. Davidson echoed and expanded on 

this point: “One of the dangers cardiac 

surgeons face is that because they have 

such a high degree of technical skills, 

they tend to not have enough appreciation 

for the degree of technical skill that 

is involved in being a good, competent 

interventional cardiologists. Sometimes, 

cardiac surgeons assume that because 

The STS meeting in January led to 

many discussions within the TSRA 

including both future and current 

events. Future events included the results 

of the recent resident survey, upcoming 

thoracic surgery review book, 

new opportunities in using social media 

and further improvement of the 

“boot camp” weekend for new residents. 

More immediate conversation 

included continued adjustments in 

work hour restrictions, job hunting 

strategies and a discussion on the 

steps of completing the board exam. 

they have good surgical skills, they can 

waltz into a cardiac catheterization lab 

and ‘figure it out’ in a short period of 

time and this is simply not true. One actually 

needs to put in a fair amount of 

time and do a few hundred cases to gain 

advanced catheter skills. One can get 

lulled into a sense of ease by doing a couple 

of easy procedures (e.g. a straightforward 

aortic stent graft) and then 

getting a sense that endovascular work is 

very easy. But in fact when one does 

‘Going forward, 

what I imagine is 

... slow evolution 

– that is not my 

dream, I would 

hope for merged 

departments.’ 

DR. WILLIAMS 

more advanced procedures, one sees that 

it actually does take a lot of technical 

skill. For a cardiac surgeon to do this 

right, they have to understand the idea 

that you can’t do a weekend or monthlong 

course and expect to have real endovascular 

competency. 

“There’s a bit of a paradox in that 

many feel it would be good to have more 

of a cardiac surgical presence in the cath 

lab; at the same time you risk having cardiac 

surgeons who are inadequately 

trained and may get into trouble assuming 

their surgical skills translate into endovascular 

skills.” 

Both went on to comment on the 

changes in training that would be necessary 

if interventional cardiology and cardiac 

surgery were to merge in the future. 

“There’s a lot of divergence of opinion 

here. I am in the camp that believes that 

the separation of interventional cardiology 

and cardiac surgery is artificial and 

based on historical models that may not 

apply anymore. I think we should go 

more towards disease based treatment 

but in doing this, there would be a blurring 

of the lines as to be who should be 

doing what. One way to avoid the ‘turf 

A Message from Dr. William A. 

Baumgartner on Behalf of the 

ABTS to the TSRA at the STS 

Annual Meeting 

Passing a board exam necessitates 

proving to the examiners you have an 

accurate plan on where to go with a 

patient. Applying for the board exam 

on the other hand necessitates an accurate 

map of where you have been 

as a training physician. Documentation 

of cases performed by a trainee 

serves as this “map” of past accomplishments. 

A case journal is not only 

used as a requirement for board ex- 

battles’ and to achieve better integration 

would be to have the training integrated 

from the beginning,” said Dr. Davidson. 

“One of the problems that has been 

brought up is in this country is that often 

the treatment a patient gets is determined 

by who they happen to go see – 

one treatment if they go to a surgeon and 

one treatment if they go to a cardiologist 

… for the same disease. 

“Ideally, if you train people from the 

ground up to be disease managers and 

then further differentiate from that point 

… say ‘outpatient clinicians’ versus ‘imaging 

clinicians’ versus those that do ‘big procedures’ 

or endovascular procedures but 

united by their core training, it may reduce 

the ‘turf battles’ that are actually not very 

good for patients. The core should be patient 

care” Davidson continued. 

In making any large-scale change, 

there are always two options: swift, radical 

action or more gradual stepwise 

changes. 

“The question becomes should we do 

this by mass upheaval or incremental 

steps over time? Hard to know,” Dr. 

Davidson remarked. 

There are multiple complexities involved 

in such a change, he noted: 

“there are a lot of realities that go into 

this. For instance, the 

idea of merging cardiology 

and cardiac 

surgery doesn’t take 

into account some 

practitioners who want 

to divide their time between 

cardiac and thoracic 

surgery. This 

group is more committed 

to keeping cardiac 

and thoracic surgery together 

and maintaining 

the general surgery 

training. So, there is an 

internal conflict/struggles 

even within CT 

surgery … in addition 

to the potential conflicts 

between cardiac 

surgery and cardiology.” 

On his vision of the 

future, Dr. Williams 

commented, “going for- 

News from the TSRA 

ams. Hospitals, insurers, and industry 

can also use these data to choose who 

is going to perform their next test or 

treatment. 

It is the responsibility of the trainee 

to maintain their case log to confirm 

they are getting their index cases 

completed. More and more applicants 

for the ABTS are applying with holes 

in their resume with categories of 

cases not completed. Often the cause 

of this is not a program’s lack of exposure, 

but poor documentation during 

the period of training. 

Much like not getting paid for poor 

ward, what I imagine is continued slow 

evolution – that’s not my dream; I would 

hope for merged departments.” 

He went on to express concern regarding 

the future of cardiac surgery 

training. “Cardiac surgery is moving 

too slowly, in my opinion. At our institution, 

for example, we’ve been starting 

a six-year training program but given 

the amount of thoracic and general 

surgery they are required to do, we are 

not going to be training the cardiac surgeon 

of the future. Unless we radically 

change the training structure, true 

integration of the fields is never going 

to happen.” 

Dr. Williams pointed out that in his experience, 

the primary force of resistance 

to the idea of the integration of interventional 

cardiology and cardiac surgery 

was not from the medical side: “Actually 

in my experience, the cardiologists 

have embraced this a lot more than cardiac 

surgery. 

“The resistance is not so much from 

the medical side as the surgical side. 

They have been a lot more receptive to 

this. Cardiothoracic surgeons seem to be 

more interested in fighting about turf instead 

of really looking at what the appropriate 

training is.” ■ 

See current and 

archived issues of 

THORACIC SURGERY NEWS 

online at www.aats.org 

documentation of procedures when 

out in practice, the ABTS will soon 

become stricter on documentation of 

index cases. 

The good news is that the program 

for logging cases will soon follow the 

CPT coding system for CT Surgery 

residents starting in July, 2011. The 

program will provide for more accurate 

documentation and will also 

give a more “real world” experience. 

In the meantime, check your case log 

regularly and expeditiously discuss 

with your program director any deficiencies 

that may exist.

4 ADULT CARDIAC MARCH 2011 • THORACIC SURGERY NEWS 

Half of Recurrent ACS Due to Existing ‘Mild’ Lesions 

I t 

BY MARY ANN MOON 


should not come as a surprise that 

approximately half of the acute coronary 

syndromes that recur within 3 

years of an index ACS treated percutaneously 

involve a different lesion that 

was visualized on angiography at that 

time but was not severe enough to require 

treatment, as has been recently reported 

in the New England Journal of 

Medicine. 

“Pathologic studies … have illustrated 

that plaques when ruptured were substantially 

bulky and associated with thin 

fibrous caps. These lesions at the time of 

diagnosis may not have been sizable but 

grow at a faster rate to become eligible 

for rupture,” Dr. Jagat Narula, who is 

chief of cardiology at the University of 

California in Irvine, said in an interview. 

The bigger question concerns the potential 

role for newly available radiofrequency 

intravascular ultrasonography 

(RF IVUS) in early assessment of patients 

with ACS. 

The study in question showed that 

the rate of recurrent major adverse cardiovascular 

events was 20% in this multicenter 

prospective study involving 697 

patients with ACS who were successfully 

treated with PCI and medical therapy, 

then followed for 3 years, reported Dr. 

Gregg W. Stone of Columbia University 

Medical Center/New York Presbyterian 

Hospital and the Cardiovascular Research 

Foundation, New York, and his associates. 

The Providing Regional Observations 

to Study Predictors of Events in the 

Coronary Tree (PROSPECT) study was 

conducted at 37 medical centers in the 

United States and Europe. 

Study subjects were enrolled after undergoing 

successful and uncomplicated 

PCI for all coronary lesions thought to be 

responsible for their index ACS. At that 

time, the subjects underwent angiography, 

then conventional gray-scale intravascular 

ultrasonography and the 



SAN DIEGO – Although the right internal thoracic 

artery is biologically identical to the left internal thoracic 

artery, it is rarely used in coronary artery bypass 

grafting. 

In a study comparing the use of different graft 

sources for coronary artery bypass grafting (CABG), Dr. 

James Tatoulis and his colleagues found that the right 

internal thoracic artery (RITA) showed equivalent results 

to using the left internal thoracic artery (LITA). 

Dr. Tatoulis of the Royal Melbourne Hospital and his 

colleagues evaluated consecutive RITA graft angiograms 

performed from 1986 to 2008. Patency was 

examined over time by coronary territory and by 

whether the RITA was in situ or free, and was compared 

with other coronary conduits, according to the study 

presented at the annual meeting of the Society of 

Thoracic Surgeons. 

A total of 5,766 patients had a RITA graft, usually as 

newly available RF IVUS of the left main 

coronary artery and the proximal 6-8 cm 

of each of the major epicardial coronary 

arteries. 

The median age of the study subjects 

was 58 years; 24% were women, and 

17% had diabetes. 

“We found that approximately one in 

five patients with [ACS] ... had recurrent 

major adverse cardiovascular events 

within 3 years. Events were nearly equally 

divided between those 

related to initially treated 

lesions and those related to 

previously untreated lesions,” 

Dr. Stone and his 

colleagues said. 

“Most events were rehospitalizations 

for unstable 

or progressive angina; 

death from cardiac causes, 

cardiac arrest, and MI were 

less common,” they noted. 

“Despite [certain] 

caveats, PROSPECT study 

has contributed immensely 

to understanding plaque 

anatomy, plaque composition 

and the prognostic relevance 

of the 

atherosclerotic lesions,” 

said Dr. Narula. 

RF IVUS at baseline re- 

vealed that most of the 

“nonculprit” coronary lesions 

– those that had been 

considered mild on the index 

angiography and were 

not treated at that time – 

were characterized by a large plaque 

burden, a small luminal area, or both. 

Half of them also were thin-cap fibroatheromas. 

These traits had not 

been visible on conventional angiography. 

“I think the major message is that the 

angiogram is a very poor discriminator 

of how much atherosclerosis is present 

and which type of atherosclerosis is going 

to go on and cause unexpected 

events,” Dr. Stone said in an interview. 

“Radiofrequency IVUS provides significantly 

more information than just regular 

gray-scale IVUS in helping 

differentiate the nature of these plaques 

and which ones are going to progress.” 

Conventional gray-scale IVUS works 

by sending out ultrasound waves and the 

resulting reflection signal can reveal 

structural information. Gray-scale IVUS 

measures only the amplitude of the reflected 

waves. However, RF IVUS also in- 

Color coding reveals location, size, and type of four different 

vessel tissue types seen with radiofrequency sonography. The 

bottom image shows the corresponding gray-scale intravascular 

ultrasound images indicating lumen size and plaque burden. 

terprets frequency information from the 

reflected waves. 

“That radiofrequency signal has been 

mapped pixel by pixel to actual histology 

from human pathologic specimens.” So 

a four-color coded map with four different 

types of tissue can be created to 

map plaque composition. 

“RF IVUS has a much higher signal-tonoise 

ratio because it’s a catheter that is 

right next to the coronary plaque. So the 

resolution is much greater and you can 

part of bilateral internal thoracic artery CABG. The operative 

mortality was 1.1%, and the rate of deep sternal 

infection was 1.5%. Of the nearly 7,800 coronary 

conduits studied, 991 RITA conduits were examined at 

a mean of 100 months postoperatively. 

The overall 10-year RITA patency 

was 90%. RITA graft patency 

to the left anterior 

descending artery (n = 149) was 

95% at 10 years and 90% at 15 

years. Ten-year RITA patency to 

the circumflex marginal artery 

was 91% (n = 436), 85% (n = 199) 

to the right coronary artery 

(RCA), and 86% (n = 207) to the posterior descending 

artery (PDA). Ten-year patencies of RITA and LITA to 

the left anterior descending artery were identical. 

In situ RITA (n=451) and free RITA (n=540) had similar 

10-year patencies, 89% vs. 91% respectively. 

RITA patency was found to be significantly better 

see plaque composition the way that 

noninvasive modalities currently can’t,” 

Dr. Stone said. 

However, “there are several reasons 

why the methods we have used are not 

currently suitable for clinical application 

as a means of identifying sites in the 

coronary vasculature for potential intervention,” 

the investigators noted (N. 

Engl. J. Med. 2011:364:226-35). 

First, this method lacks specificity 

at present. RF IVUS identified 

a total of 595 thincap 

atheromas in these 

subjects, but only 26 of 

them caused recurrent 

ACS. Similarly, fewer than 

10% of the lesions that 

carried plaque burdens of 

70% or more and the lesions 

with a 4-mm or 

smaller luminal area 

caused recurrent ACS. 

“Even when all three predictive 

variables were present, 

the event rate rose to 

only 18%,” they said. 

Second, catheters used 

for this type of ultrasonography 

could only access the 

proximal 6-8 cm of the 

coronary tree. This meant 

COURTESY DR. GREGG W. STONE 

that only 51 of the 106 

“nonculprit” lesions seen 

on angiography could be 

evaluated by RF IVUS. 

Third, the technique was 

associated with very serious 

adverse events in 11 patients 

in this study: 10 coronary 

dissections and 1 perforation, which in 

turn caused 4 nonfatal MIs. 

While the ability of RF IVUS to assess 

luminal stenosis, plaque burden and positive 

remodeling is a useful tool, there are 

other diagnostic modalities to consider as 

well, said Dr. Narula. “Optical coherence 

tomography is the only technique that 

may accurately measure the cap thick- 

ness [and] CT angiography allows an as- 

Continued on following page 

Right Internal Thoracic Artery Should Be Used More in CABG 

than radial artery and saphenous vein grafts for the circumflex 

marginal artery, the RCA, and the PDA. The 

10-year survival of patients with RITA and LITA for 

triple-vessel coronary disease were identical at 89%. 

RITA patency was 

Dr. Tatoulis and his colleagues 

stated that late patencies of RITA 

better than radial are excellent, equivalent to the 

artery and saph- LITA for identical territories, and 

enous vein grafts always better than radial artery 

for the circumflex and saphenous vein grafts. 

marginal artery, “Unfortunately, less than 10% 

the RCA, and PDA. of all coronary artery surgery 

worldwide is performed with two 

DR. TATOULIS internal thoracic arteries,” Dr. 

Tatoulis said in an interview. 

He added that the use of this technique could im- 

prove patient outcomes and could offer an even better 

revascularization alternative to stents, particularly for 

triple-vessel coronary disease. 

Dr. Tatoulis and his colleagues reported that they had 

no relevant disclosures. ■

MARCH 2011 • THORACIC SURGERY NEWS ADULT CARDIAC 5 

Continued from previous page 

sessment of both positive remodeling and the 

magnitude of necrotic cores.” 

Intravascular optical coherence tomography 

(OCT) is similar to IVUS but light is used instead 

and resolution is greater. OCT uses a single 

fiberoptic wire that emits light and records the reflection 

as it is rotated and pulled back along the 

artery. OCT can be used to guide interventions, 

assess the lumen, visualize thrombi and dissections. 

It can also allow physicians to evaluate lesion 

cap thickness. 

The advent of multislice CT – 264 slices and 

even greater – offers better and better resolution 

for non-invasive CT angiography. CTA can identify 

the presence of positive vessel remodeling and 

low-attenuation plaques, which along with a 

necrotic core, are thought to be associated with 

subsequent plaque rupture. 

In the PROSPECT study, they also found that 

no major events arose from arterial segments with 

a plaque burden that blocked less than 40% of the 

lumen. And nonfibroatheromas rarely caused 

such events, regardless of their plaque burden or 

the luminal area they blocked. 

These study findings suggest that thin-cap fibroatheromas, 

lesions with a large plaque burden, 

and lesions with a small luminal area are particularly 

prone to cause recurrent ACS. 

For now though, the early identification of such 

lesions needs to be validated in randomized trials 

and is limited by unclear therapeutical options. 

“We need to answer two questions,” said Dr. 

Narula. “First, can we define the high-risk lesions 

especially when of intermediate angio- 

866.623.4137 

www.acuteinnovations.com 

21421 NW Jacobson Rd 

Suite 700 

Hillsboro, OR 97124 

graphic severity? Second, even if it is possible, 

are we justified in recommending widespread 

imaging studies, especially when only a small 

fraction of nonculprit vessel plaques progress to 

acute events … plaques form, rupture, and heal 

all the time, and it would be difficult to precisely 

identify a high-risk plaque associated with a major 

event, let alone identify it in a treatable proximity 

to an event.” 

Dr. Stone agreed. “We haven’t yet done the 

randomized trials to say that if we find one of 

these lesions that the patients are better off if we 

then treat them. If so, what do we treat them 

with?” 

“For now, statins remain the cornerstone of 

management of the non-obstructive disease. 

Whether new agents targeted at inflammation 

… or non-injurious stent implantation become 

worthy of clinical application, would depend 

upon the capability of imaging techniques to 

identify temporo-spatial proclivity of lesions 

for the occurrence of events, as also the demonstration 

of the virtue and benign nature of the 

intervention,” said Dr. Narula. 

PROSPECT was funded by Abbott Vascular and 

Volcano. Abbott participated in the study design, 

site selection, data collection, and data analysis. 

Dr. Stone reports receiving grant support, 

consulting fees, and/or lecture fees from numerous 

pharmaceutical and device firms, including 

Abbott Vascular, TherOx, the Medicines 

Company, and Boston Scientific. Other investigators 

reported financial relationships with Abbott 

Vascular, Boston Scientific, Volcano, 

Bristol-Myers Squibb, Sanofi-Aventis, the Medicines 

Company, and others. ■ 

Locate your local representative today - www.acuteinnovations.com 

PROM Score 

Long-Term • from page 1 

rates for 24,222 patients who underwent cardiac surgery at a 

single academic center during 1996-2009. Long-term all-cause 

mortality was determined by referencing the national Social Security 

Death Master File. Logistic and Cox survival regression 

analyses were used to evaluate the long-term predictive utility 

of PROM. 

The AUROC (area under the receiver operator characteris- 

tic) curve measured 

the discrimination 

of PROM at 1, 3, 5, 

and 10 years. Kaplan-Meier 

curves 

were stratified by 

quartiles of PROM 

risk to compare 

long-term survival. 

All analyses were 

performed for both 

the whole sample and 30-day survivors. 

This may have 

profound 

implications for 

informed consent 

and comparative 

effectiveness 

studies. 

DR. PUSKAS 

The investigators found an overall 30-day mortality rate of 

2.78%. 

Among all patients and 30-day survivors, AUROC values for 

PROM at 1, 3, 5, and 10 years were remarkably similar to the 

30-day end point for which PROM is calibrated. 

Moreover, PROM was highly predictive of Kaplan-Meier survival, 

even when this analysis was restricted to patients surviving 

beyond 30 days, he added. 

Among 30-day survivors, each percent increase in PROM 

score was significantly associated with a 9.6% increase in instantaneous 

hazard of death (P less than .001). 

Dr. Puskas and his colleagues reported no relevant disclosures 

with regard to their study. ■ 

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6 GENERAL THORACIC MARCH 2011 • THORACIC SURGERY NEWS 

Lung Debris May Help Identify Surgical Margins 

BY PATRICE WENDLING 


CHICAGO – A novel technique utilizing 

stapled lung debris could help determine 

adequate and inadequate surgical 

margins in resected non–small cell lung 

cancer, results of a prospective study 

suggest. 

Researchers at Albany (N.Y.) Medical 

College and the Hospital of St. Raphael 

in New Haven, Conn., are using cytology 

to analyze lung tissue taken from 

spent staple cartridges used during sublobar 

resection. The staple cartridge is simply 

mixed with 30 cc of normal saline 

and serves as the cytologic margin, Dr. 

Thomas Fabian explained at the Chicago 

Multidisciplinary Symposium in Thoracic 

Oncology. 

“People have [observed] that certain 

staples used through cancers can potentially 

contaminate new tissue planes, so 

that is how the idea was born,” he said 

in an interview. 

Dr. Fabian and his colleagues prospectively 

compared staple-line cytology with 

traditional histopathologic evaluation of 

surgical specimens taken from 97 patients 

undergoing diagnostic sublobar 

wedge resection between November 

2007 and September 2009. Of the 98 

specimens retrieved, 30 were benign and 

2011 

American Association 

for Thoracic Surgery 

mitral 

c o n c l av e 

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, MD 

Cytology reveals the presence of adenocarcinoma cells in a specimen retrieved 

from debris adhering to the surgical stapler. 

68 were malignant. 

Staple-line cytology was 100% accurate 

in the evaluation of benign lesions 

when compared with histology, he said. 

In the 68 malignant nodules, initial 

blinded cytologic evaluation was positive 

in 7, surgical pathology was positive in 

6, and both were positive in 4. 

Subsequent unblinded review of both 

specimens changed the final pathologic 

interpretation in 4 (6%) of the 68 cases, 

decision making 

OUTCOMES 

surgical video sessions 

said Dr. Fabian, chief of thoracic surgery 

at the Albany Medical Center. The interpretation 

changed from a negative 

margin to a positive margin in 3 surgical 

specimens (7%) and in 1 staple-line cytology 

specimen (2%). 

According to analysis of the unblinded 

data, staple-line cytology 

demonstrated an overall accuracy of 

96%, with 88% sensitivity, 97% specificity, 

70% positive-predictive value, and 

99% negative-predictive value. 

Dr. Fabian described staple-line cytology 

as a simple technique that could 

serve as an adjunct to the gold standard 

of histopathology, which he said is prone 

to inaccuracies including both false positives 

and false negatives. 

“We need to reevaluate the techniques 

that allow us to accurately assess surgical 

margins – particularly in the setting 

of sublobar resections, given the growing 

interest in this technique,” according 

to Dr. Fabian. 

“The cytologic technique appears to 

be sensitive, specific, and accurate, but it 

does need to be validated at other institutions 

and with additional studies,” he 

added. 

Dr. Fabian acknowledged that by design 

the study lacked clinical outcome 

data and said further evaluation is ongoing. 

The next step is to evaluate the 

technique in patients undergoing sublobar 

resection with curative intent. 

Of the 68 malignant samples, 43 were 

diagnosed as adenocarcinoma, 7 as squamous 

cell carcinoma, 3 as large cell, 1 as 

small cell, 5 as carcinoid, and 9 as other 

histologies. 

Dr. Fabian disclosed serving as a speaker 

for, and receiving research funding and 

honoraria from, Covidien. His coauthors 

reported no conflicts. ■ 

MAY 5-6, 2011 

Sheraton Hotel & Towers 

New York, New York, USA 

REGISTER ONLINE AT: 

www.aats.org/mitral 

Program Available Online 

The American Association for Thoracic Surgery 

is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. 

COURTESY DR. THOMAS FABIAN 

This activity has been approved for AMA PRA Category 1 Credits.

MARCH 2011 • THORACIC SURGERY NEWS GENERAL THORACIC 7 

Low-Dose Aspirin Cut Cancer Death Rates 30%-40% 

BY SARA FREEMAN 


LONDON – The daily, long-term use of 

low-dose aspirin cuts the risk of death 

from several types of cancer, according 

to a large meta-analysis. 

In a meta-analysis of eight randomized 

clinical trials involving 25,570 patients, 

low-dose aspirin taken for 5 years or longer 

reduced mortality from esophageal, pancreatic, 

brain, stomach, colorectal, 

prostate, and even lung cancer, with doses 

as low as 75 mg/day having an effect. 

This is the first time that low-dose aspirin 

has been linked to a reduction in 

cancer mortality other than colorectal 

cancer, said Dr. Peter M. Rothwell, who 

conceived and coordinated the research. 

Dr. Rothwell of the John Radcliffe Hospital 

and the University of Oxford, United 

Kingdom, and his associates in October 

2010 showed that low-dose aspirin reduced 

the 20-year risk of new colon cancer cases 

by approximately one-quarter and deaths 

by a third (Lancet 2010;376:1741-50). 

The current study looked at all deaths 

from cancer that occurred during or after 

completion of eight randomized clinical 

trials that had been performed to 

look at the effects of daily aspirin vs. control 

for the primary or secondary prevention 

of vascular events (Lancet 2010 

[doi:10.1016/S0140-6736(10)62110-1]). 

Across all eight trials, 674 cancer 

deaths occurred in 25,570 patients, with 

aspirin treatment significantly reducing 

the risk of death, compared with no aspirin 

treatment (pooled odds ratio [OR] 

0.79, 95% confidence interval [CI] 0.68- 

0.92, P = .003). 

Using individual patient data available 

for seven of the trials and in which 657 

cancer deaths occurred in 23,535 patients, 

the benefit of aspirin therapy was 

apparent only after 5 years or more of 

follow-up. The hazard ratio (HR) for 

death from all types of cancer was 0.66 

(95% CI 0.50-0.87, P =.003), with a 

greater effect seen in patients with gastrointestinal 

tumors (HR 0.46, 95% CI 

0.27-0.77, P =.003). 

“We found that within the trials, while 

people were still on aspirin vs. no aspirin, 

the aspirin group had about a 30%-40% 

reduction in cancer deaths between year 

5 and the end of the trial,” Dr. Rothwell 

said at a press briefing. 

To determine the longer-term effects 

of aspirin on cancer mortality, the team 

looked more closely at data from three 

of the trials. These had all been conducted 

in the United Kingdom and continued 

to collect information on cancer 

deaths via national death certification 

and cancer registration systems long after 

the trials had concluded. 

In all, individual patient data were obtained 

on 1,634 cancer deaths that had 

occurred in 12,659 patients. Aspirin was 

found to reduce the 20-year risk of death 

from all solid cancers by 20% (HR 0.80, 

95% CI 0.72-0.88, P less than .0001). 

Again, the effect on gastrointestinal cancer 

was greater (HR 0.65, 95% CI 0.54- 

0.78, P less than .0001), but there was no 

effect on hematologic malignancies. 

At least 5 years of therapy were needed 

to reduce the risk of death from 

esophageal, pancreatic, brain, or lung 

cancer, with 10 years or more treatment 

required to see an effect on stomach and 

colorectal cancer death rates, and 15 

years or more for prostate cancer. With 

regard to both lung and esophageal cancer, 

the effect of aspirin was limited to 

adenocarcinomas. 

While the findings do not mean that 

everyone over the age of 40 years should 

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now start taking daily aspirin to prevent 

cancer, given the increased risk of bleeding 

in some individuals, “We should 

probably stop taking people off aspirin 

unless they’ve got side effects,” Dr. Rothwell 

said in an interview, adding “We 

probably shouldn’t discourage those who 

want to take aspirin as actively as we 

have been doing.” 

“There is a fundamental difference between 

the treatment and the prevention 

of a disease,” said Dr. Peter Elwood, 

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professor of epidemiology at Cardiff 

University, Wales. Dr. Elwood suggested 

that deciding to take a daily dose of aspirin 

to prevent cancer could be another 

choice patients make once they have all 

the relevant facts, much as lifestyle 

changes are advised but not prescribed 

for cardiovascular disease prevention. 

Dr. Rothwell has received honoraria 

from pharmaceutical companies with an 

interest in antiplatelet therapy, including 

AstraZeneca and Bayer. ■ 

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8 GENERAL THORACIC MARCH 2011 • THORACIC SURGERY NEWS 

Microscopic Vascular Invasion Emerging as a 

Powerful Prognosticator in Early Lung Cancer 

BY PATRICE WENDLING 


CHICAGO – New data suggest that 

microscopic vascular invasion may be a 

more powerful prognosticator in early 

lung cancer than are the tumor 

size–based categories suggested in the 

new TNM staging system. 

Italian researchers used histologic and 

immunohistochemical techniques to 

identify microscopic vascular invasion 

(MVI), or the presence of neoplastic 

structures inside the lumen of a vessel, 

in one-third (154) of 512 patients with resected, 

pathologically staged T1a to T3 

node-negative non–small cell lung cancer 

(NSCLC). The 2009 edition of the tumor, 

node, metastasis (TNM) staging system 

for lung tumors was used. 

MVI was significantly correlated with 

the presence of tumor-infiltrating lymphocytes 

(odds ratio 1.65, P value = .03), 

adenocarcinoma histology (OR 1.32, P = 

.003), and increased tumor size (OR 1.13, 

P = .009). 

Five-year overall survival was significantly 

lower for patients with MVI at 

50% vs. those without MVI at 66% (P = 

.001), Dr. Enrico Ruffini said at the 

Chicago Multidisciplinary Symposium 

in Thoracic Oncology. 

The difference in survival remained 

significant even in those with squamous 

cell carcinoma (45% vs. 61%, P = .05), 

although it was more pronounced in 

those with adenocarcinoma (56% vs. 

70%, P = .03). 

“Microscopic vascular invasion is a significant 

independent negative prognostic 

factor,” he said. 

BY EMILY HAYES 

“The Pink Sheet” 

Genentech Inc. and partner OSI Pharmaceuticals Inc. 

are set to pursue a broader label for Tarceva (erlotinib) 

in the United States as a first-line treatment of 

advanced non–small cell lung cancer with epidermal 

growth factor receptor mutations, after reporting positive 

top-line results in that setting from a phase III European 

study. 

Genentech announced that compared 

with platinum-based chemotherapy, 

Tarceva, an EGFR inhibitor, 

improved progression-free survival 

in an interim analysis of the EUR- 

TAC study of 178 newly-diagnosed 

advanced NSCLC patients who had 

tested positive for the mutations. 

Safety was in line with Tarceva’s 

profile. In light of the efficacy and 

safety results, the trial was halted early on the recommendation 

of its independent data monitoring committee. 

Tarceva is currently approved in the United States and 

Europe as a maintenance and second-line treatment for 

advanced or metastatic NSCLC with and without EGFR 

activating mutations. An estimated 10% of NSCLC carries 

the EGFR mutations and according to Genentech 

a first-line indication would mean Tarceva could 

When patients with pT1a-T2b tumors 

were stratified by T-size category, the 

presence of MVI resulted in a one-category 

upstaging for each T category, said 

Dr. Ruffini of the division of thoracic 

surgery at the University of Torino 

(Italy). For example, T1a patients with 

MVI had a prognosis similar to that of 

patients with T1b tumors without MVI. 

The number of T3 cases was too small 

to stratify. 

T size was prognostic of survival in the 

MVI-negative patients (P = .03) but was 

not a statistically significant factor in 

MVI-positive patients (P = .9), indicating 

that MVI is indeed a more powerful 

prognosticator, he said. 

The 2009 TNM stresses the importance 

of tumor size as a major prognostic 

factor, but no TNM edition has so far 

included MVI as a major determinant in 

the staging of NSCLC. 

In a multivariate survival analysis 

that included age, sex, histology, grading, 

T-size determinant, MVI, perineural 

invasion, and tumor-infiltrating 

lymphocytes, MVI was a stronger prognostic 

indicator (hazard ratio 1.43, P = 

.02) than T-size determinant (HR 1.06, 

P = .06), Dr. Ruffini said. 

“The use of adjuvant chemotherapy in 

NSCLC patients with MVI may be considered,” 

he said. 

Invited discussant Dr. Mark Socinski 

pointed out that 88% of patients in the 

analysis had 5 cm or smaller tumors, a 

category of patients in which the role of 

adjuvant therapy has been discouraged. 

He highlighted the recent LACE metaanalysis 

of 4,584 NSCLC patients in five 

cisplatin-based adjuvant chemotherapy 

trials that showed an overall significant 

survival benefit of 4% at 5 years, but also 

a potentially negative effect in resected 

stage 1A (Ann. Oncol. 2010 Oct;21 Suppl. 

7:vii196-vii198). 

“We need to make sure [MVI] is easily 

reproducible amongst pathologists, 

and we also clearly need to demonstrate 

that adjuvant therapy can overcome the 

biologic impact of this histopathologic 

finding,” said Dr. Socinski of the 

Lineberger Comprehensive Cancer Center 

at the University of North Carolina, 

Chapel Hill. 

Dr. Ruffini acknowledged that bias 

could have been introduced into the study 

COMMENTARY 

Subtle histologic markers have 

long been championed as a potential 

means to this end, but historically 

gain little traction because 

essentially all are trumped by the 

presence of either metastic disease 

or regional lymph node involvement 

as important risks for recurrence. 

Consequently, the use of more sophisticated, 

but perhaps less reproduceable, 

pathologic markers is 

retricted to node-negative cancers, 

where T (of TNM) descriptors are 

important. This represents only 

about one-quarter of all lung cancers 

detected. 

The authors have proposed microscopic 

vascular invasion (MVI) as 

an important factor that might be a 

reasonable addition to the T aspect 

of the new staging system. Their 

data demonstrate that MVI (found 

emerge as the first-choice for that sliver of the patient 

population, ahead of chemotherapy and other drugs approved 

for first-line NSCLC. 

Genentech’s parent company, Roche, had already 

submitted a bid to expand the drug’s label to the European 

Medicines Agency in June 2010. 

Then, in November 2010, Roche announced that it 

was sublicensing a diagnostic assay for EGFR mutations 

from Genzyme Corporation and collaborating with 

OSI on the development of a 

PCR- based companion diagnostic 

test to identify people with 

non–small cell lung cancer that 

harbors EGFR activating mutations. 

Genentech and OSI plan to talk 

to the Food and Drug Administration 

about possibilities for a 

first-line indication in NSCLC and 

also for the companion diagnostic 

test in development, but timing on these discussions has 

not yet been decided. 

It’s unclear whether the drug would be submitted to 

the FDA simultaneously with a diagnostic test, which was 

the case in a recent approval of a new, narrow indication 

for Herceptin in a particular type of gastric cancer. 

The test in development by Roche and OSI was not 

the same diagnostic used in the EURTAC study, which 

through its retrospective design, use of 

overall survival rather than disease-free 

survival as an outcome measure, and the 

long study period of January 1998 to August 

2008. Prospective validation of MVI 

is underway using the prospective International 

Association for the Study of 

Lung Cancer database, he said. 

The median tumor size among the 512 

patients was 3.4 cm, with 164 classified 

as having T1a (less than 2 cm) tumors, 

123 T1b (2-3 cm), 164 T2a (3-5 cm), 50 

T2b (5-7 cm), and 11 T3 (greater than 7 

cm) tumors. 

The researchers and Dr. Socinski disclosed 

no relevant conflicts. ■ 

in a relatively small cohort of all 

node-negative patients in their 

study) appears to be an important 

risk for mortality. However, the road 

to the perfect staging system is 

paved with new histopathologic 

markers, and few are adopted because 

another one soon emerges 

and it is difficult for pathologists to 

keep up. 

I think that molecular and radiologic 

characterization will eventually 

supplant all such subjective 

histopathologic markers and, within 

the next few years, will make the 

microscope something we’ll be 

telling our grandkids about. 

DR. SUDISH MURTHY is an ACS 

Fellow and surgical director of the 

Center for Major Airway Disease, 

Cleveland Clinic. 

First-Line Tarceva May Benefit NSCLC With EGFR Mutation 

GENENTECH AND OSI PLAN TO 

TALK TO THE FOOD AND DRUG 

ADMINISTRATION ABOUT 

POSSIBILITIES FOR A FIRST-LINE 

INDICATION IN NSCLC. 

was designed and sponsored by the Spanish Lung Cancer 

Group. Genentech said it still needs to validate the 

test used in the EURTAC study using samples from the 

trial, prior to talks with FDA. It’s also unclear at this 

time whether another study beyond EURTAC would be 

needed to expand the U.S. label. 

Genentech did not disclose the magnitude of the benefit 

for progression-free survival – the primary end point 

– in the EURTAC trial. Secondary end points include 

overall survival, 1-year survival, objective response 

rate, and safety profile. 

In the SATURN trial of Tarceva as a maintenance 

therapy for NSCLC, the drug showed only a modest 

PFS benefit for NSCLC patients overall (12.3 weeks for 

the drug versus 11.1 weeks for placebo). Its use as a 

maintenance treatment has proven controversial since 

the FDA approved the indication despite a negative vote 

by an advisory committee. 

However, SATURN showed dramatically better results 

for patients who had EGFR mutations. In this subgroup, 

which accounted for 11% of the total 

population, PFS was 44.6 weeks for the treated group 

versus the 11 weeks for placebo. Based on the data, 

some physician surveys have suggested more willingness 

to use Tarceva as a maintenance treatment in the 

case of EGFR mutations. 

Elsevier Global Medical News and “The Pink Sheet” 

are published by Elsevier. ■

MARCH 2011 • THORACIC SURGERY NEWS CONGENITAL HEART 9 

Pediatric Transplants 

Indications • from page 1 

tients had prior surgical procedures or surgery ranging 

from banding to Fontan operations; 55% of the patients 

were boys; 8% of patients were bridged with either 

ECMO (extracorporeal circulation membrane oxygenation) 

or VAD (ventricular assist devices). 

Overall survival of transplant patients was 81%, 

76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. 

Survival was best in those patients who were transplanted 

for cardiomyopathy (1-, 3-, 5-, and 10-year 

survival of 90%, 84%, 81%, and 81%, respectively) and 

worst in patients with failed palliations for SV anomalies, 

especially failed Fontan procedures (1-, 3-, 5-, and 

10-year survival of 66%, 61%, 61%, and 53%, respectively). 

“Our results demonstrate the high-risk nature of 

transplants in patients with failed palliations for SV 

anomalies, including Fontan procedures performed 

during infancy. As the survival with early palliation for 

SV anomaly patients improves, more centers will be referred 

with these patients who will require transplantation 

at some point,” said Dr. Voeller in an interview. 

“This will not only impact pediatric heart transplant 

programs, but it will also influence adult transplant programs 

as well. Patients following SV palliation, including 

Fontan procedure, are much more difficult patients 

to transplant because of a variety of factors. Risk factor 

analysis will be needed to determine which patients 

might benefit from earlier transplant referral and how 

to better prepare these patient for transplant in order 

to reduce the risk of the procedure,” he concluded. 

Dr. Voeller reported that none of the authors had any 

financial disclosures. ■ 

Good Late Outcomes Seen After 

CABG Plus Adult CHD Repair 



SAN DIEGO – More and more patients with congenital 

heart disease are surviving into adulthood, resulting 

in a growing number of operations performed 

to repair adult congenital heart disease (ACHD). 

Many of these patients also have atherosclerotic coronary 

artery disease that may need to be addressed at 

the time of ACHD surgery, but data on the prevalence 

of coronary artery disease in this population, as well 

as outcomes after such surgery, are limited. 

To address this issue, Dr. John M. Stulak of the 

Mayo Medical School, Rochester, Minn., and his associates 

conducted a study of 122 patients (77 male) 

who underwent concomitant coronary artery bypass 

grafting (CABG) for atherosclerotic coronary 

artery disease (CAD) at the time of ACHD repair. Dr. 

Stulak presented the results at the annual meeting of 

the Society of Thoracic Surgeons. 

Dr. Stulak noted that, based on his findings, “Concomitant 

CABG may be required at the time of repair 

of ACHD. Disease of the LAD [left anterior 

descending coronary artery] is most common, and 

survival is higher when a LIMA [left internal mammary 

artery] graft is used. Late functional outcome 

is good with a low incidence of late angina, MI, or 

the need for percutaneous coronary intervention.” 

The patients, mean age 64 years, had surgery between 

February 1972 and August 2009. A total of 25% 

had angina, 6% had prior myocardial infarction, and 

5% had previous percutaneous intervention. 

The most common primary cardiac diagnoses were 

secundum atrial septal defect (ASD) in 60%, Ebstein 

anomaly in 11%, partial anomalous pulmonary venous 

connection (PAPVC) in 7%, and ventricular 

septal defect (VSD) in 6%. A total of 17% of the patients 

had a prior cardiac operation. 

The most common operations included ASD repair 

in 64%; tricuspid valve surgery (11%), pulmonary valve 

surgery (8%), VSD repair (8%), and PAPVC repair 

(7%). A single bypass graft was performed in 69 patients, 

2 grafts in 32 patients, 3 grafts in 14 patients, 4 grafts in 

5 patients, and 5 grafts in 2 patients. The LIMA was used 

in 57 of 82 patients (70%) with LAD disease. 

The median follow-up was 6 years for 111 available 

patients. During that time, recurrent CAD was reported 

in 9 patients (8%); 8 patients (7%) had angina, and 

5 (4%) had an MI. Six (5%) patients underwent intervention. 

All but 11 patients achieved NYHA functional 

class 1 or 2. The overall survival observed was 76% 

at 5 years, 56% at 10 years, and 33% at 15 years. In those 

patients with LAD disease, 10-year survival was significantly 

higher when LIMA was used (66% vs. 36%). 

Dr. Stulak added the importance of this study is also 

to stress that each treatment approach should be individualized 

whether it is conventional CABG, offpump 

CABG, or a staged hybrid technique with 

percutaneous coronary intervention for CAD. 

Dr. Stulak and his colleagues had no disclosures. ■

10 NEWS FROM THE AATS MARCH 2011 • THORACIC SURGERY NEWS 

May 7 – 11, 2011 

Pennsylvania Convention Center 

Philadelphia, PA 

The 2011 AATS Annual Meeting 

promises to deliver outstanding 

education in the field of thoracic 

and cardiovascular surgery. As in years 

past, participants will have the opportunity 

to attend sub-specialty focused 

courses on Saturday and Sunday prior 

to the Annual Meeting. Several other 

courses on Saturday provide education 

and training for the entire cardiothoracic 

surgical team. 

Saturday, May 7, 2011 

Developing the Academic Surgeon 

Symposium 

Saturday, May 7, 2011 

1:00 p.m. – 5:10 p.m. 

Chair: Bryan F. Meyers, MD, MPH, 

Washington University School of Medicine 

The symposium 

is part of 

an ongoing effort 

to help develop 

the 

Academic Cardiothoracic 

Surgeon. Personal 

success 

stories of sever- 

al CT surgeons 

who have 

achieved fund- 

ed research grants will be augmented 

by discussion of pathways towards extramural 

funded research accessible to 

cardiothoracic surgeons. The faculty 

will identify several options for collaboration 

or mentorship outside the 

field and will detail the true potential 

cost in time and seed money necessary 

to launch and support a new investigator 

towards independence. Other issues 

pertinent to engaging and 

recruiting young surgeons into academic 

cardiothoracic surgery will be covered 

as well. This course will address 

the ABMS Core Competency of Professionalism. 

AATS/STS Adult Cardiac Surgery 

Postgraduate Symposium 

Sunday, May 8, 2011 

7:55 a.m. – 5:00 p.m. 

Chair: John A. Kern, MD, University of 

Virginia 

This symposium will address important 

new developments 

and 

updates in the 

broad field of 

adult cardiac 

surgery, particularly 

in the areas 

of aortic 

and mitral 

valve disease 

and therapies, 

as well as the 

treatment of 

thoracic aortic aneurysms, dissections, 

penetrating ulcers, and intramural 

hematomas. Participants will have a 

better understanding of the impor- 

Attend the 91st AATS Annual Meeting 

DR. BRYAN F. MEYERS 

DR. JOHN A. KERN 

tance of data management and utilization, 

and will hear evidence based recommended 

changes in practice 

patterns, particularly as they relate to 

ischemic heart disease. Participants will 

also hear presentations on the optimal 

use of pre-operative cardiac imaging, 

the optimal treatment of hypertrophic 

cardiomyopathy, techniques for safer 

re-do cardiac surgery and when to consider 

LVAD therapy. Panel discussions 

will follow each session to allow time 

for questions and answers. This course 

will address the ABMS Core Competency 

of Medical Knowledge. 

AATS/STS Cardiothoracic Critical 

Care Postgraduate Symposium 


8:00 a.m. – 5:00 p.m. 

Chairs: Nevin 

M. Katz, MD, 

Johns Hopkins 

University and 

Michael S. Mulligan, 

MD, University 

of 

Washington 

Medical Center 

Emphasis will 

be placed on 

the unique specialty 

aspects of 

Cardiovascular- 

Thoracic 

(CVT) Critical 

Care including 

ECMO, mechanicalsupport, 

transplant 

perioperative 

care, and management 

of patients 

after 

aortic surgery. 

Fundamental 

DR. NEVIN M. KATZ 

DR. MICHAEL S. 

MULLIGAN 

areas of critical care will be presented 

in a case related format in order to 

practically relate them to specific cardiothoracic 

applications. These areas 

include: evidence based blood conservation 

and transfusion guidelines, nutritional 

support, renal replacement 

therapies, optimal antibiotic utilization, 

vasopressor and inotrope support, 

and arrhythmia management. 

Significant challenges exist to the establishment 

of cardiothoracic critical 

care units at different institutions. A 

review of relevant issues and potential 

solutions will be discussed in an open 

forum and hemodynamic simulation 

luncheon session. Attendees are encouraged 

to share the issues and concerns 

that have arisen at their own 

institutions. This course will address 

the ABMS Core Competency of Patient 

Care. 

AATS/STS Congenital Heart Disease 



7:55 a.m. – 5:00 p.m. 

Chair: Pedro J. del Nido, MD, Children’s 

Hospital Boston 

Participants will be provided data to assist 

them in understanding techniques 

for valve reconstructioncovering 

the 

spectrum of 

congenital and 

acquired valve 

defects, and the 

comparative results 

versus replacement 

in 

children. Vari- DR. PEDRO J. DEL NIDO 

ous options for 

reconstruction of the regurgitant aortic, 

mitral, and tricuspid valve will be 

presented. Faculty will stress the impact 

of timing of surgery on late outcomes 

in pulmonary valve insertion 

and provide an overview of non-invasive 

imaging techniques for assessing 

valve function. 

This course will address the ABMS 

Core Competency of Patient Care. 

AATS/STS General Thoracic Surgery 



7:55 a.m. – 5:00 

p.m. 

Chair: David R. 

Jones, MD, University 

of Virginia 

This symposium 

features a 

number of educationalfor- 

mats including 

didactic lec- DR. DAVID R. JONES 

tures, “How-I- 

Do-It” sessions, and a debate. In 

addition to other topics, the current 

status of the management of Pancoast 

tumors, stage IIIA NSCLC, esophageal 

diverticuli, and gastroesophageal cancers 

will be reviewed by experts in the 

field. In addition, surgeon experts will 

discuss technical advances and how to 

avoid potential pitfalls for a number 

of operative procedures including thoracoscopic 

thymectomy, VAMLA and 

TEMLA, VATS segmentectomy, superior 

vena cava resection, and reconstruction 

and chest wall resection and 

reconstruction. Finally, important updates 

on the current status of lung 

cancer screening as well as targeted 

therapies for NSCLC will be presented. 

This course will address the 

ABMS Core Competency of Medical 

Knowledge. 

Plenary Sessions and Special 

Lectures: 

Don’t miss the outstanding plenary sessions 

on Monday and Tuesday, May 9th 

and 10th, featuring presentations in all 

three cardiac surgery sub-specialties selected 

by the Program Committee. Of 

particular interest is the opening paper 

on Monday morning, Late Breaking 

Clinical Trial: Frequency and Severity 

of Neurologic Events after Aortic 

Valve Replacement or Transcatheter 

Aortic Valve Implantation in High Surgical 

Risk Patients with Aortic Stenosis: 

The PARTNER Trial Stroke 

Substudy, presented by D. Craig Miller, 

MD on behalf of the PARTNER Trial 

Investigators. 

The Basic Science Lecture will take 

place on Monday morning and will be 

delivered by Susan B. Shurin, MD, of the 

National Heart, Lung and Blood Institute 

at the NIH, who will discuss “Public 

Support of Biomedical Research.” The 

Honored Speaker Lecture will take place 

on Tuesday morning and will be delivered 

by Michael J. Mack, MD of Baylor 

Health Care System, who will discuss 

“The Only Constant is Change.” 

Another important session to attend 

is the Presidential Address on Monday 

morning. Irving L. Kron, MD, of the 

University of Virginia, will speak to fellow 

members and attendees on the important 

topic of “Surgical Mentoring.” 

Reserve your space at the AATS Annual 

Meeting, register for Saturday and 

Sunday symposia at www.aats.org/annualmeeting/Registration-and-housing. 

Target Audience 

The AATS Annual Meeting is specifically 

designed to meet the educational 

needs of: 

• Cardiothoracic Surgeons 

• Physicians in related specialties including 

Cardiothoracic Anesthesia, 

Critical Care, Cardiology, Pulmonology, 

Radiology, Gastroenterology, Thoracic 

Oncology and Vascular Surgery 

• Fellows and Residents in Cardiothoracic 

and General Surgical training programs 

•Nurses, Physician Assistants, Perfusionists 

and Allied Health Professionals 

involved in the care of cardiothoracic 

surgical patients 

•Medical students with an interest in 

cardiothoracic surgery 

AATS Annual Meeting Accreditation 

The American Association for Thoracic 

Surgery is accredited by the Accreditation 

Council for Continuing Medical 

Education to provide continuing medical 

education for physicians. 


Surgery designates this educational activity 

for a maximum of 35 AMA PRA 

Category 1 Credits. Physicians should 

only claim credit commensurate with 

the extent of their participation in the 

activity. 

This program will be submitted to the 

American Academy of Nurse Practitioners 

for continuing education credit. 

Conference organizers plan to request 

AAPA Category I CME credit from 

the Physician Assistant Review Panel. 

Total number of credits yet to be determined. 

For additional information please 

visit www.aats.org or contact: 

American Association for Thoracic 

Surgery 

900 Cummings Center 

Suite 221-U, Beverly, MA, USA 01915 

Telephone: (978) 927-8330 

Fax: (978) 524-8890 

E-mail: meetings@aats.org

MARCH 2011 • THORACIC SURGERY NEWS NEWS FROM THE AATS 11 

Visit New York for the 

2011 MITRAL CONCLAVE 

MITRAL CONCLAVE 

May 5 – 6, 2011 

Program Director 

David H. Adams, MD 

Mount Sinai School of Medicine 

New York, New York 

Program Committee 

Ottavio R. Alfieri, MD 

Milan, Italy 

W. Randolph Chitwood, Jr., MD 

Greenville, North Carolina 

Robert A. Dion, MD 

Genk, Belgium 

A. Marc Gillinov, MD 

Cleveland, Ohio 

Friedrich W. Mohr, MD 

Leipzig, Germany 

The 2011 MITRAL CONCLAVE will 

bring the world’s leading figures in 

mitral valve disease together for two 

days to discuss the latest information 

regarding management guidelines, 

imaging, pathology, minimally invasive 

approaches, percutaneous approaches, 

surgical techniques, 

devices, and long-term results. 

Faculty presentations of the latest 

available data, techniques, and state 

of the art reviews will be supplemented 

by abstract and video presentations 

covering: 

� Degenerative Valve Disease 

� Mitral Regurgitation in Heart 

Failure 

� Ischemic Mitral Regurgitation 

� Mitral Valve Endocarditis 

� Congenital Mitral Valve Disease 

� Other Mitral Valve Disease 

� Repair Techniques & Strategies 

� Mitral Valve Replacement 

� Long Term Outcomes 

� AFib in Mitral Valve Disease 

� Tricuspid Valve Disease 

Log on to the 2011 MITRAL CON- 

CLAVE Website at www.aats.org/mitral 

to view the Preliminary 

Program and faculty listing. Register 

by March 28, 2011, and save. 



Council for Continuing 

Medical Education to provide continuing 

medical education for physicians. 

This activity has been approved 

for AMA PRA Category 1 Credits. 

Online Articles in Press in the JTCVS 

The Journal of Thoracic and Cardiovascular Surgery has greatly expanded its 

online articles in press section. At last count, more than 150 articles were 

available for subscribers to view and cite, months before print publication. 

The cutting edge of cardiothoracic surgical science is now just a click away. 

Go to www.jtcvs.com/inpress to view these articles today! ■ 

2011 AATS Meetings & 

Sponsored Events 

May 5 - 6 

Mitral Conclave 

Sheraton New York Hotel and 

Towers 

New York, NY 

May 7 - 11 

AATS 91st Annual Meeting 


Philadelphia, PA 

May 26 

AATS/ASCVTS Postgraduate 

Course* 

Hilton Phuket Arcadia Resort & Spa 

Phuket, Thailand 

September 8 - 10 

International Society for Rotary 

Blood Pumps Annual Meeting * 

Marriott Downtown 

Louisville, Kentucky 

September 22 - 24 

Masters of Minimally Invasive 

Thoracic Surgery* 

Waldorf Astoria Orlando 

Orlando, Florida 

October 13 - 15 

2011 Heart Valve Summit: 

Medical, Surgical and Interventional 

Decision-Making 

JW Marriott Chicago 

Chicago, Illinois 

October 20 - 21 

7th Triennial Brigham Cardiac 

Valve Symposium* 

Fairmont Copley Plaza Hotel 

Boston, Massachusetts 

* = Co-Sponsored by AATS 

Save the Date for the 

2011 Heart Valve Summit 

2011 Heart Valve Summit: 

Medical, Surgical and 

Interventional Decision-Making 

October 13 – 15, 2011 

JW Marriott Chicago 

Chicago, IL 

Program Directors 

David H. Adams, MD, FACC 

Steven F. Bolling, MD, FACC 

Robert O. Bonow, MD, MACC. 

Howard C. Herrmann, MD, FACC 

Nurse Planner: Michele Langenfeld, 

RN, MS 

PROGRAM OVERVIEW 


Surgery (AATS) and the American College 

of Cardiology Foundation (ACCF) 

have partnered once again to bring you 

the only educational program that addresses 

valvular heart disease from a cardiology 

and surgical point-of-view, the 

2011 Heart Valve Summit. 

Using an integrative approach to managing 

medical, surgical and interventional 

challenges in valvular heart disease, 

world renowned cardiologists and cardiac 

surgeons will provide clinically relevant 

information on the current and future directions 

in valvular heart disease. This 

unique, inter-disciplinary program will include 

real world, interactive case-based 

patient management discussions, review 

of current practice guidelines, and fo- 

cused breakouts for cardiologists, cardiac 

surgeons, nurses and physician assistants. 

TARGET AUDIENCE 

Cardiologists, interventional cardiologists, 

cardiothoracic surgeons, internists, nurses, 

physician assistants and all health care 

professionals involved in the evaluation, 

diagnosis and/or management of patients 

with valvular heart disease are strongly 

encouraged to attend this program. 

ACCREDITATION 

� Physicians 



Council for Continuing Medical Education 

to provide continuing medical 

education for physicians. 

This activity has been approved for 

AMA PRA Category 1 Credits. 

� Nurses 

The American College of Cardiology 

Foundation is accredited as a provider of 

continuing nursing education by the 

American Nurses Credentialing Center’s 

Commission on Accreditation. 

Register today at www.aats.org/valve to 

see first-hand why this program continually 

receives high-rankings and has been 

referred to as “one of the best meetings 

I have ever attended – practical, patientoriented 

and the lecturers really had true 

clinical experience.” 

Cardiothoracic Surgery Exploring 

Collaborative Clinical Research Opportunities 

An AATS and NHLBI Workshop: Save the Date: April 26-27, 2011 

To be held at the Hyatt Bethesda Marriott, Bethesda, Maryland. 

See full agenda, faculty and REGISTER online at www.AATS.org 

Sample topics include: Structural Valve Disease, Ischemic Heart Disease, Therapies 

for Advanced Heart Failure, Neuroprotection, Endografts, and Arrhythmias. 

The Board and Commissioners of CAAHEP want to thank the 

for joining us as a partner 

in the important process 

of accrediting perfusion 

educational programs. 

The quality assurance 

that accreditation of 

these programs promotes 

protects patients and students 

as well as enhancing 

the profession. 

American Association 

for Thoracic Surgery 

DR. HAROLD LAZAR, 

REPRESENTATIVE TO 

CAAHEP AND 

PERFUSION AFFAIRS 

DR. ERLE AUSTIN, 

REPRESENTATIVE TO 

CAAHEP

12 NEWS FROM THE AATS MARCH 2011 • THORACIC SURGERY NEWS 

Apply for AATS Research 

And Graham Awards 

AATS Online Award Applications 

Now Available at www.aats.org, 

Deadline July 1, 2011 

David C. Sabiston Research Scholarship 

2012 – 2014 provides an opportunity 

for research, training, and 

experience for North American 

surgeons committed to pursuing 

an academic career in cardiothoracic 

surgery. 

• Research program must 

be undertaken within the 

first three years after completion 

of an approved 

North American cardiothoracic 

residency. 

• Applications for the 

scholarship must be submitted 

during the candidate’s first two 

years in an academic position. 

• The scholarship will begin July 

1, 2012 and conclude on July 1, 

2014. 

• The Scholarship provides an annual 

stipend of $80,000 per year 

paid to the host institution for direct 

salary support and related research 

expenses. 

Deadline: July 1, 2011 

Evarts A. Graham Memorial 

Traveling Fellowship, 2012-2013 

grants support for training of international 

surgeons who have been 

regarded as having the potential for 

later international thoracic surgical 

leadership. 

• Candidate must be a non- 

North American who plans a 

cardiothoracic surgery training 

program in a North 

American center and who 

has not had extensive (exceeding 

a total of six 

months in duration) clinical 

training in North America 

prior to submitting an 

application. 

• Candidate should have 

completed his/her formal training 

in general surgery and in thoracic 

and cardiovascular surgery, but 

should not have reached a senior 

position. 

• The Fellowship provides a 

stipend of $75,000 US, a major portion 

of which is intended for living 

and travel expenses incurred when 

visiting other medical centers. 

Deadline: July 1, 2011 

Register and Reserve Housing Now! 

www.aats.org 

A ATS 91 ST 

ANNUAL MEETING 

May 7–11, 2011 

Philadelphia, PA, USA 


New Tool to Assess Fields 

Covered by CSR Study Sections 

Anew tool to assess the fields of science 

covered by CSR’s review 

groups holds the promise of helping us 

better develop and manage them. 

Mapping publication data: The Center 

for Scientific Review recently used data 

on how papers resulting from funded 

applications cite references across different 

research specialties to construct 

linkage maps, visually illustrating the 

connections between diverse disciplines 

covered by some of our study sections. 

This bibliographic analysis revealed that 

there are differences in the extent of interdisciplinarity 

across study sections. 

A study section with a sharp focus or 

Keep up with the newest developments 

in cardiothoracic surgery and 

maintenance of certification requirements. 

Earn journal-based continuing 

medical education (CME) credits from 

reading The Journal of Thoracic and Cardiovascular 

Surgery! 

Choose a CME activity in your area of 

interest at a time that is convenient for 

you: 

s� 

s� 

s� 

s� 

s� 

s� 

s� 

Featuring: 

Cutting-edge Skills Courses 

A Full-Day PA/NP/Perfusion Course 

AMERICAN ASSOCIATION 

FOR THORACIC SURGERY 

We Model Excellence 

Developing the Academic Surgeon Symposium 

High Performance Teams in the Operating 

Room: Using the NOTSS Program to Improve 

Communication, Understanding and Performance 

AATS/STS Postgraduate Symposia 

Building the Hybrid OR Program 

high interdisciplinarity present different 

review challenges. Knowing the degree 

and interdisciplinarity of the work 

emerging from funded grants reviewed 

by each study section may help CSR (1) 

keep pace with changing science and 

design or redesign effective study sections; 

(2) identify the best review platform; 

(3) recruit reviewers; and (4) 

assign applications to study sections 

and reviewers. 

For more information along with graphs 

mapping the contrasting study sections, 

please visit http://cms.csr.nih.gov/ 

NewsandReports/PeerReviewNotes. ■ 

Continuing Medical Education in the JTCVS 

� Surgery for Acquired Cardiovascular 

Disease 

� General Thoracic Surgery 

� Surgery for Congenital Heart Disease 

Go to http://cme.ctsnetjournals.org to access 

CME activities. Read a CME-designated 

article; take the CME activity test 

and evaluation quiz; and print your own 

certificate. ■ 

AATS Reception - National Constitution Center 

AATS Annual Meeting Accreditation 

The American Association for Thoracic Surgery is accredited by the 

Accreditation Council for Continuing Medical Education to provide 

continuing medical education for physicians. 

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

MARCH 2011 • THORACIC SURGERY NEWS DEVICES, DRUGS & TRIALS 13 

PROTECT Opens Door to Biomarker-Guided HF Therapy 

BY BRUCE JANCIN 


CHICAGO – Using N-terminal prohormone 

brain natriuretic peptide levels to 

guide therapy in patients with systolic 

heart failure proved superior to standard 

of care management in terms of cardiovascular 

event rates, quality of life, and 

echocardiographic parameters in the randomized 

prospective PROTECT trial. 

“If duplicated in larger cohorts, treatment 

guided by NT-proBNP may represent 

a new paradigm for heart failure 

care,” Dr. James L. Januzzi Jr. said at the 

annual scientific sessions of the American 

Heart Association.. 

PROTECT (the ProBNP Outpatient 

Tailored Chronic Heart Failure Therapy 

study) was a single-center unblinded trial 

of 151 patients with systolic heart failure 

and a mean left ventricular ejection 

fraction of 27%. They were randomized 

to standard guideline-driven management 

on the basis of heart failure signs 

and symptoms or to the same approach 

with the added goal of reducing NTproBNP 

levels to 1,000 pg/mL or less, a 

threshold previously shown to predict 

risk in heart failure patients. 

Participants were scheduled for quarterly 

clinic visits, with extra ones as needed 

to achieve therapeutic goals, said Dr. 

Januzzi, director of the cardiac intensive 

care unit at Massachusetts General Hospital, 

Boston. 

The study was halted early for ethical 

reasons after 10 months. At that point a 

total of 100 cardiovascular events – worsening 

heart failure, heart failure hospitalization, 

acute coronary syndrome, 

ventricular arrhythmias, cerebral ischemia, 

or cardiovascular death – had 

If duplicated in 

larger cohorts, 

NT-proBPN–guided 

treatment may 

represent a new 

paradigm for 

heart failure care. 

DR. JANUZZI 

occurred in the standard-treatment group, 

compared with 58 events in patients on 

NT-proBNP–guided therapy. The major 

difference between the two study arms 

was the sharply lower likelihood of worsening 

heart failure or heart failure hospitalization 

in the NT-proBNP–guided arm. 

Importantly, the reduction in cardiovascular 

events was similar in patients over 

age 75 and in those who were younger. 

The secondary outcome of quality of 

life, assessed using the Minnesota Living 

with Heart Failure Questionnaire, also 

showed significantly greater improvement 

in the guided-treatment arm. In all, 

61% of subjects in the NT-proBNP–guided 

arm achieved at least a 10-point improvement 

over baseline, considered 

clinically meaningful, compared with 

39% on standard management. 

The guided-treatment group also did 

significantly better in terms of secondary 

echocardiographic end points, with larger 

improvements in left ventricular 

ejection fraction and in ventricular remodeling 

as reflected by changes in LV 

end-systolic and end-diastolic volume index, 

the cardiologist continued. 

NT-proBNP–guided therapy proved 

safe and was well tolerated, with no significant 

increase in adverse events. 

Patients in the guided-treatment arm 

had a median of six clinic visits, compared 

with five with standard management. The 

median baseline NT-proBNP level in the 

guided-therapy arm was 2,344 pg/mL. It 

fell to 1,125 pg/mL, with 44% of subjects 

in the guided-therapy arm attaining an 

NT-proBNP of 1,000 pg/mL or less. 

Up-titration of heart failure medications 

was common in both study arms, 

but was significantly greater in the NTproBNP 

group. A total of 63% of patients 

in the guided-therapy arm were 

placed on an aldosterone blocker, com- 

pared with 45% of controls. 

Session cochair Dr. Gregg C. Fonarow 

said in an interview that he views PRO- 

TECT as a successful proof-of-concept 

study. But before biomarker-guided treatment 

of heart failure becomes part of 

guideline-recommended, routine outpatient 

care, it will be necessary to see if the 

Massachusetts General Hospital experience 

can be extended to other settings, including 

primary care practices, where 

many patients with heart failure receive 

their treatment. This will require a large 

multicenter trial with a diverse group of 

clinicians; randomization by site; and hard 

clinical end points, including mortality. A 

proposal for such a study has been presented 

to the National Heart, Lung, and 

Blood Institute for funding consideration. 

“It’s a large and expensive trial, but the 

impact is potentially profound,” said Dr. 

Fonarow, professor of medicine and director 

of the Ahmanson-UCLA Cardiomyopathy 

Center, Los Angeles. 

“Given the costs of heart failure and the 

tremendous number of outpatient visits 

for this disease, if we truly had a well-validated 

guide using biomarkers, that 

would be a phenomenal advance.” 

The PROTECT trial was sponsored in 

part by Roche Diagnostics. Dr. Januzzi 

declared he serves as a consultant to and 

speaker for the company. ■

14 MARCH 2011 • THORACIC SURGERY NEWS 

CLASSIFIEDS 

Also available at www.imngmedjobs.com 

FELLOWSHIPS 

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 careycr@upmc.edu 

Disclaimer 

THORACIC SURGERY NEWS assumes the statements made in classified advertisements are accurate, 

but cannot investigate the statements and assumes no responsibility or liability concerning 

their content. The Publisher reserves the right to decline, withdraw, or edit 

advertisements. Every effort will be made to avoid mistakes, but responsibility cannot be 

accepted for clerical or printer errors. 

CLASSIFIED DEADLINES 

AND INFORMATION: 

Contact: Robert Zwick 

(973) 290-8226 

Email ad to: 

r.zwick@elsevier.com 

R 

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So You Can Do More 

**Due to stronger knife bar, higher compression force, and improved firing mechanism. 1. Indicated tissue thickness range: Endo GIA black reload (2.25mm to 3.00mm) vs. Echelon Flex* green reload (2.00mm). 

COVIDIEN, COVIDIEN with logo, and Covidien logo, are U.S. and/or internationally registered trademarks of Covidien AG. *Trademark of its respective owner.

To learn more and request a demonstration of 

Tri-Staple Technology, visit www.tristaple.com. 

COVIDIEN, COVIDIEN with logo, and Covidien logo, are U.S. and/or internationally registered trademarks of Covidien AG. 

Get in the thick of it 

Covidien’s new black reloads enable surgeons to 

staple into extra-thick tissue previously beyond 

the indications of any MIS stapler. 

Innovating More 

So You Can Do More

PROM Score Predicts Long- Term Survival - Thoracic Surgery News

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