Embracing Innovation: A Surgical Resident’s Experience at the Southern Thoracic Surgical Association 68th Annual Meeting

Donald D. Chang, MD PhD

Department of General Surgery, Henry Ford Hospital, Detroit, Michigan. Correspondence: dchang1@hfhs.org

“Before our able discussant embarks

On his salient and probing remarks

I happen to have a rhyme

Not that I’m buying time

COVID you were never welcomed here

You’ve taken so much we hold dear

But we’re resilient and strong

In a case that can’t go wrong

We surgeons are in the bullpen

Gladly back at the Southern again”

Dr. EH Stephens, with permission

STSA 68th Annual Meeting

November 4, 2021

The Southern Thoracic Surgical Association (STSA) is a regional society whose mission is to support members of the cardiothoracic community. Since 1954, STSA has held its annual meeting to promote the scholarly work and networking of its members. This year, I had the privilege of attending the 68th Annual Meeting as a James W. Brooks scholar, named in honor of the Society’s 23rd President for his lifelong support and contribution to the society.

This year’s meeting was held in Atlanta, Georgia and brought together over 300 attendees, including active STSA members (122), faculty (75), and trainees (92) which included fellows, residents, and medical students. Importantly, 25% were women, who had a formidable presence yet remained underrepresented, underscoring the need for further support and sponsorship of women in our field. Attendees came from all over the country with over 30 states represented. Over the four-day meeting, 188 presentations and posters would be shared as we discussed some of the latest developments in cardiothoracic surgery. Beyond the science, we also heard from our leaders in the field and celebrated accomplishments.

Here, I share my experience as a resident attendee and offer some advice for others interested in attending in the future. As with most conferences, parallel sessions transpired simultaneously so unfortunately, I am not able to provide a comprehensive summary, but instead will share selected highlights. Complete details on this year’s presentations and abstracts can be found on the STSA website (https://stsa.org/annualmeeting/).

Day 1, Wednesday, November 4

The meeting opened Wednesday evening with a reception followed by the Postgraduate Course series of video case presentations themed “How I Do It and Avoiding Pitfalls” with breakout rooms for cardiac, congenital, and thoracic surgery. I attended the cardiac room where highlights included techniques on aortic valve annular enlargement presented by Dr. Bo Yang (University of Michigan), Minimally Invasive Cardiac Surgery Carotid Artery Bypass Graft (MICS CABG) from Dr. Marc Ruel (University of Ottawa Heart Institute), and convergent procedures for treating atrial fibrillation by Dr. Faraz Kerendi (Cardiothoracic & Vascular Surgeons, Austin). Perhaps since many of us had not enjoyed the vigor of in-person meetings for a while, the discussion was particularly animated and engaging. Live audience polls

during the discussion revealed that even amongst the most seasoned attendings, surgical approaches varied – an observation that impressed upon me just how complex this field can be.

Day 2, Thursday, November 5

The second day opened with the Robert M. Sade Ethics Lectureship moderated by Dr. Sade (Medical University of South Carolina). This session was comprised of a debate centered around a clinical case of a 60-year-old male recently diagnosed with lung cancer who requests surgical intervention but refuses radiotherapy and continues smoking. Dr. Stephanie Chang (NYU Langone Health) and Dr. Mark Orringer (University of Michigan) argued for the Pro (to operate) and Con (not to operate) sides, respectively. Both parties presented intriguing arguments themed around the tenets of ethics (Beneficence, Nonmaleficence, Autonomy, Justine) which made for a great discussion and reminded me that as surgeons, knowing when not to operate is just as important as knowing the operation itself.

The First Scientific Session followed, beginning with Dr. Mark Bleiweis’s (University of Florida Health) presentation in which he demonstrated how surgical palliation and ventricular assist device (VAD) insertion for hypoplastic left heart syndrome (HLHS) or hypoplastic right heart syndrome (HRHS) in preparation for heart transplant was a viable treatment option. Dr. Vinod Thourani then presented on the differences in using measured versus predicted indexed effective orifice area to define prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) and demonstrated that measured PPM, which is the metric used in transcatheter aortic valve replacement (TAVR) clinical trials, overestimates PPM severity. Both Dr. Bleiweis and Dr. Thourani were later awarded the best congenital and adult cardiac presentation, respectively.

Other memorable moments included when Dr. Elizabeth Stephens (Mayo Clinic), after presenting on outcomes of reoperations on patients with Ross procedure over a 30-year period, concluded her talk with a poetic interlude shared above with her permission. Another memorable talk was delivered by Dr. Clauden Louis (University of Rochester), who shared survey findings on factors impacting CT interest amongst integrated and general surgery residents. Mentorship was reported to be a major determinant for choosing a career in CT surgery, and in the discussion that followed his talk, I was bolstered by witnessing how many surgeons participated and similarly shared their concerns in training young trainees.

The Harold Urschel History Lectureship then followed with Dr. Jeffrey Jacobs (University of Florida) delivering a memorial lecture on Dr. George Ronald Daicoff, Sr, who passed last year. Dr. Daicoff was a true legend in congenital heart surgery and he was a founding member of the Congenital Heart Surgeons’ Society. In 1971, he won the STSA best manuscript award for research describing intraoperative evaluation of surgical systemic-to-pulmonary shunts (Daicoff, 1971). This seminal paper stands out in today’s publishing landscape for its remarkable succinctness as it only contains 8 references, 1 figure, and 1 author! Dr. Daicoff was fiercely devoted to STSA and he was still in attendance at age 89 in 2019. Notably, because of his enormous contributions, the STSA best congenital heart surgery presentation award now bears his namesake. Dr. Jacobs delivered a stirring tribute, and it was a privilege to learn about Dr. Daicoff’s life.

The President’s Invited Lecture followed with Dr. Laurence Sperling (Centers for Disease Control) who spoke on the impact of COVID-19 on cardiovascular care and disease – bringing to forefront a pandemic very much part of our current climate as Dr. Sperling delivered his talk remotely given CDC travel restrictions.

Next came one of the most anticipated talks of the meeting, the Presidential Address by Dr. Vinod Thourani. After a moving introduction by Dr. Dan Miller, Dr. Thourani then shared insights into his journey and how innovation and quality are paramount to the advancement of cardiothoracic surgery in his address titled “The Marriage Between Innovation and Quality: Sometimes a Bumpy Road but Worth the Sacrifices”. Dr. Thourani shared with us his own story of perseverance, traveling as far as China to learn endovascular techniques. We heard of the story of how Dr. Charles Bailey failed four times before successfully performing the first mitral commissurotomy in 1948 and how he then presented his patient on post-operative day 7 at the American College of Chest Physicians, a thousand-mile journey by rail at the

time. Dr. Thourani cautioned us that not all innovations are progressive, citing the historical remedy of scorching one’s head to treat epilepsy. And he reminded us that our successes are achieved on the background of the unconditional support we receive from mentors, family, and loved ones. Dr. Thourani delivered an inspirational Presidential Address and received a well-deserved, prolonged standing ovation.

Day 3, Thursday, November 6

Day 3 opened with the Fourth Scientific Session series and I attended the Cardiac Mitral Valve (MV) Symposium. Dr. Edward Percy (Brigham and Women's Hospital) opened the session by sharing their findings comparing MV repair outcomes between high (≥25) and low volume (<25) surgeons at their institution and showed that, despite longer cross clamp times and higher rates of conversion for low-volume surgeons, there was no difference in mortality or morbidity compared to high-volume MV repair surgeons. This was followed by Dr. Tom Nguyen (University of California, San Francisco) who shared 3-year outcomes on over 4,200 Medicare patients that underwent MV repair for degenerative mitral regurgitation. His findings revealed low re-intervention rates (~2%) while patients with concomitant tricuspid valve repair or atrial fibrillation (AF) ablation had higher mortality and cardiac re-admission rates. The subsequent talks were invited lectures on various approaches of MV repair and replacement including the transcatheter landscape as discussed by Dr. Gilbert Tang (Mt. Sinai, New York) and Dr. Gorav Ailawadi (University of Michigan). Dr. Kevin Accola (AdventHealth, Orlando) shared insights on choosing ring prosthesis in MV repair and Dr. Matthew Romano (University of Michigan) discussed the latest updates on when to perform concomitant tricuspid valve repair. These invited lectures highlighted the rapidly evolving landscape and technology available for MV repair and underscored Dr. Thourani’s Presidential message for surgeons to stay afront of innovation.

The late morning general session was then highlighted by three fantastic talks. First, the annual Kent Trinkle Educational Lectureship was delivered this year by Dr. Richard Prager (University of Michigan). Dr. Prager took us on a historical journey where he illustrated the contributions University of Michigan faculty towards the field, including Dr. Herbert Sloan, the legendary surgeon who pioneered adult and pediatric cardiac surgery.

Second, was an invited lecture by Brian Ferguson, a former Navy SEAL and founder of Arena Labs, who spoke on optimize performance as surgeons and the application of lessons learned from Olympic athletes, military special forces, and high endurance performers. He shared the interesting observation that while most professions spend the majority of time training before a performance, surgeons are inverted: the majority of our “training” time is actually accrued while operating in live situations. His talk shared some valuable tips and insight into how we, as surgeons, can perform and operate at our optimal performance.

The last invited lecture was by Dr. William Cohn (Texas Heart Institute) titled “Pathways in Innovation”. Dr. Cohn started off by illustrating how many of the innovations in CT surgery were rooted with simple starts, often with resources one can find in their own home. He showed the infamous picture of Dr. DeBakey designing the first prototype of a prosthetic aortic graft using his wife’s sewing machine and shared the story of how Dr. Tom Fogarty first tested his idea for balloon embolectomy while still a medical student. Dr. Cohn then shared his own remarkable journey from how he used kitchen spoons to prototype what would eventually become the Genzyme off-pump coronary artery bypass retractor system. His subsequent inventions including the NextStitch suture chain and the SentreHEART LARIAT percutaneous atrial ligation device, both of which also had origins rooted in prototypes developed in part at his home. I was struck by how simple his ideas often were and how, with just the supplies available at a local store or at home, he could bring an idea from conception to application. His talk inspired me to think outside the box and adopt a more active stance to look for creative opportunities in my residency training

The Fifth scientific session was held in the afternoon with a strong representation with resident presentations including Dr. John Duggan (Walter Reed Medical Center) who shared their findings on 30-day postoperative pulmonary complications in veterans after undergoing video assisted thoracic surgery, Dr. Felix Orelaru (St. Joseph, Ann Arbor) who discussed aortic root disease progression after Type A

dissection surgery, and Dr. Jacqueline Olive (Duke University) who shared her research on factors influencing female and minority matriculation into integrated thoracic residencies.

The evening brought on another highlight of the meeting, the Dinner Gala Reception. This formal event celebrated the past few days with awards handed out for best congenital paper (Daicoff Award), best adult cardiac paper (Clifford Van Meter Award), best thoracic paper (Carolyn Reed Award), and best resident presentation (Hawley H. Seiler Award). Other awards included the STSA Inspiration Award given to recognize a member who excelled in mentorship, the Osler Abbott Award for the individual who exemplified “discussionmanship”, and the Tiki Award given for the most memorable slide. Dr. Dan Miller was formally inducted as the new STSA president and, in an exciting announcement, Dr. Melanie Edwards was announced as the newly elected second vice present. After the awards and dinner, the evening then progressed to a fun night of relaxing and socializing. In a particularly meaningful gesture, Dr. Thourani had arranged for the same band that played at his wedding to provide the musical entertainment, making the evening a true celebration by all accounts.

Day 4, Saturday, November 6

The last day of the meeting started off with the Postgraduate Course sessions on “Hot Controversies” with breakout rooms for cardiac, congenital, and thoracic surgery. In the cardiac breakout room which I attended, topics discussed included surgical versus transcatheter management of mitral annular calcification, the undertreatment of AF, mini-VAD versus full sternotomy VAD, and a memorable debate between Dr. Tom MacGillivray and Dr. Tom Nguyen on whether to recommend a SAVR or TAVR for low-risk patient needed aortic valve replacement.

Next, Dr. Vinod Thourani hosted a “Legend on Legend” interview with Dr. Michael Mack (Baylor Scott and White) and Dr. Joseph Bavaria (University of Pennsylvania). During this interview, Dr. Mack and Dr. Bavaria shared with us their upbringings, how they chose this career, and lessons they learned along the way. Dr. Thourani’s last question in the interview was what they would want people to say with regard to their legacy, to which both replied that they made an impact and difference, a fitting remark as this interview left a lasting impression on all of us in the audience.

Dr. Felix Fernandez (Emory University) then shared with us updates on the STS Database followed by Dr. John Calhoon (University of Texas Health Science Center) who gave us a glimpse to the future by framing the current resident training landscape. Lastly, the 68th annual meeting concluded with current STS President Dr. Sean Grondin (University of Calgary) speaking on leadership and imparting practical lessons and tips on how to be an effective leader.

Closing Thoughts and Reflections

As trainees, conferences can sometimes be overwhelming. The sheer number of abstracts and presentations coupled with crowds of unfamiliar faces can displace most residents. The STSA annual meeting distinguishes itself as a conference that goes against this grain and emphasizes inclusivity and collegiality. Indeed, in most years attendees will bring their families along and it is not uncommon to see children around the conference sites.

Similar to residency training, mentorship during a conference is key for optimizing the experience. A conference mentor can help a resident navigate the complex itinerary of a conference and provide tailored advice to the trainee’s interest. I was fortunate to have two mentors: Dr. Scott LeMaire (Figure 1) and Dr. Mara Antonoff who, while unfortunately unable to attend, continued to provide guidance remotely. By serving as mentors, they were able to help distill complex surgical topics and discussions into understandable teaching points for me.

In contrast to large scale conferences where fostering relationships may be difficult, the smaller scale of STSA promoted a strong sense of family and community that was reflected in the bonds we created amongst trainees (Figure 2). The opportunity to connect with other residents across the country and share our experiences not only allowed for new friendships but also incited new ideas and discussions

surrounding the future of CT surgery. All of us agreed that this conference ranked as one of the most memorable in terms of camaraderie and mentorship and building these relationships with my peers strengthened my resolve to pursue CT surgery.

During the Gala dinner, I sat next to Dr. Constantine “Gus” Mavroudis (Peyton Manning Children's Hospital, Ascension Medical Group) who remarked that STSA not only has exceptional members, but also produces quality research - a sentiment I believe captures the essence of what makes the STSA conference special.

The decision to pursue CT surgery is not easy. And in today’s rapidly evolving surgery practice, the resolve to stay committed to this career can be even more challenging. Conferences such as the STSA Annual Meeting help ground trainees such as myself on why this career remains our passion. From historical lectures to inspiring talks on leadership and innovation, I began to grasp the true impact CT surgeons have. Their reach goes far beyond the operating room. They are leaders like Dr. Mack and Dr. Bavaria, innovators such as Dr. Cohn, and lifelong contributors to the field as exemplified by Dr. Daicoff. Seeing the multi-faceted sides of CT surgery manifest over the conference not only reminded me of why I wanted to pursue this field but reinforced my commitment to it.

The future of cardiothoracic surgery will be reliant on our ability to innovate and progress our field. To that end, this year’s STSA 68th Annual Meeting was a catalyst for novel ideas and discussion, and I look forward to attending the meeting in the years to come.

Acknowledgements

I would like to express my gratitude to Dr. Mara Antonoff and Dr. Scott LeMaire for their guidance and feedback in the preparation of this conference summary as well as their valued mentorship.

Dr. Scott LeMaire (right) from Baylor College of Medicine was my assigned mentor through the scholarship at the conference. He helped guide me through my first STSA meeting and I am grateful for his mentorship and friendship at this year’s STSA meeting.

Trainees at the STSA from Left to Right: Dr. Andrew Vekstein, PGY-5, Integrated CT Surgery, Duke University; Dr. Elizabeth Norton, PGY-1, Integrated CT Surgery, Emory University; Steven A. Buckeridge, MS4, Morehouse School of Medicine; Dr. Jacqueline Olive, PGY-1, Integrated CT Surgery, Duke University; Dr. Donald Chang, PGY-1, General Surgery, Henry Ford Hospital; Dr. Anthony Norman, PGY-2, General Surgery, University of Virginia; Dr. Felix Orelaru, PGY-3, General Surgery, St. Joseph Mercy Hospital