SCTS Bulletin Issue 08 by Open Box Media & Communications

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Issue 08

August 2020

Society for Cardiothoracic Surgery in Great Britain and Ireland

YEARS

OF THE

PERICARDIAL VALVE Setting up a Heart Institute in Pakistan p36

The power of art in cardiothoracic surgery p38

Patients and outcomes during COVID-19 p60

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August 2020

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In this issue... 4 6 10 13

From the Editor Indu Deglurkar The Pericardial Heart Valve – 50 years of Clinical Use Anand P. Tandon From the President Simon Kendall Cardiothoracic Surgical Community: United by a Common Goal Narain Moorjani

The annual meeting that never happened Daisy Sandeman

Nursing and Allied Health Professional 18 update Helen Munday Cardiac Surgical Audit – Are we in a position 20 to progress to unit level reporting?

Simon Kendall, Rajesh Shah, Narain Moorjani, Enoch Akowuah, Uday Trivedi, Doug West

The 2020 Getting it Right First 22 Time (GIRFT) Programme in

cardiothoracic surgery Doug West

Society for Cardiothoracic Surgery in Great Britain and Ireland

Hands-on surgical training for congenital 40 heart surgery: From A to Z Nabil Hussein

Coronavirus – Trainee Representative 70 Perspective Duncan Steele, Abdul Badran

How our heart program has prepared for and 42 responded to COVID-19 Lars G. Svensson

Update on what is happening in the speciality 43 - NADMEC November meeting

Ter-Er Kusu-Orkar

Teaching and training – touching lives 44 David J. O’Regan 45

Reflections of a thoracic surgical trainee during COVID-19 outbreak Ashvini Menon

MERITS: Multi-centre Evaluation of 46 Renal Impairment in Thoracic Surgery, a

collaboration of 17 thoracic units across the UK Vinci Naruka, Aman Coonar

The National PeriCCT Fellowship Scheme 48 in Cardiothoracic Transplantation

E. Khoshbin, S. C. Clark

Cardiac ACP Redeployment to ICU Transplantation Kathryn Hewitt 54

A potential study tool for the aspiring cardiothoracic surgeon Josiah Joseph

SCTS Education report: June 2020

My Cardiothoracic Elective at Huế Central Hospital, Vietnam Sam Jenkins

SCTS Education tutors’ report

Cardiothoracic surgery research during Covid-19 Aung Oo, Julie Sanders

Debbie Harrington, George Asimakopoulos

SCTS Nurses and Allied Health 28 Professional Educational report 2020

Bhuvaneswari Krishnamoorthy, Tara Bartley

Report of the 2020 SCTS-Ionescu Fellowships

Education and Implementation of Lung and Sternal Ultrasound for Nurses and Physiotherapists in the Cardiothoracic Ward

Sri Rathinam

Lynda Tivendale

Aortic surgery training in the UK – current perspectives

Edward Caruana, Akshay Patel

62 SCTS Student Engagement Aman Coonar The Jack A. Roth Fellowship in Thoracic 64 Surgical Oncology – an Invaluable Experience Across the Pond Gerard J Fitzmaurice

Adapt, Innovate and Communicate! 66 – A perspective from Southampton on

Ana Lopez-Marco, Aung Oo

running a thoracic surgical service amidst a pandemic Aiman Alzetani

‘Heal the Heart’ mission: setting up a Heart Institute in Mardan, Pakistan

Cardiac Surgery Experience Abroad: Trainees Perspective

The Power of Art in Cardiothoracic Surgery

Pro-activity and preparedness: A medical 69 student’s perspective on pursuing a career

Ishtiaq A Rahman

Keith Buchan, Sayed Abdulmotaleb Almoosawy, Megan Williams

Society for Cardiothoracic Surgery in Great Britain and Ireland

SCTS, 5th Floor, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PE T: 020 7869 6893 E: sctsadmin@scts.org W: www.scts.org

Hannah Jesani, Sanjni Bhudia

in cardiothoracic surgery

Michalis Anestis Patsalides

Open Box Media & Communications l Director Stuart.Walters@ob-mc.co.uk l Director Sam.Skiller@ob-mc.co.uk l Studio Manager Mark.Lamsdale@ob-mc.co.uk l Production Matt.Hood@ob-mc.co.uk l Advertising Sales Rupinder@ob-mc.co.uk

Ramez AbuKhalil

SCTS-Ionescu Consultant Team Fellowship 2018: Bristol Royal Infirmary Elaine Teh

Challenges to Reduce Surgical Site Infection in Cardiac Surgery Melissa Rochon

76 77

Silos to collaboration Sunil K Bhudia

2018 SCTS Education Ethicon Trainee Fellowship: One year training in Complex Aortic Surgery at St Barts Ana Lopez-Marco

SCTS-Ionescu Consultant Travelling Fellowship 2018 Fraser Sutherland

SCTS-Ionescu NTN Travelling Fellowship 80 2019 – Adult cardiac surgery at The Prince

Charles Hospital, Brisbane, Australia Eshan Senanayake

in Aalst, Belgium Syed M Rehman

SCTS-Ionescu Nursing & Allied 84 Health Professional Fellowship 2019

59 In virus veritas Antony Walker Cardiothoracic Interdisciplinary Research 60 Network (CIRN) Luke Rogers, Ricky Vaja,

The Medical Training Initiative sponsorship scheme by the Royal College of Surgeons, an International Surgeon’s experience

SCTS-Ethicon Surgical Trainee Fellowship 82 2019 – Minimally Invasive Cardiac Surgery

Thoracic Audit Update: where next 24 for LCCOP? Doug West Sri Rathinam, Carol Tan

Julie Sanders

SCTS-Ethicon Surgical Trainee Fellowship 86 2019 for Robotic Thoracic Surgery

Muhammad Asghar Nawaz

SCTS-Ionescu Consultant Travelling 88 Fellowship 2019 Marius Berman SCT-Ionescu Exceptional Fellowship 90 Award 2019 – The Advanced Practitioner’s

Approach to Aortic Surveillance Kathryn Hewitt

Exceptional SCTS-Ionescu 92 Non-NTN Surgical Fellowship 2018

Adrian Crucean

SCTS-Ionescu Medical Student 94 Fellowship 2019 Manveer Rahi 2019/20 Ionescu Nursing/AHP Fellowship – 96 Lung Ultrasound in Cardiac Surgery

Critical Care Jonathan Johnston

97 Obituary: Jitendra Rathod 98 Crossword

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From the Editor Indu Deglurkar, Publishing Secretary, SCTS

“Change is the only constant in life.” Heraclictus

his profound truth was stated 2,500 years ago and indeed one cannot step into the same river twice. Usually change brings hope, a sense of balance, authenticity and sometimes a sense of fear. But how does one cope with the tragedy and turmoil caused by a small strand of RNA which has galvanised the globe into action inducing changes in behavioural patterns and shutdowns of day-to-day functioning? It would be appropriate to say that this edition of the Bulletin captures the COVID19 calamity across the breadth of our practice. The record number of articles, mostly COVID related, reveal the extra-ordinary resilience and an ability to adapt in the face of extreme adversity. Dr Tandon’s leading article is a candid and fascinating narration of a 50 year odyssey of the pericardial valve beginning on the 4th April 1971 when our pioneering innovator and patron Marian Ionescu implanted the valve in the mitral position. Curiosity and imagination are the foundation of all invention and innovation. Millions of patients across the world have benefitted and will continue to do so in future due to this genius invention. Simon Kendall takes charge as the President of the SCTS with a trail blazing record having served as an elected trustee 2003-06, deputy meeting secretary 200507, meetings secretary 2007-12, Honorary secretary 2013-18 and was President elect 2018-2020. Simon begins his tenure having to manage the consequences of the most

unimaginable catastrophic devastation of humans due to COVID-19. Paying homage to our deceased colleagues and recognising the tremendous work of the NHS staff, Simon Kendall along with Rajesh Shah, President elect, and the SCTS team have already embarked on building a 5 year strategy for the SCTS. I am sure the membership will join me in extending a very warm welcome to our new President. A leader’s vision, dynamism, agility and personal touch influences the culture of the organisation and we look forward to exciting advances in the Society. Diversity of articles abound ranging from multi-centre collaboration for service

other sponsors to continue to bring in a wealth of knowledge and skills into the SCTS from all over the world. COVID-19 has cruelly unleashed its effects and infected over 16 million people causing nearly 657,000 deaths globally and over 45,000 deaths in the UK. We have become the COVID warriors and attempted to succeed in sadness, develop an inner resilience to endure disaster and the tragic loss of the lives of 312 health care workers. The lost human lives and deep global recession will leave perennial scars due to its devastating effects across the world amidst economic and political turmoil. The challenge will be protracted despite the extraordinary efforts of governments to counter the downturn with fiscal and monetary policy support. The SCTS pays respectful homage to all the lost lives including Mr Jitendra Rathod in Cardiff & Muhanad Nowar Eltayib. I would like to thank the artist Mr Juan Lucena and our trainee Ana Marco Lopez who used her Spanish influence to acquire permission to print the painting (see opposite page). I was absolutely struck by this painting in honour of all the deceased grandparents due to COVID-19 who passed away without saying goodbye to their grandchildren. A picture says more than a thousand words ... The world will never be the same again and as a society, we will adapt and rise to the challenges, hoping for the best and preparing for the worst. n

“We have become the COVID warriors and attempted to succeed in sadness, develop an inner resilience to endure disaster and the tragic loss of the lives of 312 health care workers.” delivery, research, setting up a surgical institute to tips to study effectively. Not surprisingly, the COVID experiences of staff including those across the Atlantic coping with the pandemic and their resilience come through strongly. The disappointment of meetings that never happened after tremendous effort, the disruption of services, redeployment and the emotional turmoil faced with changes in lifestyle have given birth to a new norm. Walker’s brilliantly written satirical article about HMS NHS staying afloat in this tsunami revealing all its strengths and weaknesses is outstanding. Numerous Fellowships enabled by Mr Ionescu and

indu.deglurkar@wales.nhs.uk

August 2020

â&#x20AC;&#x153;The SCTS is grateful for the generosity of the artist, Juan Lucena, Jerez de la Frontera (Spain) for providing the image of Que haremos sin ellos? (What we will do without them?)â&#x20AC;?

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The Pericardial Heart Valve - 50 years of Clinical Use Anand P. Tandon, Consultant Cardiologist (rtd.), Calderdale Hospital

n the 4th April 1971 the first Pericardial Valve was inserted in a patient in the mitral position. This was the beginning of a journey, indeed an Odyssey, which continues today as we approach 50 years of worldwide use of this enduring and remarkable prosthesis. That surgical operation was performed by Marian Ionescu, the pioneering surgeon who invented and constructed the first pericardial valves; and it happened at the General Infirmary in Leeds, UK.

As we approach half a century since the invention, and the introduction of this original valve in surgical practice, it is important to describe the evolution of its journey over the years. To understand the evolution of this unique invention, one needs to establish the historical framework of that period. The possibility to replace diseased heart valves remained for a long time just a dream. Sporadic attempts had been made to create an acceptable artificial heart valve without success. The real work of designing and constructing artificial heart valves took place during the decade 1961 to 1971. During an interview in 2015 Marian Ionescu speaking on the history of open heart surgery said: ‘It is hard to single out one investigator or one discovery which made this brave new world of heart valve surgery possible, but this seemingly sudden eruption of brilliant exploits was due to decades of smouldering intellectual curiosity

compounded by the dormant torment of the forgotten predecessors, those gifted fools who by their work saved their successors the trouble of thinking’. In artificial heart valve work, as in all innovation there are two ways to advance: revolutionary creation and modifications on the same theme. There were three personalities who created the main three events which brought heart valve replacement into the modern era. 1. In 1961 Lowell Edwards, an American engineer imagined and built a cage and ball valve as well as a bi-leaflet valve. This second one was not pursued due to lack of adequate materials. He teamed up with a surgeon, Albert Starr, and the well-known StarrEdwards ball valve was born and used, with occasional modifications, for decades. This was the beginning of the heart valve replacement era. This revolutionary invention was followed by a plethora of variations on the same principle, all interesting but ephemeral. 2. In 1971 another American engineer, Donald Shiley in his garage, created and built the floating, tilting disk valve. It was another revolutionary creation but Donald Shiley needed a surgeon to start using it. Viking Björk from Sweden accepted, with certain conditions, the offer. The new valve became

“The Pericardial Valve was born out of the dream of Marian Ionescu to create a tissue heart valve which will perdure and will not require anticoagulation.”

August 2020

the Björk-Shiley tilting disk valve. Like the Starr-Edwards valve this new and interesting device carried a high risk of valve thrombosis and embolism. In 1979, in order to help reduce these risks, the shape of the valve was slightly modified. This change reduced its strength and catastrophic valve failures occurred in a large number of patients. As a consequence of this, Pfizer, the giant pharmaceutical group and the parent company of Shiley Laboratories, decided in 1987 to close Shiley as a commercial entity and sell all the individual manufacturing units. 3. The third revolutionary creation, the Pericardial Valve, was born out of the dream of Marian Ionescu to create a tissue heart valve which will perdure and will not require anticoagulation. From the very beginning of this project he stated that ‘This is not only a valve but a concept of man - made devices. As such the embodiment of this concept, the Pericardial Valve lends itself to infinite permutations of shape and physico-chemical interventions in order to improve its function while maintaining the exceptional haemodynamic performance and the very low propensity for embolisation’. And this is exactly what happened over the years. When asked how this major leap occurred, from where the concept of using bovine pericardium, such a different material from the porcine aortic valve came from, he went a little deeper into the unspoken life of ideas. ‘Out of the many dreams which burn softly inside the mind, occasionally one becomes prevalent, that triggers the dream to imagine, to look, to see with your inner eyes that which is not there, a sliver of silvery silken veil of light lifts ... and the rest is just toil, unending trials, repeated failures, more hard work and perseverance until the vision become reality. It takes what it takes in time. It is said that success depends on knowing how long it will take to succeed, but us, little creatures, we are not allowed to read the future. Sometimes the Goddess

Fortuna may smile on you. You may reach the point where success will make you bask in the prize of critics and the envy of your colleagues and suffer when your work falls into the wrong hands. Do not despair, Invidia Medicorum Pessima has always been an old companion of our profession’. The evaluation of the pericardial heart valve went through several stages during the two years prior to its first clinical use. Initially the valves were made in Ionescu’s hospital laboratory by Dr Christina Ionescu. Between 1971 and 1976, 212 patients received hospital made valves. Away from the light of the ramp thorough investigations were carried out in

these patients. In addition to the usual clinical and laboratory tests, haemodynamic investigations, at rest and during exercise, were performed on 110 patients (51 aortic; 44 mitral; 12 multiple and 3 tricuspid valve replacements). Nineteen of these (13 aortic and 6 mitral) were subjected to sequential haemodynamic studies at intervals of approximately 1, 3.5 and 5.7 years post-implantation. These studies demonstrated excellent function, better than with porcine valves and equal to the best mechanical valves. In the six years of usage the valves implanted retained their physical and functional integrity. In those days echocardiography was in its infancy. During these first six years anticoagulants were not used beyond the first six post-operative weeks in any patients with aortic or with mitral valve replacement. Valve thrombosis was not encountered and the rate of embolic events was as low as in patients with mitral valve disease treated medically. Due to the experience gained in these first six years of function, the exceptional haemodynamic performance and a low propensity for embolism, the American company Shiley Inc. began in 1976, following some modifications, the manufacture and worldwide distribution of the Ionescu-Shiley Pericardial Xenograft. In 1983 more changes were made to create the Low Profile Pericardial Xenograft. In 1986 the Ionescu-Shiley Optimograft was created by a different mounting of the pericardium inside a double, thinner stent in order to avoid the abrasions of the pericardium on the Dacron cloth covering the Delrin support. Just before the start of manufacturing of the Optimograft, some unfortunate evidence arose showing many failures in one of the modified models of >>

the 8 bulletin

BjĂśrk-Shiley mechanical valves. Pfizer decided to stop all production and end the Shiley Company as a commercial entity. The Porcine Aortic Valve was not included in this description because it is not an invention but a hybrid construction created by Marian Ionescu in 1967 for the first time for mitral valve replacement. The aortic valve of the pig created by Mother Nature, was chemically treated and attached to a supporting frame to allowing suturing into the mitral annulus. This is neither an invention nor a concept. Despite its many shortcomings, the porcine valve was extensively used in preference to mechanical valves which have their own imperfections. Following the Pfizer decision, a few companies started, during the1980s, to manufacture pericardial valves. Some of them with very poor results abandoned the project while two or three continued successfully to manufacture the pericardial valve with some changes but always maintaining all the characteristics and exceptional qualities of the original Ionescu Pericardial Valve. During the long term follow-up of the Ionescu-Shiley Pericardial Xenografts a crucial discovery was made in 1985. It was already known that calcification of the pericardium is by far the main cause of valve dysfunction and eventual failure. Statistical analysis of the two largest series of patients with the Ionescu-Shiley pericardial valves (Denton Cooley with 2,720 and Marian Ionescu with 1,171 patients) revealed that calcification of the pericardial valves occurred more often and advanced much quicker in younger patients than in those older than 70 years. In short, the process of calcification is age related. The consequence of this significant discovery was to restrict the use of pericardial valves solely for patients above the age of 70 years. In this way the pericardial valves of the second generation were protected from calcification, the main cause of valve failure and the results improved substantially. In a strange way, the difference in the results between the original and the second generation pericardial valves was made by a statistical event which brought in evidence a biological phenomenon. The difference in long term results between two identical types of pericardial valves, the Ionescu-Shiley Pericardial Xenograft and the second generation

â&#x20AC;&#x153;Out of the many dreams which burn softly inside the mind, occasionally one becomes prevalent, that triggers the dream to imagine, to look, to see with your inner eyes that which is not there, a sliver of silvery silken veil of light lifts ... and the rest is just toil, unending trials, repeated failures, more hard work and perseverance until the vision become reality.â&#x20AC;? - Marian Ionescu pericardial valves is simply explained by the following facts. 1. The Ionescu-Shiley valves were used, between 1971 and 1987, in patients of all ages from children to 70 years old (most of them were middle-aged people) and the valves were implanted in all three cardiac valvular positions (about half of them in the mitral position). 2. The second generation pericardial valves were used since 1987 almost exclusively in patients older than 70 years and only in the aortic position.

The comparison of results obtained in these two series of patients is illogical and whenever published it would be in mala fide. Dixit et anima mea salvavit. Now the real, serious solution to the calcification of tissue heart valves ought to be a scientific approach to the study of the causes of tissue calcification in man in general and in heart valves in particular. Solving this problem would make the Pericardial Heart Valve the ideal valve replacement for a long time to come, or until the white bell of progress will ring three times. Sublata causa tollitur effectus.

August 2020

Some of the manufacturers of the second generation pericardial valves assert that a special solution or treatment of the valves possesses anti-calcification properties. There is not a shred of scientific evidence to support this assertion. At the same time they advise surgeons not to use such valves in patients younger than 70 years. Quod erat demonstrandum. It is strange that the manufacturers of pericardial valves, of all types including those used in TAVI, whose essential material for constructing the valves is pericardium, systematically omit this word ‘pericardium’ from their advertisements. All of them have opted for bizarre names which have no relationship with heart valves or the material from which they are made (Trifecta, Intuity, Perceval, Sapien, etc.). Has the heart ceased to be the noble symbol of our existence? Some valve manufacturers and even surgeons had the temptation to appropriate the paternity of Ionescu’s whole pericardial valve concept. To claim to have

discovered the ‘philosopher’s stone’ 10 years after its creation is ridiculous, but to consider to arrogate someone else’s intellectual property is always reprobative. In general the second generation of pericardial valves are well made. Following changes in the mounting of the pericardium onto the supporting frame, all the exceptional characteristics of the original Ionescu valve were maintained intact. They function well and many published accounts on the long term results of their use demonstrate good performance of these valves up to 20 years in the aortic position of older patients. Progressively the utilisation of pericardial valves has increased to reach a now dominant position of approximately 80% of all heart valves used worldwide and this is without taking into account the very large number of pericardial valves inserted through TAVI. One of the most fascinating examples of the use of the pericardial valve concept is the transcatheter aortic valve implantation (TAVI or TAVR) imagined and created by

Alain Cribier in Rouen while acknowledging the patent of Dr. Henning Rud Anderson, a cardiologist from Denmark who first arrived at the valve- by- wire idea to treat his father. Following several years of research and trials Cribier succeeded in 2002 to use the technique of inserting pericardial valves through a catheter. This technique obtained FDA approval in 2012 and since then some 300,000 procedures have been performed in 65 countries. This figure is increasing by 40% year on year. It is considered that by 2025 there will be 280,000 such procedures performed yearly. The medium and long term follow-up demonstrated very good results. It is gratifying that now we have the privilege to extol the Pericardial adventure, which through all the meanders of its evolution, is still here and in a strong position nearly 50 years after its creation here in the UK and it serves loyally its purpose for the treatment of patients. None of this would have been possible save for the ingenuity and perseverance of Marian Ionescu who is undoubtedly the ‘Father’ of the Pericardial Heart Valve. When a scientific remedy to prevent calcification will be found, the initial dream of Marian Ionescu for an artificial heart valve which will perdure and not require anticoagulation would have been fully realised. n Grateful thanks are extended to Mr Marian Ionescu for his insight and help with details and photographs for this article.

the 10 bulletin

From the President Simon Kendall

ow the world has changed since the last bulletin. The pandemic has been an unprecedented event in the modern world and has therefore had a major impact on our modern way of life. In our professional lives cardiothoracic surgery nearly came to a complete halt as the health service reassigned facilities and staff to manage the expected tsunami of sufferers. Those early days in late March were frightening, with London at the forefront and the rest of us outside of the M25 watching, learning and preparing as fast as we could. There are some specific events around the pandemic in relation to SCTS that I would like to highlight: Firstly, with great sadness, two very respected and popular colleagues died during the pandemic. Jitendra Rathod in Cardiff and Nowar Eltayib in Belfast. It is hard, near impossible, to imagine the grief felt by their families, and the impact of such news on their respective surgical units during a time of crisis. Secondly, to recognise the impact of the pandemic on the junior surgeons and the allied health professionals in cardiothoracic surgery. For the junior surgeons, their training was abruptly put on hold with many of them deployed to the ‘front line’ to use their transferable skills for the benefit of Covid patients. There was, and remains, a significant risk and fear of suffering the worst effects of the virus which became more disturbing as it became apparent that BAME colleagues were more at risk. Their courses, their exams, their aspirations all put on hold while they committed to help the service as best they could. Equally, all the allied health professionals in the SCTS who have also dedicated themselves to the cause, risking their own health and working in unfamiliar and uncomfortable conditions to help the NHS. We have seen Specialist nurses and Surgical Care Practitioners going back

into ‘front line’ roles applying their new skills or their previous competencies, often returning to shift work with the subsequent challenge to their home lives. An appreciation of the extraordinary commitment of our anaesthetic and intensive care colleagues during the pandemic. Level 3 and level 2 care was to be crucial during the pandemic and, as a limited resource, everyone involved in such care was made available to look after the Covid patients. It is these colleagues that have had to work flexibly, with night shifts, putting their own health at risk and working in the uncomfortable and claustrophobic personal protection. Many of them have had to look after patients with a grim prognosis who could not even be allowed the compassion of their loved ones to be with them. Several of our colleagues work in ECMO centres where the youngest and fittest patients were treated often with a poor prognosis. This is not health care that any of them were prepared for and presumably will take time to recover from, and we as surgeons should bear this in mind in the coming months as we look to resume our surgical programmes. Many members have suffered the infection and several required hospital admissions. It is with great relief that they have survived and may they have a speedy and full recovery. Lastly, on behalf of SCTS, I sincerely thank the team at St Bartholomew’s for sharing their experience and their protocols with our surgical community. These were of immense help in supporting our specialty in the most uncertain of times. But from every threat there are opportunities. In his article as Honorary Secretary, Narain has elegantly summarised the resourcefulness of our specialty and the unexpected potential benefits of the pandemic. It was striking how there was a sense of community and mutual support between us all.

On SCTS matters, Maninder Kalkat and the meetings team had worked so hard to prepare an outstanding AGM in Wales only to see events overtake them. After the decision to cancel the meeting he and the team have had to continue their efforts to negotiate new dates of February 7th – 9th 2021 at the same venue and thankfully with minimal financial impact on the Society. At that time we will be able to formally acknowledge the dedication and leadership of Richard Page as President. It was a pleasure and a privilege to work with him and to witness his utter commitment to the members and the specialty. Looking forward we welcome Rajesh Shah as president elect. He is already having a major impact on our Society and has proposed we prepare a 5 year strategy across all our areas of work. These conversations are exciting as they show the significant agendas that all the membership need to work on together to improve our professional lives and also the way we deliver care. We will be sharing these ideas with you so you can shape the course the Society takes. In the coming months may we support each other to re-establish our surgical programmes, ensuring our patients and our colleagues remain protected and safe. We are working with ACTACC to define the level of screening and PPE, trying to influence the national agenda through NHSE and the Royal College of Anaesthesia. And we also need to consider how we give our junior colleagues the exposure they so need in theatre when there are pressures of time imposed by the infection protocols. May you stay safe and well, and that life after the pandemic, or the ‘new normal’, is tolerable and even enjoyable. Our practice will not be the same, especially with regard to MDTs, consultations, meetings and learning events and it would appear these changes will enhance our lives and the care we can provide. n

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The Latest Class of Valves

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EDWARDS INTUITY Elite Valve System Trusted Platform Rapid Deployment* Smaller Incisions

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Important Safety Infirmation: Use of the EDWARDS INTUITY Elite valve system may be associated with new or worsened conduction disturbances, which may require a Permanent cardiac Pacemaker Implant (PPI). The rate of PPI for the EDWARDS INTUITY Elite valve is within the range reported in the literature for various rapid deployment valves, but higher than that reported for surgical aortic valves. Physicians should assess the benefots and the risks of the EDWARDS INTUITY Elite valve prior to implantation. See instructions for use for additional information. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards Lifesciences devices placed on the European market meeting the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC bear the CE marking of conformity. Edwards, Edwards Lifesciences, the stylized E logo, EDWARDS INTUITY, and EDWARDS INTUITY Elite are trademarks of Edwards Lifesciences Corporation. © 2020 Edwards Lifesciences Corporation. All rights reserved. E9128/02-19/SUR Edwards Lifesciences • Route de l’Etraz 70, 1260 Nyon, Switzerland • edwards.com

August 2020

Cardiothoracic Surgical Community: United by a Common Goal Narain Moorjani, Honorary Secretary

he past few months have been unprecedented in many ways to both our personal and professional lives, and it may be that we never return to life as it was before. Whilst this may be sad in one way, there are numerous positives that have emerged from the coronavirus pandemic and many that we should hold on to as we try and define what the ‘new normal’ will look like. Before looking to the future, it is important to appreciate the remarkable sense of togetherness that has developed during the pandemic in the cardiothoracic surgical community, encompassing nurses, doctors, allied health professionals and everyone that has contributed to the delivery of care during the crisis. We have seen many sacrifices, whether the willingness of professionals to be redeployed to other areas of the hospital out of their normal comfort zone; spending many exhausting hours on the frontline caring for very sick patients in sometimes very distressing situations; operating in full personal protective equipment and the accompanying difficultly in communicating with colleagues; trainees and fellows who have missed out on learning opportunities, associated with potential delays to career progression; and staff living away from their family

to protect them. The Society would like to pay tribute to all those who have contributed in this selfless way. We should also reflect on those that have lost their lives during the pandemic, including amongst others Jitendra Rathod in Cardiff and Muhanad Nowar Eltayib in Belfast, as well as friends and relatives of those working in the cardiothoracic surgical community. In particular, it is important to recognise the impact that the virus has had on black and minority

dealing with COVID-19 around the world. In a fast evolving pandemic with limited data available, dissemination of information is key to being able to deliver care to the best of our ability. We would like to thank all those who contributed to the sharing of knowledge that allowed us to create a central repository on the Society website with national and international guidance, as well as recent important publications on the epidemiology, presentation, prevention and management of COVID-19. This openness in sharing of information has been a real positive and one hopes that this attitude continues when dealing with other disease processes in our daily lives in the ‘new normal’, as it allows patients to receive the best possible care. The Society has been active in developing national recommendations that have helped guide the delivery of cardiothoracic surgical care during the pandemic to ensure that patient outcomes were optimised and that staff were kept safe, when looking after or operating on patients with COVID-19. The SCTS has also been lobbying at a national level to ensure an adequate supply of appropriate personal protective equipment was and is available to allow staff to be able to carry out their daily duties with confidence and safely.

“It is important to appreciate the remarkable sense of togetherness that has developed during the pandemic in the cardiothoracic surgical community, encompassing nurses, doctors, allied health professionals and everyone that has contributed to the delivery of care during the crisis. ” ethnic colleagues, who play such an important role in the delivery of care to cardiothoracic surgical patients. Despite all of this adversity and challenge, it has been a real pleasure to witness the remarkable ‘can do’ attitude of staff, with the ultimate aim of ensuring that, as healthcare professionals, the best care is delivered at a time of greatest need. During this period, the Society has tried to support this sense of community by sharing lessons learnt from others

Audit Lead: Carin Van Doorn

Co-opted Members: Andrew Goodwin (NICOR) Geoff Tsang (UK Aortic Group) Peter Braidley (NHS Commissioning)

Trainee Representative: Jonathan Afoke

NAHP Representative: Helen Munday

NAHP Representative: Karen Byrne

Co-opted Members: David Baldwin (BTS) John Duffy (Commissioning) Richard Steyn (Trauma)

Deputy Audit Lead: Serban Stoica

Trainee Representative: Joesph George

Education Lead: Attilio Lotto

Trainee Representative: Thomas Tsitsias

Education Lead: Sri Rathinam

Audit Lead: Doug West

NAHP Representative: Amanda Walthew

Education Lead: Deborah Harrington George Asimakopoulos

Audit Lead: Uday Trivedi

Unit Representatives: Chuck McLean Andrew Parry Mohammed Nassar Osama Jaber Andreas Hoschtitzky Phil Botha Ben Davies Conal Austin Mark Redmond Branko Mimic

Appointed Members: Juliet King Kandadai Rammohan Babu Naidu Aman Coonar

Appointed Members: Chris Satur Steven Billing Shakil Farid Thanos Athanasiou Mobi Chaudhry

Executive Co-Chair: Narain Moorjani

Executive Co-Chair: Simon Kendall

Executive Co-Chair: Rajesh Shah

Co-Chair: Rafael Guerrero

Co-Chair: Steve Woolley

Co-Chair: Enoch Akowuah

Surgical Tutors: Deborah Harrington George Asimakopoulos

Adult Cardiac Surgery Lead: Uday Trivedi

Consultant Lead: Prakash Punjabi Shahzad Raja Non-NTN Lead: Uday Dandekar Student Lead: Farah Bhatti Karen Booth

Deputy Congenital Cardiac Surgery Lead: Serban Stoica NAHP Representative: Julie Sanders Co-opted Members: Andrew Goodwin (NICOR)

Accreditation Lead: Shafi Mussa

Trainee Representatives: Duncan Steele Abdul Badran

NAHP Representative: Bhuvana Bibleraaj

Congenital Cardiac Surgery Lead: Carin Van Doorn

Deputy Thoracic Surgery Lead: Kandadai Rammohan

Congenital Cardiac Surgery Lead: Attilio Lotto

Executive Co-Chair: Rajesh Shah

Executive Co-Chair: Simon Kendall

Thoracic Surgery Lead: Doug West

Co-Chairs: Sri Rathinam / Carol Tan

Co-Chair: Doug West

Co-opted: Stephen Clark (SAC) Andrew Goodwin (NICOR) Luke Rogers (ASSL) Ricky Vaja (ASSL) Serban Stoica (Congenital Audit)

Trainee Representative: Marius Roman

NAHP Representative: Julie Sanders

Communications & Membership Lead: Zoe Barrett-Brown

Patient Liaison: Chrissie Bannister

Research Lead: Julie Sanders Vacancy

Education Leads: Tara Bartley

Audit Lead: Julie Sanders

Congenital Cardiac Surgery Lead: Vacancy

Thoracic Surgery Lead: Amanda Walthew

Adult Cardiac Surgery Lead: Helen Munday

Thoracic Surgery: Eric Lim Babu Naidu Congenital Cardiac Surgery: Massimo Caputo Nigel Drury

Meeting Lead: Daisy Sandeman

Deputy NAHP Lead: Bhuvana Krishnamoorthy

Chair: Helen Munday

Adult Cardiac Surgery: Mahmoud Loubani

Executive Co-Chair: Narain Moorjani

Co-Chair: Gavin Murphy

Cardiothoracic Dean: Neil Roberts

SAC Chair: Marjan Jahangiri

Research Co-Chair: Gavin Murphy

Tutors: Deborah Harrington, George Asimakopoulos

Audit Co-Chair : Doug West

Congenital Co-Chair: Rafael Guerrero

Exam Board Chair: Rana Sayeed

Perfusion Representatives: Phil Botha, Chris Efthymiou

Nursing & AHP Representative: Helen Munday

Thoracic Co-Chair: Steve Woolley

Co-opted Members / Ex-Officio Members

Elected Trustees: Mahmoud Loubani, Carin Van Doorn, Mobi Chaudhry, Enoch Akowuah, Aman Coonar

Lay Representative: Sarah Murray

Honorary Secretary: Narain Moorjani

Trainee Representatives: Duncan Steele, Abdul Badran

Meeting Secretary: Maninder Kalkat

Honorary Treasurer: Amal Bose

President Elect: Rajesh Shah

Education Secretaries: Sri Rathinam, Carol Tan

President: Simon Kendall

Sarah Murray Rajesh Shah Helen Munday Doug West

Professional Standards

Conference Organisers: Isabelle Ferner Tilly Mitchell

NAHP Representative: Daisy Sandeman

Associate Meeting Secretary: Sunil Bhudia

Deputy Meeting Secretary: Cha Rajakaruna

Meeting Secretary: Maninder Kalkat

Meetings Team

Bulletin: Indu Deglurkar

SCTS Website: John Butler Clinton Lloyd

Communications

Emma Ferris

Letty Mitchell

Tilly Mitchell

Isabelle Ferner

the 14 bulletin

August 2020

Moving forward, the SCTS is developing guidance to help the cardiothoracic surgical community restore services to care for many patients that have not been able to receive care over the past few months and often whose clinical condition may have deteriorated during the pandemic. The SCTS have developed these guidelines with other national bodies, such as NHS England, Association of Cardiothoracic Anaesthesia and Critical Care, British & Irish Society for Minimally Invasive Cardiac Surgery, British Cardiovascular Society and Society for Clinical Perfusion Scientists, to name a few. It is this collaboration, which has shown the true community spirt and sense of working together for the greater good that has been gratifying to observe. It is ironic that the coronavirus pandemic was able to break down barriers to bring professionals from many different disciplines together, while obviously maintaining social distancing. Whilst understanding the importance of continuing to collect data to get a greater appreciation of the impact that COVID-19 has had on patients who underwent or did not undergo surgery during the period, the Society are in negotiations with NICOR to ensure that cases operated on during the coronavirus pandemic are not included in surgeon specific mortality. It maybe that this can be used as a step towards moving away from the publication of outcome measures attributable to an individual and recognising that the care of patients undergoing cardiothoracic surgery is a delivered by a team. Moving forward, the resilience and flexibility of staff has brought with it a great cause for optimism. The ability of the cardiothoracic surgical community to adapt, plan, organise and deliver care during a period of crisis are invaluable skills that will hold us in great stead in the future, especially if we had to deal with a crisis of such magnitude again, or even a second wave of COVID-19. It has also taught us or accelerated us into new ways of working, such as virtual clinics & MDTs. We have all suddenly become masters of this evolving technology, which should make our lives easier.

â&#x20AC;&#x153;The resilience and flexibility of staff has brought with it a great cause for optimism. The ability of the cardiothoracic surgical community to adapt, plan, organise and deliver care during a period of crisis are invaluable skills that will hold us in great stead in the future, especially if we had to deal with a crisis of such magnitude again, or even a second wave of COVID-19.â&#x20AC;? The ability to use private sector facilities for care of NHS patients has always existed and yet it seems that the coronavirus has had the ability again to break down barriers to facilitate this to a greater extent. The Society would like to express its sincere gratitude to all cardiothoracic surgical practitioners for

their professionalism, resilience and commitment during these challenging times. It is a real privilege to be working with such colleagues and is a true testament to the strength of the cardiothoracic surgical community that has been united by a common goal in supporting the global effort to combat the pandemic. n

the 16 bulletin

The annual meeting that never happened Daisy Sandeman, on behalf of the organising team

ne year of general planning ... 6 months of accelerated focus ... 3 months of intensive late night after work zoom meetings ... it all came to an abrupt end due to the threat of COVID -19 and its effects on a large scale meeting like ours … The meeting dates were set to be from March 22-24, 2020. Let’s rewind a bit ... the venue was chosen (when it was just bricks and scaffolding) ... but we had a great vision and ICC Wales materialised in September 2019 when the meeting committee got to see the final product. A state of the art conference centre beautifully set amidst acres of Welsh woodlands ... an extension of the historic Celtic Manor. Every month the meeting committee met dutifully and progressed with the logistical planning required to undertake a conference on this scale. An illustrious list

of guest speakers were invited from all over the world who promised to bring along with them the best in Cardiothoracic Surgery. This year, Mr Richard Page would hand over the presidential reins to Mr Simon Kendall and the meeting would have taken the opportunity to celebrate his remarkable tenure and leadership. The Plenary was also set to focus on ‘Thoracic Surgery’ and to recognise renowned Cardiothoracic surgeon, Mr William Walker, by presenting the ‘Life Time achievement’ award. This year saw the submission of a record number of abstracts. The Review Committees spent several hours deliberating, marking and selecting the final abstracts, chosen either for oral presentation with a few also for poster presentation. In addition to this, the SCTS-Ionescu fellowship presentations by nurses and AHPs were also scheduled to be highlighted at the meeting. There was interest from many and various exhibitors ready to display their technical and scientific goods who were also preparing to teach, train and support SCTS members in their professional roles. This year for the first time ever in the history of the annual meeting, the usual football tournament was switched to an energetic 5K run supported by the local charity ‘Welsh Hearts’. The woodlands around Celtic Manor would have been the perfect setting to clear the proverbial cobwebs and kick start the annual meeting and most importantly support an incredible local cause. To start the annual meeting on Sunday, the University day was set to be packed with

educational sessions designed for surgeons, nurses and allied health professionals. The wetlab session would give everyone an opportunity to engage in ‘hands-on’ education on the anatomy and physiology related to Cardiothoracic surgery. The next two days were set to be filled with scientific, evidence based sessions in cardiac, thoracic, congenital and transplant surgery. Also for the first time, an exclusive ‘Research clinic’ was scheduled to guide, support and facilitate a research environment within the SCTS. No meeting is complete without the much anticipated annual Gala dinner. This year, the historic ‘Exchange hotel’ would have hosted the grand event and the theme chosen was ‘Great Gatsby’. The 1920’s inspired event would have been memorable and fun-filled, giving attending members a chance to let their hair down and network with their friends and colleagues. But alas, as the threat of the pandemic started to become real, several telephone exchanges and correspondence within the executive committee led to the final decision. It was with a heavy heart that the 2020 annual meeting was declared cancelled. And now as we all remain in various forms of lockdown, the world has witnessed the incredible resilience and courage shown by all health care workers including and especially members of SCTS. We have also sadly lost some of our colleagues to this cruel virus. The next year’s meeting has been scheduled from 7th to 9th February, 2021 at the same venue, ICC wales and preparation has once again commenced in earnest. We wait to see how the global situation evolves and are exploring virtual platforms available worldwide to embrace whatever form 2021 takes and to effectively deliver the SCTS annual meeting. n

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the 18 bulletin

Nursing and Allied Health Professional update Helen Munday, SCTS Nursing and AHP Representative

hoever would have thought that in Florence Nightingale’s bicentennial year, the year in which the World Health Organisation designated as the first ever Global Year of the Nurse and Midwife, we would be facing the greatest challenge of our professional lives with the coronavirus outbreak? It certainly wasn’t the attention that we had hoped for but it has most definitely put a spotlight on the commitment, compassion and expert clinical care that drives healthcare professionals every single day. I’m sure we will all have our own personal memories and experiences of this time, overwhelming sadness at the loss of family, friends and much valued colleagues, and stories of unbelievable acts of kindness and that incredible, emotional feeling when we see patients recovering and being discharged from hospital. It has been quite astonishing to witness the way in which professional groups have all worked together to respond to the crisis, and how staff have supported each other, and supported those who are less familiar with the environment they find themselves working in. Novel ways in which we help patients keep in touch with friends and families have proved to be a lifeline for many as we, and our patients, have adapted to an almost inhuman rule of heavily restricted visiting and social isolation. I have reflected throughout this period on the Yoga and Mindfulness session, delivered by Letty Mitchell last year at the CT Forum;

her words during that presentation were inspiring, her take-home message – “be kind to yourself ”. Nobody knows yet what the long term impact on the psychological well-being of staff will be, but we do know that staff are exhausted – physically and mentally. The immediate response and the measures put in place enabled an unprecedented increase in ICU capacity across the country, in exceptional circumstances, but they are not sustainable and should not become the new normal. As we move toward a post-Covid era, workforce modelling is becoming a much debated topic with national bodies

offers flexibility in interpretation whilst adhering to fundamental principles and is a useful document to support decision making at a local level. Normally, it would be in this edition of the Bulletin that I would be talking about the CT Forum at the Annual Meeting, which this year was to have been held at the ICC in Wales. It was with great disappointment that the meeting was cancelled, both for all the delegates and presenters, but also for the meeting team who had spent a considerable amount of time and effort in the planning of the meeting. Under the circumstances, there was no doubt that it was the correct decision and I know the team welcomed the messages of support they received from colleagues acknowledging this. It is probably too early to predict how large gatherings will happen by 2021 but we remain optimistic that next year’s meeting will go ahead in some form or another. As time goes on, we are learning to adapt to this new virtual world in which we connect with colleagues. There have been several SCTS sub-committee meetings held via video-conferencing in the last few weeks, including a meeting of the Nursing and AHP sub-committee, and the first virtual meeting of the SCTS Executive is scheduled to take place on the 5th June. Part of the meeting will be dedicated to discussing the five year strategy for the SCTS, in which the nursing and AHP strategy will be incorporated. There will be more news about this in the next edition

“Novel ways in which we help patients keep in touch with friends and families have proved to be a lifeline for many as we, and our patients, have adapted to an almost inhuman rule of heavily restricted visiting and social isolation.” such as the RCN, cautioning against moving away from the pre-pandemic national recommendations for nurse-patient ratios in level 2 and level 3 areas. However, with concern never far away about a second surge, hospitals will need to be in a state of readiness to meet the potential demand. It is likely that organisations will adopt a more measured and planned approach, enabling staff to receive training in acute care core skills and opportunities to rotate to level 2/3 areas, thus growing a more flexible workforce alongside an increase in critical care bed base. The Faculty of Intensive Care Medicine have published “Bridging guidance for critical care during restoration of NHS services” in May 2020, which

SCTS ANNUAL MEETING 7th-9th February 2021

CALL FOR ABSTRACTS 17th August 2020: Submission Open

23rd October 2020: Submission Deadline 1st December 2020: Registration Open

#SCTS2021

www.scts.org

the 20 bulletin

of the Bulletin, but one of the immediate priorities is to ensure there is a nurse or AHP SCTS representative in every cardiothoracic unit in the UK and Ireland to be a point of contact for two-way communication between centres and the Society. We have almost achieved this and I hope in the coming months to have this information available in the members’ area of the SCTS website. As unit representatives are established, it is hoped the Society will be able to reach out to potential new members – maybe staff who are new to the specialty, and/or have recently qualified as registered nurses, and are interested in hearing about what the Society can offer as they embark on their cardiothoracic career. Similarly, I am very keen to hear from you, as members, to know what you want from the Society and how we can best deliver on those expectations. To that end, I will be sending out a survey in due course to all nursing and AHP members to ask exactly those questions. I would be

really grateful if you would take the time to complete it as this will help inform the way we develop the nursing and AHP strategy for the future. Educational courses, access to research opportunities and travel fellowships will remain integral components of our strategy, with further consideration to availability of resources on the website, specifically for members as well as a patient access area. There are many opportunities for nurses and AHPs to be involved with the SCTS in a variety of areas of their personal interest – cardiac, thoracic, congenital as well as research, audit and education. The nursing and AHP membership of the SCTS continues to grow and is testament to the value of our collaborative relationship and the benefit of having a specialty specific network in which ideas are shared widely and practice can develop and adapt according to need. This has never been so clearly demonstrated as in the past

few months during which time a variety of webinars have become available, ranging from those with a scientific and research focus, to resilience and well-being, and those in which experiences are shared, all allowing many more people the opportunity to listen, and contribute, to presentations, seminars or workshops, than might actually have attended in person. If you are reading this and you are new to the Society and wish to join, as a nurse or AHP, the fee is a one-off £10 administration fee and annual subscription fee of £30. Details can be found at www.scts.org In the meantime, if you require details about any of the above, or for more information about the SCTS, please do not hesitate to contact me. Take care and look after yourselves. n Helen Munday Matron – CT Surgery & Respiratory Medicine Email: h.munday@nhs.net

Cardiac Surgical Audit Are we in a position to progress to unit level reporting? Simon Kendall, Rajesh Shah, Narain Moorjani, Enoch Akowuah - Chair Cardiac Committee, Uday Trivedi - Cardiac Audit lead, Doug West - Chair Audit Committee

e are hoping to make significant changes to the reporting of outcomes for the national cardiac surgery audit. For the 2021–2024 audit cycle we propose migrating from reporting individual consultant outcomes to unit based outcomes in conjunction with a system of accreditation of standards in individual units for cardiology, perfusion, anaesthetics and ITU. There are many interested parties.

We are working with NHS, NICOR, HQIP, ACTACC, BCS and SCPS* who are broadly very supportive of the plans. Since the audit started in 2005 cardiac surgical practice has significantly changed. An individual surgeon used to accept referrals to their own practice, make operating decisions and look after the patients post-operatively. Jump forward 15 years and our practice is largely influenced by MDTs, we often have pooled lists of

in-house and elective referrals, and the post-operative care is delivered by intensivists and other teams who all have autonomy to make clinical decisions. As individual surgeons we are no longer solely responsible for a patient’s journey through their treatment. Cardiac surgeons in SCTS can be justly proud that the 2005 audit has been associated with improvements in quality, along with increased survival and fewer

August 2020

outliers at surgeon and unit level. These are world class outcomes. However, there are still significant issues which appear in the media, published independent reviews and also in the invited review mechanism (run by the RCS Eng). These have highlighted difficulties in the professional behaviours within the team as well as between specialties in the service. For this reason, we are recommending that the audit moves away from its current focus on individual surgeon’s outcomes to encompassing the whole team and the whole service. Publication of unit based outcomes alone may not necessarily prevent a patient being referred to a service where there might be significant issues with individual practice, that might affect patient care and their outcome. The audit needs to be more refined so a patient has confidence that the care throughout the unit is of a nationally accepted good standard. Our rationale to our colleagues and regulators is that the audit can be improved to give more quality assurance and enhance quality improvement in a more timely and transparent manner. We are proposing that from April 2021, the surgeons in each unit work as a team to complete the three year cycle without any colleague becoming an outlier. This will require teamwork, quarterly review of outcomes, regular multidisciplinary M and M meetings and most importantly supporting colleagues when there are issues – the new colleague, the older colleague, the locum, the colleague having a bad run. This should promote effective teamwork. The data will still be analysed at NICOR but more in ‘real time’ to reassure units of their own data and to confirm national benchmarks for outcomes And rather than focussing solely on survival it is time to include other important outcomes such as reopening, incidence of CVA, renal failure etc. After three years and reaching March 2024 without any significantly measured divergence the patients and the public will not need to see individual results because they know the service is safe. However, it will not reflect well on the team, nor the service as a whole, if they have been aware of negative divergence and not addressed the issues. This would necessitate that the individual results of all the team would need to be published and would be a negative marker against the unit. However, this really should not occur if there is contemporaneous review of

outcomes within the cycle. This would be a marked improvement on the current audit where there has to be three years of data and then analysis before variation can be defined, and results in a delay before matters are addressed. In discussions so far with NHS, BCS and ACTACC there is also an appetite to start a form of accreditation for units in association with the proposed changes to the publication of outcomes. This is to acknowledge and address that the patient needs more assurance about all aspects of care in addition to the quality of their surgery: that their care involves good standards in cardiology, in the decision making in appropriate MDTs, and in their peri-operative and post-operative care. We are considering: basic standards for the MDTs for revascularisation, aortic and TAVI, mitral, endocarditis and high risk cases; echocardiography accreditation; TOE accreditation; perfusion accreditation; ITU accreditation including the potential use of ICNARC data. These will all be drivers to improve any deficits in the service. There is also the potential to include some of the recommendations from the GIRFT reports in cardiology, cardiothoracic surgery and intensive care that are important to patient care. This outline proposal has been unanimously endorsed by the Executive.

In the coming weeks the detail will continue to be refined and will be presented to the postponed Annual Business Meeting in September (in conjunction with the Board of Representatives meeting). If accepted by the membership there will continue to be meetings with stakeholders such as Specialised Commissioning, NHS, CQC*, NICOR, BCS, ACTACC, SCPS and there is cautious optimism it might be possible to reach the ‘start line’ in April. In broad terms we are proposing we move away from ‘The pilot is fit to fly’ to ‘This airline is safe (and our pilots are all safe)’. We do hope you will support this venture. Although our audit to date has been successful in many ways it has also been a major source of tension and we sincerely hope this proposal will be seen as beneficial to the specialty. We encourage you to contact us if you can foresee issues with our plans: sctsadmin@sct.org n NICOR – National Institute for Cardiovascular Outcomes Research HQIP – Health Quality Improvement Programme ACTACC – Association of Cardiothoracic Anaesthesia and Critical Care BCS – British Cardiovascular Society SCPS – Society for Clinical Perfusion Scientists CQC – Care Quality Commission

the 22 bulletin

The 2020 Getting it Right First Time (GIRFT) Programme in cardiothoracic surgery Doug West, Cardiothoracic National Clinical Lead, Getting it Right First Time

his year sees the second GIRFT programme in cardiothoracic surgery, following David Richen’s original 2018 report. Pioneered by Prof Tim Briggs in orthopaedic surgery, GIRFT is a clinically led national quality improvement programme that addresses unwarranted variations across NHS England. It does this by developing “data packs” for trusts, which are drawn from multiple NHS sources including NICOR, cancer registries and Hospital Episode Statistics (HES), but also from questionnaires filled in by Trusts themselves. Clinical teams reflect on these data together with GIRFT personnel on-site visits, before local recommendations and an action plan are drawn up. The learning form these visits will feed into a national report and action plan, expected in early 2021. GIRFT sets out to identify examples of good practice in both its data analysis and site visits, and to disseminate these quickly through its local and national reports so that all patients can benefit from excellent care. Quality improvements come from clinical teams themselves, with GIRFT facilitating reflection, and accelerating the spread of best practices. It is not a compliance exercise; NHS Improvement has no big book of how to run a cardiothoracic unit to follow. The ideas come from clinical teams, with a pragmatic focus on what can be shown to work.

Reflecting on David Richen’s first report, themes of limited resources and a need for better treatment pathways stood out for me. In several areas, improving clinical care and the efficient use of resource find common cause. For example, day of surgery admission is routine in some units, improving patient experience while releasing bed space, but in other hospitals patients have little access to it. In emergency care, pathways

work. Similarly, the way we accept urgent referrals matters, with evidence that surgeon-of-the-week models and electronic referral tools can speed up a safe transfer to surgery. There is also a need to define subspecialty practice better. The first report set a goal to have aortovascular and mitral surgery in particular delivered by subspecialist surgeons. We need consensus around what defines subspecialisation; case volumes, training, resources and team structures probably all play a part. Lastly, GIRFT really needs real-life examples of best practice. If your unit has evidence of good outcomes in some part of your practice, please tell us. We are also interested in the blocks that you experience to safe and effective surgery. Better care will bring its own savings, as reduced complication rates and shorter hospital stays reduce waste, so our primary focus is not on cost cutting. When I was appointed to succeed David last year, I admit to some trepidation – alongside a lot of excitement – at the challenge ahead. However, our specialty abounds with innovative, motivated surgeons and surgical teams. I’m optimistic that there is much good practice to adopt and disseminate, and I look forward to meeting and learning from as many of you as possible as we start unit visits later this year. n

“GIRFT sets out to identify examples of good practice in both its data analysis and site visits, and to disseminate these quickly through its local and national reports so that all patients can benefit from excellent care.” to surgery are often complex and inconsistent, adding to stress and fuelling delays for our patients. Again, service reorganisation could improve patient care while reducing unnecessary workload on clinicians chasing results and performing administrative tasks. There is huge opportunity for our Society to provide leadership and direction. A priority at national level is to define optimal acute pathways, similar to the National Optimal Lung Cancer pathway. For example, what investigations are essential before a referral for urgent revascularisation? Which patients could wait safely at home, and what disease patterns mandate the extra resource of in-patient waiting? Standardisation here could improve care and reduce unnecessary

August 2020

the 24 bulletin

Thoracic Audit Update: where next for LCCOP? Doug West, Audit Subcommittee Chair

ith a separate article in this Bulletin dedicated to the Society’s proposals for reforming adult cardiac audit, I’ve taken the opportunity to focus this article on the significant changes to the NHS England Lung Cancer Clinical Outcomes Project (LCCOP) project this year. LCCOP began in 2014 and has provided an annual report every year since. Produced by the National Lung Cancer Audit working with the Society, it was the first compulsory audit of lung cancer surgery in England. Over time it has developed, incorporating risk adjustment, longer term outcomes and new metrics such as unit – level resection rates and readmissions in later reports. The Society has supported LCCOP as a means to reassure patients about the quality of care, and to help units reflect on and improve their service. There is more that should be done to develop it, but the universal reporting of results for every patient and every NHS unit was a milestone for lung cancer surgery. LCCOP is delivered by the NLCA as part of its wider contract with HQIP. Last year, the NLCA was re-commissioned. The

invitation to tender for the new contract was released later than expected. When it was released, the terms proposed by HQIP led the NLCA team to decide not to submit a bid. No other acceptable bids were received, and several months of negotiation between NLCA (who are hosted by the London College of Physicians) and HQIP ensued. In the last few weeks, a 15 month contract has at last been agreed between HQIP and NLCA. This agreement will deliver a pared-down version of the lung cancer audit, and with it LCCOP. Although it is welcome that LCCOP will be delivered in some form, we are concerned that there is no intention to produce a formal report; the contract agreement is only to produce data tables. The SCTS have voiced concern, believing that a report of some kind is essential both to interpret the raw data and to set it in a clinical context. We also think that a dissemination plan is vital if LCCOP is to continue to have impact. We have seen huge improvements in our specialty during the period of the LCCOP project. VATS has displaced open surgery as the commonest approach to lung resection, hospital stay has fallen significantly, and

“We have seen huge improvements in our specialty during the period of the LCCOP project. VATS has displaced open surgery as the commonest approach to lung resection, hospital stay has fallen significantly, and far more patients now receive potentially curative surgery.”

far more patients now receive potentially curative surgery, with an increase of over 1000 operations/year in just the last three years. We must not let the focus of government and other stakeholders be diverted at this vital time, when despite our efforts, resection rates continue to lag equivalent European and other nations. The Society is exploring how we could support a report and dissemination plan this year, while a longer term solution is worked upon. We are also engaging with the Roy Castle Foundation to obtain patient feedback on the audit, and to make sure that any future project meets patient needs. We should have a better idea of what is possible in the next few months. These events mean that this year’s validation round will be later than in previous years, and is now expected between mid-September and midOctober 2020. As always, your oversight of the data is an essential part of improving its quality, so please do validate your unit’s data in good time. The results are expected in the first quarter of 2021. We anticipate largely the same outcomes as reported last year (30 and 365 day adjusted survival, median length of stay, 90 day readmission), but following the reporting of the VIOLET trial last year we are trying to have VATS rates in earlystage disease included as a new metric. While the organisational structures of national thoracic audit may be changing, the Society continues to advocate for universal and transparent reporting, team-based assessment and support for clinical teams to reflect upon and improve their practice. We can’t return to an era when outcomes were unknown to patients, and to the clinicians charged with their care. Thank you all for the contributions you make to thoracic audit. n

August 2020

SCTS Education report June 2020

Sri Rathinam, SCTS Education Secretary Carol Tan, SCTS Education Secretary

he Education Team have had an exciting, challenging and very gratifying six months both prior and during the COVID-19 crisis. We were very excited at the prospect of a great AGM, to which members of education committee contributed. In addition we had the annual SCTS-Ionescu as well as SCTS-Ionescu 90 award rounds. All our excitement was stifled with the pandemic. However, the pause due to the pandemic has offered us an opportunity to streamline our committee activity as well as look at measures of sustaining the education agenda.

Changes due to COVID-19 Every crisis and challenge offers an opportunity to look at alternative ways of functioning. The COVID-19 crisis has had a significant impact with cancelled courses and logistical issues. But it has also offered us the pause time to look at

our strategy and direction of travel, as well as novel methods of functioning. We have used various virtual reality options to both conduct business as well as to offer education.

New Education Committee The education committee welcomes new members who were interviewed and appointed. Carol Tan has been appointed as Co Education Secretary. Deborah Harrington and George Asimakopolous, who have both been active as course director and faculty on the NTN courses over the past few years, have been appointed as tutors after interviews. Rajesh Shah (President Elect) returns to Education committee as the executive representative. We also welcome Prof Prakash Punjabi and Shazad Raja as consultant education leads, Prof Farah Bhatti and Karen Booth as medical student leads and Shafi Mussa as the accreditation lead. It is with great pleasure

we congratulate the new members who will drive our education agenda forward and come in with new ideas and vision.

Education Committee Co Chairs: Sridhar Rathinam and Carol Tan Executive member: Rajesh Shah Consultant Education Leads: Prof Prakash Punjabi and Shazad Raja NTN Education Leads (Tutors): Deborah Harrington, George Asimikapoulous SAS Education Leads: Uday Dandekar Congenital Lead: Attilio Lotto Medical Student Education Leads: Prof Farah Bhatti and Karen Booth AHP Education Lead: Bhuvana Krishnamoorthy Trainee Representatives: Duncan Steele, Abdul Badran Accreditation Lead: Shafi Mussa Education Administrators: Letty Mitchell, Emma Ferris

the 26 bulletin

Five year strategy Education committee had a mission statement and vision first published in 2013. It was gratifying to see we have achieved most of our goals for the first five years. We have now looked at the vision for the next five year plan and vision.

SCTS-Ionescu Collaboration The SCTS membership has immensely benefitted from the collaboration between the SCTS and Mr Marian Ionescu with his benevolent contributions to the society for educational activities over the years. Our benefactor turned 90 recently and this was commemorated with an additional round of fellowships. We have detailed that is a separate report in this bulletin.

the courses using advanced web communication models. They have detailed that in the tutors report with dates of postponed and restructured courses soon to be confirmed. In addition, we will be offering early introduction to congenital cardiac surgery under the leadership of Attilio Lotto. The Curriculum change implementation has been postponed to 2021 and the team are looking at reorganising the course portfolio to correlate with a seven year pathway. We are measuring success by getting assessment and feedback from the first cohort of NTNs which has completed the whole portfolio of courses (2013-2019).

SAS Education

Multi-Disciplinary Team Education

We will continue current structure with the wet labs and professional development in the existing two courses (Ashorne Hill). We had planned a third course with cadaveric simulation but this is now suspended due to COVID-19 crisis. There is a move to reduce the gap between NTN and Non NTN education for virtual courses planned.

The Team Human Factors Course is planned for 30th September 2020 at Harefield Hospital pending PHE guidance.

Medical Student Education

Consultant Education 3rd Master class on Mentorship planned for 21st March 2019 in the SCTS in Celtic Manor 2020 was deferred and will be offered a Webinar soon.

NTN Education The new tutors Deborah Harrington and George Asimikapolous are restructuring

Student engagement section which had a great programme for the AGM will now be offered as webinars in June. The next Student engagement event has been awarded to the joint bid from Scotland.

AHP Education The AHP team have done a great job, even during the COVID-19 crisis, with webinars and SCP examination preparation. This has been detailed in the AHP education report.

RCSEd / SCTS Webinars Webinars launched in Feb 2017 with a COVID break will recommence in June. With the advent of various platforms we are now venturing into webinar debates and panel discussions. The administrators Letty Mitchell and Emma Ferris have worked relentlessly to run all the courses very efficiently. As the course portfolio has evolved and the number of fellowships offered has increased, their workload has increased exponentially. They have welcomed that with a big smile, so please respond to their emails regarding communication details, or reports in a timely fashion. Thank you Letty and Emma! Every success relies on peopleâ&#x20AC;&#x2122;s passion, motivation and commitment; we have great section leads, faculty, and administrative team. The SCTS Education has been offering various courses to our members free at the point of delivery and has sustained that for the last seven years. It would not be possible but for the benevolence of our benefactors and strategic educational partners from industry. They have supported us in our endeavours in educational and training by offering logistics and financial support. A big thank you to all of them! We hope and pray you all stay safe and hoping to meet you all in the new normal way. n

August 2020

SCTS Education tutors’ report Debbie Harrington, SCTS Thoracic Tutor George Asimakopoulos, SCTS Cardiac Tutor

e were both delighted to be appointed joint surgical tutors earlier this year but at the same time sad to be immediately involved in decision making to cancel or at least postpone many of our NTN courses planned for this year. Fortunately the ST5A Intermediate Viva Course and the ST7A FRCS (CTh) Revision Course were both able to be held at Ashorne Hill at the beginning of the year. We also held a very successful ST6A and B course at the Johnson & Johnson Institute in Hamburg back in February, despite some challenging logistical arrangements. Once again we would like to thank the course directors and faculty for all their hard work in organising and running these courses which were extremely well received by the trainees. Sadly the ST3B Operative Cardiothoracic Course in Hamburg was cancelled at short notice due to the COVID-19 pandemic and apologies to all involved for any inconvenience caused due to this. As we go to press, all courses until September are currently postponed, although we are hopeful that we will be able to run at least some of the scheduled portfolio in the autumn. We have been exploring various possibilities in order to facilitate this including the option of a hybrid model using part virtual teaching via zoom or similar platform and the use of regional hub facilities for practical

and wetlab aspects. We are optimistic that courses planned for Ashorne Hill eg the Introduction to Speciality training in Cardiothoracic Surgery (ST3A) course planned for 7th-9th September and the Core Cardiac Surgery Course (ST4A) planned for 23rd -25th November will still go ahead, although clearly significant changes due to social distancing will be required. Going forward, one of the positive aspects of the pandemic has been the increased use of virtual learning platforms

reschedule them for next year and potentially run either 2 year’s courses together or 2 courses back-to-back. We will keep those involved updated as we find out more. Once again we would like to extend a huge thank you to Emma Ferris & Letty Mitchell in the SCTS Education administration team. They are responsible for running the entire portfolio of SCTS courses, for NTNs, non NTNs and AHPs, including organising travel, accommodation and logistical arrangements. We would encourage all trainees and faculty members to ensure the team at SCTS Education has your up-to-date contact details including email address and phone number (education@ scts.org). Please respond to emails as promptly as possible once contacted. Unfortunately the cost of courses continues to increase, so booking as early as possible at least limits our cancellation charges. We will be revising the current portfolio of courses during the next year or so to coincide with the introduction of the new curriculum from August 2021. We are also looking at providing some new courses relevant to subspecialty areas for senior trainees. More details to follow in due course. Please bear with us over the next few months as we all continue to work through the COVID pandemic. We will be in touch as soon as possible regarding rescheduled courses and an updated portfolio. Stay safe everyone. n

“As we go to press, all courses until September are currently postponed, although we are hopeful that we will be able to run at least some of the scheduled portfolio in the autumn. We have been exploring various possibilities in order to facilitate this.” which have now become a regular part of all our lives. We are planning to incorporate such virtual learning into some if not most of our courses going forwards. This will potentially enable us to improve both efficiency and make cost savings for many of our courses and prioritise face to face learning for operative and wetlab sessions. The cancelled ST3B and ST8A courses due to take place in Hamburg will unfortunately not now happen this year but we are hopeful that we will be able to

the 28 bulletin

SCTS Nurses and Allied Health Professional Educational report 2020 Dr. Bhuvaneswari Krishnamoorthy, National Educational AHP & Nurses Lead, Mrs. Tara Bartley, Co- National Educational AHP & Nurses Lead

y hearty congratulations to everyone working on the front line working during the COVID-19 pandemic. My best wishes for all of you to be safe and keep doing the great job. We are all so proud of you.

Educational Courses:

Successful webinars for Nurses and AHP were conducted on topics on “Life and role of Surgical Care Practitioners during COVID-19”, “Thoracic surgery impact during COVID”, “Impact of Cardiac surgery”, “Health & wellbeing Yoga and acupuncture session”, “Endoscopic vein harvesting during COVID” and so on. If you have missed any of them please watch on “CTSnet” ACT SCP website and https://www. youtube.com/ watch?v=-knx_ FOrq8A&t=470s

In January 2020, we had a successful Surgical Skills course in CT surgery with 42 delegates and 28 faculty members. The overall mean score of the course was 4.8 with great feedback.

Due to the COVID pandemic, we are not able to run the rest of the planned Nurses and AHP courses this year until the restrictions are lifted

Webinars:

New educational structure: Currently, I am looking for enthusiastic members who are interested in becoming “Educational tutors”. I need one tutor each for cardiac and thoracic surgery, perfusion, physiotherapy, occupational therapy, and surgical care practitioners.

Your role will be working closely with the Education lead in designing, bringing the team together, co-ordinating the faculties, raising the educational fund and conducting two national educational courses in your surgical field per year. If you are interested, then please contact Dr. Bhuvaneswari Bibleraaj, email: biblerab@edgehill.ac.uk

Annual meeting for surgical care practitioners: The main aim of this meeting was to create an educational event consisting of innovations in cardiothoracic surgery. Abbott kindly supported the meeting with the use of Abbot Medical Centre on 24th November 2019 at Solihull, Birmingham. The welcome address was given by ACTSCP President Dr. Bhuvaneswari Krishnamoorthy. The keynote speaker Mr. Richard Page, President of SCTS gave an excellent opening speech about the importance of SCPs in CT surgery. He reminiscenced about the journey of the role of the SCP and the evolution of that role over the years. He emphasised on the value that SCPs bring to the cardiothoracic surgical teams both in service delivery, enabling training both by teaching younger trainees as well as freeing up senior trainees from service obligations. The morning session started with the important issue about SCP regulation/ registration and the SCP clinical exit examination. Mr Richard Page elucidated on the importance of the valid overseeing body and the work done by SCTS with the surgical colleges. Mr. Sri Rathinam, SCTS Education secretary and Chair of the Surgical Sub

August 2020

Speciality Board for CT surgery, RCS Edinburgh, highlighted the opportunities offered by SCTS by way of courses and fellowships for SCPs. He also informed the members of the process of SCP examinations. Mrs. Helen Munday highlighted the importance of the SCP in the SCTS AHP stream and the benefits of SCTS membership. The opening clinical presentation talked about the latest technologies in CT surgery consisted of Tenedyne, TAVI, and mitral clip. The other oral presentations outlined the role of the SCP in thoracic robotic surgery, endoscopic vein and radial harvesting, surgical site infection interactive discussion, current data on mini aortic valve surgery, latest development in ECMO, 3D camera technology and the use of Collagen for sternal wounds concluded the meeting with surgical treatment for atrial fibrillation. Each session had the delegates interacting using Slido to enable an anonymous question and answer session.

Virtual online courses: We are planning to do online courses and offer educational materials which will be available on our website AHP section. All the face-to-face educational courses has been postponed until early next year. n

AQUABRID® Developed for wet conditions AQUABRID® is a fully synthetic surgical sealant for aortic surgical procedures. In contact with water AQUABRID® forms an elastic layer within 3 to 5 minutes – making it optimal for use on wet conditions. AQUABRID® stretches and shrinks with contraction of the vessel, while maintaining a strong seal in the aorta.1, 2

Benefits of AQUABRID® Reacts with water – Optimal use on wet surfaces, regardless of heparinization conditions

Strong – Maintains bond/seal in the high pressure environment of the aorta

Ready to use – No manual mixing or preparation required

100 % synthetic – No biological origin or risk of infection

Elastic – Stretches and shrinks with the vessel contractions

REFERENCES: 1. Eto M et al. Elastomeric surgical sealant for hemostasis of cardiovascular anastomosis under full heparinization. Europ. J. Cardio Surg. 2007; 730-734. 2. Oda S. et al. Experimental use of an elastomeric surgical sealant for arterial hemostasis and its long-term tissue response. Interac. Cardiov. and Thor. Surgery. 2010; 258-261.

AQUABRID_Ad_SCTS_180x130mm_UK_0620.indd 1

Contact details: TERUMO UK Ltd. Otium House, 2 Freemantle Road, Bagshot, Surrey, GU19 5LL, U.K. Phone: +44 77 40 40 54 71, E-mail: laura.haughton@terumo-europe.com

www.terumo-europe.com

10.07.20 15:34

the 30 bulletin

Report of the 2020 SCTSIonescu Fellowships Sri Rathinam, Consultant Thoracic Surgeon, University Hospitals of Leicester

he Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) offers fellowships to various members of our fraternity. The broad range of the Fellowships were offered to all SCTS members to benefit Consultants, all grades of Trainees, Nurses, Allied Health Professionals and Medical Students. This annual portfolio of Fellowships is sponsored by Mr Marian Ionescu. Marian Ionescu is a retired cardiac surgeon from Leeds. He is a surgical innovator and pioneer who introduced various techniques in cardiac surgery, as well as invented the pericardial valve. After a successful cardiac surgical career, he focused on mountaineering and has scaled most peaks in the world. Mr Ionescu has supported the SCTS with his donations to the society for educational activities for many years. His contributions over the years have enabled the SCTS-Ionescu University, SCTS-Ionescu Fellowships, the Perspectives in Cardiothoracic Surgery and recently the Ionescu Foundation courses. Mr Ionescu reached a remarkable milestone recently, he turned 90 but still has the relentless passion and continues to be a great inspiration and role model. This year we had the pleasure of offering two distinct categories of fellowships, the annual SCTS fellowships and an extraordinary round of fellowships to commemorate Mr Ionescu’s 90th birthday. SCTS was honoured and privileged to announce this special round of fellowships with Mr Ionescu’s continued support to the wider cardiothoracic multidisciplinary community. The applications were advertised in the SCTS website as well as by flyers to all the members. The deadline was 15th January 2020. All applications were scored to the SCTS Scoring Matrix by a panel of SCTS Officers and the scores were averaged to rank the candidates. The final awardees were finalised by unanimous decision by the SCTS Executive members and education leads.

Programme, to visit the Duke University Medical Centre to learn from Prof John Haney on Cardiothoracic Transplantation and Mechanical circulatory devices. The trip will also focus on donor management and perioperative care. SCTS-Ionescu Non-NTN Surgical Fellowships: 2 awards, £10,000 each The Marian and Christina Ionescu Travelling Fellowship for a consultant: 1 award, £10,000 Balacumaraswami Lognathen, Consultant

Cardiothoracic Surgeon from University Hospitals of North Midlands, to visit Dr Keita Kikuchi in the Ichinomiya Nishi Heart Centre, Aichi, Japan to observe and learn technical aspects of multi vessel minimally invasive CABG using bilateral mammary artery conduits.

Saqib Qureshi, Clinical Fellow in Nottingham

City Hospital, to support travel for a fellowship in Ottawa Heart Institute fellowship for holistic cardiac surgery including minimally invasive coronary and TAVI. Allessia Rossi, Senior Clinical Fellow St

Bartholomew’s Hospital London, to learn minimal access Mitral (and aortic) surgery, focusing more on mitral valve surgery in the Heart Hospital Gaetano Paquinucci Massa under Dr Marco Solinas.

SCTS-Ionescu Consultant Team Fellowships: 2 awards, £15,000 each

SCTS-Ionescu Non-NTN small travel awards: 1

Enoch Akowuah, Consultant Cardiac Surgeon

Anas Boulemden, Senior Clinical Fellow

in James Cook University Hospitals, to visit Prof Doug Murphy in the Emory University School of Medicine Atlanta USA and Prof Czerny Prague to learn and develop robotic mitral surgery. Apostolos Nakas, Consultant Thoracic

surgeon in University Hospitals of Leicester, to visit NYU Langone Health and Memorial Sloan Kettering Cancer Centre, New York, USA, Duke University Medical Centre, North Carolina, USA and University Hospital Zurich, Switzerland to focus on robotic thoracic surgery, mesothelioma and minimally invasive thoracic surgery. SCTS-Ionescu NTN Trainee Travelling Fellowship: 1 award, £10,000 Jason Ali, Royal Papworth Hospital specialist

Registrar East of England Training

award, £5,000 (split to two awardees)

in Nottingham University Hospital, for a clinical immersion under Mr Ulrich Rosenthal in the Royal Brompton Hospital to learn complete aortic care pathway and technique of root and arch surgery including aortic adjunct procedures. Florentina Popescu, Clinical Research Fellow

University Hospitals of Leicester, to visit Toronto General Hospital for clinical immersion in Cardiothoracic Transplant under Prof Shaf Keshavjee.

SCTS-Ionescu Nursing & Allied Health Professional Fellowships: 2 awards, £5,000 each Paula Agostini, Senior Physiotherapist

Birmingham Heartlands Hospital and Senior Lecturer University of Birmingham, to visit Alfred Hospital Monash University Melbourne and Auckland Hospital New Zealand to focus on enhanced recovery and pre-habilitation.

August 2020

Nehru Devan, Senior SCP in University Hospitals of Manchester, Wythenshawe, to visit Prof Robert Cerfolio’s unit in NYU Longone Lung Cancer Centre. This visit will focus on understanding and assisting in Robotic assisted thoracic surgery.

SCTS-Ionescu Medical Student Fellowships: 2 awards, £500 each Lauren Shipperbottom, from the University of

Birmingham, to visit the Hospital for Sick Children in Toronto. The elective clinical immersion would cover cardiology and paediatric cardiac surgery under Prof David Barron. Keeran Vickneson, from the University of

Dundee, to visit National University of Singapore under Prof V Sorokin for a 6-week clinical immersion.

Ed Peng, Consultant Cardiac Surgeon

in Royal Hospital for Sick Children Edinburgh, to visit Lucille Packard Children’s Hospital, Stanford Paolo Alto California. The team will visit Prof Hanley’s unit to learn from their experience on pulmonary atresia, VDS and major aortopulmonary collaterals with emphasise on complete uni-focalisation and incorporation of all segments. SCTS-Ionescu 90 NTN Trainee Travelling Fellowship: 1 award, £10,000 Simon Duggan, Specialist Registrar in

Wessex deanery Southampton, to go on a fellowship to Service de Chirugie Thoracique, Cardiaque and vascularie in Rennes. The fellowship will focus on aortic surgical training under Prof Verhoye. SCTS-Ionescu 90 NTN small travel award: 1 award, £5,000 Azhar Hussain, from Castle Hill Hospital

SCTS- Ionescu 90 Travelling Fellowship for a consultant: 1 award, £10,000 Indu Deglurkar, Consultant Cardiac Surgeon

University Hospitals of Wales Cardiff, to visit Harvard school of public health and university hospitals to observe operational management of cardiac services including operating theatres transformation process. SCTS-Ionescu 90 Consultant Team Fellowships: 3 awards, £15,000 each Ehab Bishay, Consultant thoracic Surgeon

Birmingham Heartlands Hospital, to attend Liverpool Heart and Chest Hospital and Isalla clinic Zwolle Netherlands for a clinical immersion in robotic assisted thoracic surgery. The Team will be supervised by Mr Steve Woolley in Liverpool and Dr Ghada Shahin in Zwolle. Jonathan Hyde, Consultant Cardiac Surgeon

in Royal Sussex University Hospitals Brighton, to take his team to the Prince of Wales Hospitals Hong Kong. The team will focus on all aspects of Aortic Surgery under the tutelage of Prof Malcolm Underwood.

SCTS-Ionescu 90 Nursing & Allied Health Professional Fellowships: 4 awards, £5,000 each Rebecca Boyles, Research Nurse University

Hospitals of Leicester to visit University Hospitals Zurich, NYU Langone Health, New York, USA, Duke University Medical Centre, North Carolina, USA to observe clinical practice in enhance recovery, perioperative care and research pathways. Jody Stafford, Senior Clinical Perfusionist

University Hospitals of Wales, to attend the simulation Instructor course and Simulation conference to gain insights into using simulation in Cardiopulmonary bypass training. SCTS-Ionescu 90 Medical Student Fellowships: 4 awards, £500 each Jamie Walsh, Queen University Belfast to

visit Children’s Health Ireland Crumlin to get clinically immersed in Paediatric cardiac surgery.

Hull Specialist registrar in Yorkshire Deanery, to visit the National Institute of Cardiovascular disease in Karachi. The visit aims to get focused experience in mitral valve surgery under Prof Rathore.

Ramanish Ravishanker, University of

SCTS-Ionescu 90 Non-NTN Surgical Fellowships: 3 awards, £10,000 each

to visit the Royal Papworth Hospital Cambridge, Great Ormond Street London and University Hospital Zurich for a comprehensive clinical immersion in paediatric cardiac surgery, transplant surgery and thoracic surgery.

Joyce Thekkudan, Senior Clinical fellow

Glenfield Hospital Leicester, to visit the Rigshospital Copenhagen to observe Prof Hansen. The fellowship also involves a visit to the Wayne state university Detroit to observe robotic thoracic surgery and thoracic trauma as well as health research. Imtiaz Manoly, senior clinical Fellow James

cook University Hospital Middlesboro to visit the Berlin Heart centre to focus on complex aortic surgery and TAVR under Prof Kempfert and Falk. It will also cover a visit to Beijing Azhen Hospital to observe complex aortic surgery. SCTS-Ionescu 90 Non-NTN small travel awards: 1 award, £5,000 each Emmanouil Kapetanakis, Thoracic Surgical Research Fellow Mater Misericordiae University Hospital Dublin, to visit the George Washington University Hospital Washington for a holistic clinical experience in thoracic surgery under Prof Keith Mortman.

Edinburgh, to visit New York Presbyterian Hospital in Columbia University to clinically immerse in high volume cardiac surgery. Savannah Gysling, University of Nottingham,

Ha Baro Trung Lee (Tommy), from University

of Edinburgh, to visit the Cho Ray Hospital in Ho Chi Minh City Vietnam. This visit will offer insight into various cardiothoracic procedures including VATS and valvular heart operations. These awards in normal times are announced in the annual gala dinner in our annual general meeting, however this year due to the Covid Crisis the meeting was cancelled. The Executive committee has decided to increase the time frame for use of the funds to these exceptional candidates so that they can make travel plans after the pandemic. The Education committee would like thank Mr Ionescu for his benevolence and the opportunity to offer these valuable fellowships to our members. n

the 32 bulletin

Education and Implementation of Lung and Sternal Ultrasound for Nurses and Physiotherapists in the Cardiothoracic Ward Lynda Tivendale, Cardiothoracic Research Nurse, The Royal Melbourne Hospital, Department of Surgery, Melbourne, Australia

oint of care ultrasound (POCUS) is supported by evidence and is fast emerging as a key imaging technology that impacts on medical and clinical patient care affording accurate and timely diagnosis of lung pathology including pneumothorax, pleural effusion, pulmonary oedema and atelectasis at the bedside. On the immediate horizon, are mobile ultrasound devices that can be carried throughout an entire shift â&#x20AC;&#x201C; the emergence of â&#x20AC;&#x153;Personal Ultrasoundâ&#x20AC;? (PERSUS). Lung ultrasound is a tool that can provide a rapid, non-invasive real-time at the bedside assessment of the respiratory system without exposing patients or staff to

Patient engaged with ultrasound imaging

ionizing radiation and without requiring transportation of the patient. In the cardiothoracic setting, it is frequently more accurate than a chest x-ray. The real-time information impacts on better quality and more timely clinical decision making; that drives better patient outcomes. Post-operative pulmonary complications are the most common complication following major cardiac and thoracic surgery causing significant increases in length of stay, use of resources and overall hospital costs. Most concerning is the significantly worse 30-day mortality rate in patients who develop post-operative

pulmonary complications in the first seven days following surgery. In a recent study of a cohort of pre-operative cardiac surgery patients, the addition of lung ultrasound led to the early detection of lung pathology in 56% of patients, and was reported to be more accurate than chest x-ray and physical examination in addition approaching accuracy of CT scans (Ford JW et al, 2016). The median sternotomy remains the most commonly utilized incision in cardiac surgery. Sternal ultrasound provides a valid and reliable means of monitoring and assessing sternal stability. This facilitates timely management to avoid progression to sternal infection or can prompt earlier operative re-intervention (El-Ansary et al 2007; Balachandran et al, 2017). The nursing and physiotherapy leadership team and staff within the cardiothoracic ward at the Royal Melbourne Hospital were very keen to train in lung and sternal ultrasound so as to integrate this into their clinical practice. Ultrasound education has traditionally been delivered using a delivery that primarily utilizes didactic workshops and online platforms. Evaluation of the traditional approaches and platforms have shown that the retention of knowledge and translation to clinical practice is minimal and therefore not ideal. As such the interdisciplinary team within the University of Melbourne Mobile Learning Unit including members from the Nursing, Physiotherapy and Medical professions collaborated to design and develop a blended education and training program for clinical lung and sternal ultrasound.

August 2020

Sternal edges

The program we have commenced includes online education, a supervised practical workshop, facilitator led and selfguided training using high fidelity ultrasound simulators in the University of Melbourne Ultrasound Simulation Centre and our novel approach of mentored clinical ultrasound ward rounds with our multidisciplinary team to Lung ultrasound being bridge the education gap. performed at the bedside The mentored clinical ward rounds are imaging skills within the held weekly and led by a facilitator within clinical setting and also the cardiothoracic ward. They provide the preferred learning an interactive learning environment with modes that facilitates integration into clinical acquisition of the image by the nurse/ practice. The project was presented at the physiotherapist leading to discussion of recent European Association of Cardiothe clinical implications and findings at the Thoracic Surgery (EACTS) conference in bedside. All findings are communicated Lisbon 2019 and Australian New Zealand to the treating medical team and images Cardiothoracic Surgery (ANZSCTS) uploaded onto the hospital system for staff to Scientific Allied Health Day conference in utilize to inform patient management. Hobart, Australia 2019. As this is the first blended learning To date 33 of our cardiothoracic nurses education program to include all four modes and 5 cardiothoracic physiotherapists have of teaching and learning delivery, we are completed the education program. Lung evaluating the outcomes in the form of a and sternal ultrasound assessments are research project that investigates knowledge now commonly practiced by the nurses acquisition and translation of ultrasound

â&#x20AC;&#x153;The nursing and physiotherapy leadership team and staff were very keen to train in lung and sternal ultrasound so as to integrate this into their clinical practice.â&#x20AC;?

Professor Royse leading the clinical mentored ward rounds

Pleural effusion measuring 780 mls

and physiotherapists in our cardiothoracic ward. The patients are receiving real time management of the common presentations of pleural effusions, collapse and consolidation in the post-operative period. The patients are very engaged with ultrasound at the bedside and the discussion around the implications and management of the findings. To increase the accessibility to training and implementation into the clinical practice we have developed a fully online course inclusive of simulation cases and ward round case studies. For further information: go.unimelb.edu.au/bx4r or lynda. tivendale@mh.org.au. The implementation of lung and sternal ultrasound as an assessment tool is in line with robust evidence to support it and has been embraced with enthusiasm and commitment by the cardiothoracic nurses, physiotherapists and senior management. The primary focus is constantly highlighted, as we seek better outcomes for our patients. n

the 34 bulletin

Aortic surgery training in the UK â&#x20AC;&#x201C; current perspectives Ana Lopez-Marco, Aortic Surgery Fellow Professor Aung Oo, Consultant Cardiac and Aortic Surgeon Barts Heart Centre, St Bartholomewâ&#x20AC;&#x2122;s Hospital, London

he current training programme in Cardiothoracic Surgery in the UK encourages sub-specialisation with the trainees usually declaring their preferred area of interest during the last years of training in order to arrange the appropriate fellowships. However, any Adult Cardiac Surgeon in the UK has to be competent in performing routine aortic procedures (i.e. ascending aorta and root replacements) and also emergency aortic dissection repair. With that in mind, we wanted to have an idea of the current level of aortic training delivered to the current senior trainees in the UK. This information will be very useful to incorporate on the entry criteria for the Post CCT UK Fellowship in Aortic Surgery programs that we are currently developing.

Methods We designed a short survey using Google Survey platform. The survey was aimed to National Trainees currently at ST7-8

level or those with CCT waiting to secure a consultant job. We sent the link to the survey to 40 people and have obtained 25 responses (62% participation rate).

Results The majority of the trainees contacted who participated were in the ST7 year (44%). Ten trainees (40%) were at ST8 Level and four people (16%) had already finished the program and achieved the CCT. We had a broad representation from almost all Training Deaneries: London (28%), Wessex (12%), West Midlands (12%), East of England (8%), North East (8%), North West (8%), Wales (8%), South West (4%), Yorkshire (4%), Scotland (4%) and Ireland (4%). Aortic Surgery seems to be a very popular sub-speciality career choice. While 40% recognized openly to be interested in persuading an aortic career, another 48% keep their mind open to that possibility and only 12% (three people) declare no interest in aortic surgery.

However, only three people (12%) have done an aortic fellowship during or after their training. Two of those fellowships (67%) were UK-based (London) and only one was done abroad (Brussels).

Training oportunities in aortic surgery Ascending aorta replacement Overall, the majority of the trainees had performed several ascending aorta replacements, distributed as follows: 44% had performed between 1-5, 20% had done between 5-10 and 16% of the trainees had done more than 10 aortic procedures. Only 20% of the trainees had not performed any ascending aorta replacement. (Fig. 1) Aortic root replacement The exposure to aortic root as primary operators is less frequent during training. Overall, 44% of the trainees had done 1-5 root replacements, 8% had done between 5-10 and 12% of the trainees had done more than ten roots. However, 36% of the trainees had not managed to perform any root replacement during their training. (Fig. 2) Complex aortic surgery When questioning about complex aortic procedures (i.e. arch or descending thoracic aorta replacements) only 36% of the trainees had performed at least one of those procedures during their training. (Fig. 3) Aortic surgery emergencies The traineeâ&#x20AC;&#x2122;s exposure to aortic emergencies as first operator seems quite low, with only 44% having done at least more than one case, but with none having done more than five emergency cases. (Fig. 4)

August 2020

Level of training seems to be an important factor, as the ST8 trainees had performed more aortic procedures than their ST7 colleagues. All the complex aortic surgery and the aortic emergencies seem to be performed during the last year of training. Geographical analysis revealed that the trainees who had performed more number of aortic cases were based at London, Wessex and Wales. In terms of providing complex aortic cases, London, Wessex, West Midlands and Northeast were the leading Deaneries. For aortic emergencies, only trainees from London, Wessex, West Midlands, East of England, Wales and Yorkshire had the opportunity to perform at least one aortic emergency during the last years of their training. Aortic Surgery Fellowships in the UK Liverpool Hearth and Chest has a wellestablished Aortic Fellowship programme that has been running for several years. The Aortic Fellowship is nationally advertised and is currently supported by the industry. Their training ethos has been broadly demonstrated, having trained some of the current Aortic Consultants in the country and overseas. Barts Heart Centre has welcomed this year their first nationally appointed Aortic Fellow, using funding from the awarded SCTS Ethicon Scholarship. In the previous years they have a dedicated Senior Registrar for the Aortic Team. The NTNs who participated in the survey after having done an Aortic Fellowship reported the widest experience in aortic cases, having done more than 10 ascending aortas and/or root replacements and having had exposure to aortic emergencies and other complex aortic cases. As previously mentioned, the Fellowships were done in London (Barts Heart Centre) and Brussels. We did not have response from the NTN Aortic Fellow at Liverpool Heart and Chest but as previously said their training history has been broadly demonstrated nationally.

Conclusions Results from this survey have highlighted areas to be targeted for improvement. Whilst the number of aortic cases performed during training does not currently preclude entry to complex aortic surgery fellowships programmes, it would be desirable that trainees have a wider experience in simple aortic procedures and emergencies before reaching the consultant status. n

Figure 1.

Figure 2.

Figure 3.

Figure 4.

the 36 bulletin

‘Heal the Heart’ Team: (l-r) Oluremi Laketu; Hunaid Vohra; Raza Rathore; Ishtiaq Rahman; Ettorino di Tomasso; Alessandra Navoni; Joel Dunning

‘Heal the Heart’ mission: setting up a Heart Institute in Mardan, Pakistan Ishtiaq A Rahman MD, FRCS C-Th, Post-CCT Fellow in Cardiothoracic Surgery, James Cook University Hospital

n February 2020 the ‘Heal the Heart’ team left for the first of three humanitarian missions to set up the first Heart Institute in Mardan, in NorthWest Pakistan. The team comprised of nine from four UK centres. To garner a local perspective, a UK trained surgeon and perfusionist were recruited from Karachi and Abbottabad respectively. The objective, of the first mission, was to perform the first ever cardiac operations, on below poverty-line patients, in Mardan.

ancient cities, farms, valleys and mountain ranges makes it an adventurers paradise. Mardan (population 400K), is the second-largest city of KP, after Peshawar. Here, the ancient Buddhist monastery of ‘Takht-i-Bahi’, a UNESCO World Heritage site, stands atop a hill looking down on the city. Mardan is a growing industrial centre and home to one of South Asia’s largest sugar mills. An economic zone is planned as a part of the multi-billion dollar ChinaPakistan Economic Corridor (CPEC).

Region

Stars Aligned

Khyber Pakhtunkhwa (KP) is one of Pakistan’s four provinces (population 28million). A reputation for hospitality and landscape of

The combination of hearing first-hand the sad story of a farmer, whose wife succumbed to heart failure as they could not afford

mitral surgery, an impromptu dinner with the Mardan Medical Complex (MMC) Hospital Director and a visit by my Consultant-trainer, Hunaid Vohra (Bristol), to Mardan presented both the need and the chemistry for a charitable mission. Hunaid and I visited the MMC, a 520-bed tertiary-care facility. The operating theatres and clinical sterilisation department were impressive. The cardiologists were enthusiastic as their bid to the government for catheter suite funding had failed due to lack of cardiac surgical back-up. Provincially, there had been a history of cardiac centres opening but not surviving. The cardiac units at Lady Reading Hospital, Peshawar, and Abbotabad Hospital were amongst the latest casualties following poor

August 2020

outcomes. The two closest centres of repute were two hours away in the capital Islamabad; Armed Forces Institute and Institute of Medical Sciences. There was desperate need for a good quality cardiac surgical centre in KP as waiting lists were over two years. A meeting with the Chairman of the Board of Governors of MMC energised us by his agreement to sponsor the mission.

‘Heal the Heart’ On returning to the UK the realisation of the magnitude of the commitment slowly dawned. The first step ‘to build a team’ seemed straight forward. However, this changed after the cautious Foreign and Commonwealth Office travel advice was shared. After widening the call nationally, the team was formed and ‘Heal the Heart’ registered with the Charities Commission. We liaised with Joel Dunning and Enoch Akowuah (Middlesbrough) who shared their Ghana mission experience and document templates. Joel kindly agreed to act as our ‘mission proctor’. Over the next six months our model to link our team members with counterparts in Mardan worked well. Required equipment lists were shared, relationships were built with up-skilling of the centre. Raza Rathore (local surgeon) and Zubair Ahmed (St Barts), made a visit

Ishtiaq Rahman and Hunaid Vohra performing first CABG in Mardan

to MMC to check on progress and Zubair made arrangements to host his anaesthetic counterpart. Bristol Heart donated a Sorin S3 heart-lung machine and heater-cooler. ‘Justgiving’ crowdfunding donors kindly supported (£7,000) shipping to Karachi port and team flights. Equipment gaps were filled by donations from UK centres and borrowed from the cardiac unit at Lady Reading Hospital. In the last month, prior to departure, weekly team meetings on a webchat platform developed our team relationships and refined our plans.

Mardan After having reassured the team of Pakistan’s safety it was unsettling to be collected by a security detail of six vehicles at Islamabad Airport. After a short tour of the capital, we moved onto MMC. Here we peeled off with our counterparts and meticulously checked both equipment and patients. Jet-lagged, we retired to our quaint Parisian-style hotel, to enjoy local cuisine and slept. On the first day both stress levels and morale were high. After a ‘stitch by stitch’ dry run the months of preparation culminated in the first ever successful CABG case in Mardan. Over the next four days a further four cases were performed free of cost. It only

Alessandra Navoni teaching pacing wire removal

Joel Dunning with our first CABG patient

‘Heal the Heart’ Team: (l-r) Hunaid Vohra; Ettorino di Tomasso; Salman Khan; Oluremi Laketu; Joel Dunning; Ishtiaq Rahman; Alessandro Savi; Salman Butt; Zubair Ahmed; Hidayat Ullah

struck us what ‘below poverty-line’ really meant when the patients attended without shoes. As the MMC started to feel like a Heart Institute, the media broadcasted the success and the hospital was inundated with visitors and calls from more patients. Flaws in the local post-operative ICU care were exposed but thanks to our two intensive care nurses, these were identified and managed expeditiously.

Further Missions To enhance our next mission, planned for February 2021, we have agreed with the MMC executive to focus on developing the ICU. We will increase our ICU commitment to six nurses and two Intensivists whilst taking a more supervisory role. We have committed to offering their ICU nurses, perfusionist and scrub team clinical observerships in UK centres. The MMC has advertised for two Cardiac Surgical positions. We hope through our recommendations, the appointment of two surgeons and development of scrub, perfusion and ICU team the goal to establish a Heart Institute providing state of the art cardiac surgical practice free at point of delivery will be realised soon.

Final Thoughts Every member of our group expressed their desire to return for this highly rewarding humanitarian cause. Speaking to similar charitable groups, the intensity of the feeling of fulfilment is shared universally. We recommend other charities planning missions to seek support and guidance from experienced teams. Meticulous planning and preparatory visits to the receiving centre is advised. Nationally there is a role for development of the SCTS Charitable Missions Group to provide a platform to promote, sponsor and co-ordinate overseas missions whilst offering a forum for reporting. Overall, the high standard of UK cardiac surgical expertise is a welcome transferable asset to developing countries. Those interested should get involved as a short commitment can hugely impact the patients but also oneself in keeping with the philosophy of the 17th century Peshawar poet, Abdur Rahman Mohmand that ‘Humanity is all one body’. n Video: https://www.youtube.com/ watch?v=R9wHpScu-RU&t=10s

the 38 bulletin

The Power of Art in Cardiothoracic Surgery Keith Buchan, Cardiothoracic Surgeon Sayed Abdulmotaleb Almoosawy, Third Year Medical Student Megan Williams, Third Year Medical Student

ach year our third year medical students undertake a six week Medical Humanities project. They can choose to be associated with a wide range of departments at the University of Aberdeen. Some choose to be attached to a school-teaching course and get a chance to deliver lessons in a real school classroom, others do projects on historical subjects which are of particular interest to them. I have had two students who did their historical projects on important surgeons – John Hunter and Norman Bethune. Last year there was an option to do a medical art project. The results were displayed in the Medical School, now part of the Aberdeen Royal Infirmary complex. It was impressive to see how many of our students have a natural talent for art. Two of them resonated with me and having discussed it with the relevant students they have given The specimen of the lung by Sayed Abdulmotaleb

permission for their pictures to be published in this article with them as co-authors. The specimen of the lung has been drawn quite faintly so as to help disguise the fact that there is a story going on in the pulmonary parenchyma which requires a commentary. At first glance it might bring back memories of lung specimens in pathology museums. But on closer inspection there are little groups of houses which are being bombarded with explosives. Sayed follows the Cleveland Clinic twitter feed which from time to time relates interesting medical stories. One of them concerned a young Syrian refugee who fled his home town seeking refuge in America away from warfare and relentless attacks. Having reached America he was diagnosed with severe bilateral pulmonary fibrosis with no alternative causes and required extensive respiratory support. His story was the inspiration for the drawing. Art has a different effect on each of us but it struck me that there are parallel stories going on. The helicopter pilot’s view of the carnage that he is inflicting is comfortably distant from what is happening on the ground. Maybe we can be like that with our patients. Despite our carefully monitored and generally acceptable outcome results there is no doubt that for a small percentage of our patients we do inflict serious damage, although it could be argued that in most cases it was the peculiar combination of co-morbidities that was the principle agent of harm. I warn my students that there is an inverse relationship between how exciting and successful our careers are and the quality of our social and family life. Cardiothoracic Surgery is one of the more engaging and spectacular branches of medical practice. There is a danger for us that what is exciting and dramatic can have devastating consequences for our families due to the pull it has on us. To quote one former Aberdeen Professor of Cardiology – “The life which determines that a man leaves

home at 6.30am and doesn’t return until 7 or 8pm in the evening can destroy family life as effectively as infidelity”.1 I like the superhero comic strip layout of the student teaching session in Respiratory Medicine. This artwork accompanied a website based game that takes the player through medical cases from presentation to management under the guidance of a friendly consultant (www.ontheward.co.uk). The purpose of this project was to create a fun way for students to engage with their course material. I am allocated 24 two hour bedside medical student group teaching sessions per year and we often go to the medical wards to see patients, especially when they have been referred to me. There is the strange juxtaposition of what at one level seems very mundane (learning about causes of breathlessness) with the implied adventure and excitement of the cartoon book format. I often find it helps in getting a job done to trick my mind into thinking something is more important than perhaps it really is – think of filling in DVLA or critical illness forms or complying with “mandatory online generic training modules”. It has been a long time since I was a medical student but I have always felt that the value for money part of medical school was the patients we saw in clinical settings – we remember them and the knowledge they embodied far better than any lecture we listened to. It is vital that there is a personal encounter with a real patient – case based learning and actors may have their place but are not as effective as the authentic individual with a real condition. The simple story of this comic strip conveys the value of the clinical encounter to the medical student, especially when it is encouraged by the participation of an experienced clinician. n Reference

1. Real Success. D Short. Christian Focus Publications (1998), p81

August 2020

the 40 bulletin

Hands-on surgical training for congenital heart surgery: From A to Z Nabil Hussein, Cardiothoracic Surgery NTN Trainee, Yorkshire & Humber Deanery The Hospital for Sick Children (Sickkids), Toronto, Canada

n recent years the number of national cardiothoracic trainees choosing to subspecialise in congenital heart surgery (CHS) in the UK has been low. The reasons are multifactorial ranging from political instability, training limitations and increased public scrutiny1. Up to 20 new consultants will be required in the next decade based on predicted surgeon retirement and the effects of centres expanding the number of surgeons2. Therefore, there is a need to address this emerging workforce issue and has led to calls to evolve training paradigms to augment current curricula. At the Hospital for Sick Children (SickKids), Toronto, we have developed a reproducible simulation platform within CHS using 3D-printed heart models and have incorporated this into the training curriculum for our surgical residents and fellows. The 3D models are anatomically accurate and are developed from cross-sectional image data and subsequently modified to focus on the surgical anatomy. The pliable nature of the print material makes them an excellent modality to rehearse surgical procedures. The Hands-on Surgical Training (HOST)

curriculum covers the wide spectrum of congenital heart operations a surgeon may experience, with over 30 surgical simulation cases to choose from. We run both an annual 3-day HOST course open to trainees and consultants worldwide and an in-house monthly HOST session for our local trainees. The procedures for the curricula were chosen by the consultant surgeons within our institution. A congenital chest simulator was developed to increase the fidelity of simulation, closely resembling intraoperative ergonomics (Figure 1). Every case performed was video recorded for retrospective assessment using procedure-specific assessment tool developed to evaluate performance and provide fellows with objective feedback. The website (www.3dprintheart.ca) was created which includes training videos of the procedures for surgeons to refer to. In the past year we have successfully run two international HOST courses and completed a full year curriculum of the in-house HOST program (Jan-Nov 2019). Each month congenital heart surgical fellows performed a surgical case twice on 11 different cases (Table 1). 115 cases were completed by 7 fellows. 93% of the surgeons’ time improved (p=<0.0001) with 71% improving in overall score between the two cases (p=<0.005). The assessment tools have been validated and have a greater inter and intra-rater reliability than existing assessment tools used in surgical simulation3. The SCTS has developed an excellent training curriculum for cardiothoracic trainees and continues Figure 1: Surgeon performing a transannular patch on a 3D printed to grow from strength to strength. model of a tetralogy of Fallot in a chest wall simulator during the However, there now exists a platform 5th annual Hands-On Surgical Training (HOST) course

Table 1: Topics included in the in-house hands-on surgical training (HOST) 2019 curriculum at the Hospital of Sick Children

to train our UK trainees in congenital heart surgery in a risk-free environment and take advantage of the benefits derived from deliberate practice and simulation. The incorporation of hands-on surgical training with 3D models is reproducible worldwide and could potentially be included into the SCTS curriculum. As training moves from a number to competency-based approach, simulation will play a crucial role in the development and evaluation of the next generation of congenital cardiac surgeons. n References:

1) Van Doorn C., “Congenital Cardiac Surgery,” Society for Cardiothoracic Surgery: Bulletin, pp. 24-25, Aug-2019 2) SCTS. Speciality Advisory Committee, “SAC and SCTS UK Cardiothoracic surgery Workforce Report 2019,” 2019 3) Hussein N, Lim A, Honjo O, Haller C, Coles JG, Van Arsdell GS, Yoo SJ. Development and validation of a procedure-specific assessment tool for hands-on surgical training (HOST) in congenital heart surgery. J Thorac Cardiovasc Surg. 2019 Dec

7 Reasons Why you want to bring the Right Energy to your thoracic cases with the Ligasure™ Maryland jaw thoracic device (LF1930T): 1. Reliable hemostasis

For 7 mm pulmonary vasculature, the device also seals and transects adhesions1–7.

REASONS TO ENERGISE YOUR PROCEDURES

2. Better visualization

The curved jaw allows for better access, visualization and easy skeletonization of vessels8,19.

3. Access

30 cm shaft designed specifically for access to the thoracic cavity3–7.

4. Effective blunt dissection

For dissecting around the recurrent nerve and lymph nodes without causing damage8,10.

5. Cooler jaws

Cooler jaw temperature and faster cool down times compared to Harmonic HD1000i™*8,11,§.

The LigaSure™ Maryland Jaw Thoracic Device

6. Multifunctionality

The device has the benefits of being a Maryland dissector8,10, one – step sealer12, atraumatic grasper8,10, cold scissors8,12 and it may reduce instrument exchanges9,10 and procedure time8,13.

7. Coated jaws

Proprietary nano‑coating on the jaws to reduce sticking8,14,Φ, eschar buildup14,15 and cleanings8,16,Ω.

REFERENCES †

Based on a US database search of Ethicon Enseal, Harmonic, Olympus Thunderbeat, Medtronic, Applied Medical, Aesculap devices (March 10, 2019).

Based on systemic vasculature.

Φ Tissue sticking to device jaws instances measured over 110 seals per device (ForceTriad™ energy platform). F1930T is only compatible with the Valleylab™ FT10 energy platform. Ω Cleaning effectiveness assessed after each of two cleaning cycles. 1. Based on internal report #RE00147462, Pulmonary sealing claims for the LigaSure™ LF1930T device (memo). March 29, 2018. 2. LigaSure™ Maryland Jaw Thoracic Sealer/Divider, Nano‑Coated [instructions for use]. Boulder, CO: Medtronic; 2017. ±As of Nov. 19, 2018, based on indications for use for laparoscopic LigaSure™ devices. 3. Based on internal report #RE00138840, LIG‑45 memo, device length recommendation, thoracic (LF1930T). Feb. 6, 2018. 4. Based on internal test report #RE00125866, Jaw force and gap range burst pressure evaluation of EB4 thoracic Maryland device (LF1930T); conducted on bovine tissue. Nov. 20 –21, 2017 and Nov. 27–30, 2017. 5. Based on internal test report #RE00134865, Burst pressure verification of pulmonary bovine veins using the LigaSure™ LF1930T device. Jan. 17–18, 2018. 6. Based on internal test report #RE00122515, Verification of the LigaSure™ LF1930T device in a GLP chronic hemostasis canine study on pulmonary vasculature. Jan. 8–10, 2018. 7. Based on internal test report #RE00128442, GLP acute pulmonary vasculature hemostasis verification study of the LigaSure™ LF1930T device in hounds. Dec. 8, 2017

8. Based on internal test report #RE00140529 rev A, LigaSure™ Maryland device, nano‑coated (LF19X X) tissue testing (memo). March 5, 2018 9. Based on internal test report #RE00071598, Maryland validation labs, Houston and Los Angeles: independent surgeon feedback collected during porcine labs. April 16–18 and April 30 –May 3, 2013. ≠ 30 of 33 surgeons surveyed after use. 10. Based on internal test report #R0035742, Maryland validation, Houston and Los Angeles: independent surgeon feedback collected during porcine labs. April 16–18 and April 30–May 3, 2013. 11. Based on internal test report #R0032385 rev A, Thermal profile comparison of Ethicon Harmonic™* HD1000i shears versus nano‑coated LigaSure™ Maryland jaw device on the Valleylab™ FT10 energy platform. May 17–18, 2017 and June 14, 2017. 12. LigaSure™ Maryland Jaw Sealer/Divider, Nano‑Coated [instructions for use]. Boulder, CO: Medtronic; 2016. 13. Okada M, Miyata Y, Takamochi K, Tsutani Y, Oh S, Suzuki K. Prospective feasibility study of sealing pulmonary vessels with energy in lung surgery. J Thorac Cardiovasc Sur. 2018. 14. Based on internal test report #RE00073194, Tissue sticking comparison of the Ethicon G2™*, Voyant™* 5 mm Fusion, LigaSure™ LF1737, and LigaSure™ LF1937 devices conducted on porcine tissue using the ForceTriad™ energy platform. Jan. 18, 2017. 15. Based on internal report #RE00147462, Pulmonary sealing claims for the LigaSure™LF1930T device (memo). March 29, 2018. 16. Based on internal test report #RE00071599, LF19XX MJC marketing claims testing conducted on porcine tissue, Feb. 7–22, 2017.

medtronic.com/covidien/uk

the 42 bulletin

How our heart program has prepared for and responded to COVID-19 Lars G. Svensson, MD, PhD Chairman of Cleveland Clinic’s Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute

t present, Cleveland Clinic finds itself well prepared for the challenges the COVID-19 pandemic has brought to the communities we serve. Our state of Ohio has kept community spread of the virus relatively contained, allowing us and other Ohio healthcare providers to avoid a surge of high-acuity COVID-19 cases to date. While Cleveland Clinic continues to care for patients with COVID-19 at our hospitals, in early May we were able to resume offering surgery and other procedures to patients beyond those requiring immediate intervention. Patients are tested for COVID-19 prior to procedures and surgery, and scheduling is based on careful consultation around symptoms, risks and benefits. Cleveland Clinic health system has made extensive preparations to be ready for worst-case scenarios under the direction of our CEO and President Tom Mihaljevic, MD, who has closely advised Ohio’s governor. I share here an overview of a few ways we have prepared for and responded to the pandemic, particularly within our Miller Family Heart, Vascular & Thoracic Institute.

COVID-19 patients. This included fresh instruction in the use of ventilators and post-intubation management, conducted with our cardiothoracic anesthesiology and critical care colleagues. Additionally, our respiratory ECMO management team carefully prepared a triage algorithm to cover our usual ECMO demands for lung transplant patients and others needing urgent procedures while maximizing our ability to meet new COVID-19 demand. We supplemented our existing ECMO machines with an order for more, and our perfusion team devised means to convert other pumps for use in ECMO if needed.

on April 15. It has not yet been needed, but it remains a reassuring supplement to the 2,800 general medical beds and 550 ICU beds in our Northeast Ohio hospitals (including some 120 beds in the Heart, Vascular & Thoracic Institute).

Keeping patients and caregivers safe Like others, Cleveland Clinic has witnessed a concerning decline in demand for emergency care. For instance, acute activations of our cardiac catheterization labs decreased by 58% in the month from March 15 to April 15 compared with the average for that period over the prior five years. We also have anecdotal reports of patients delaying coming to the hospital for acute myocardial infarction, including one patient with a post-infarction ventricular septal defect who survived emergency surgery. We have responded by doing public education via the media about the importance of not delaying emergency care-seeking during this pandemic. For those patients we’ve been able to see, we have revised or introduced a host of care protocols to reflect the new COVID-19 reality. Protocol revisions have addressed everything from ST-elevation myocardial infarction to increased vigilance for QT interval prolongation on remote cardiac telemetry monitoring of inpatients receiving hydroxychloroquine and azithromycin, who represent half of our non-ICU patients with COVID-19.

“Another crucial element of safety is supporting our caregivers’ mental health and helping them meet new work-life balance demands.”

Preparing for a potential surge Ohio’s suspension of nonessential procedures in mid-March freed up many of our 2,100 Heart, Vascular & Thoracic Institute caregivers to cross-train for new roles to help staff labour pools to support efforts to prepare for a potential surge in

The centerpiece of Cleveland Clinic’s preparations has been the conversion of our 477,000,000-square-foot Health Education Campus building to a temporary surge hospital to house up to 1,000 beds for low-acuity COVID-19 patients. That feat, accomplished in less than a month, was undertaken to meet projected demand under modeling-based worst-case scenarios. The surge hospital – located across the street from the hospital buildings of our main campus for easy transfer of patients and supplies – was ready to accept patients

August 2020

We have asked patients to use virtual visits to receive care when possible and a physical exam is not essential. Our physicians are also using telemedicine platforms to remotely conduct some inpatient rounding and consultations via iPads in patient rooms to reduce the bidirectional risk of patientprovider virus transmission and help preserve personal protective equipment. Another crucial element of safety is supporting our caregivers’ mental health and helping them meet new work-life balance demands through programs for counseling, mentoring, childcare assistance, neighborhoodbased support groups and more.

Ramping up research In mid-March, Cleveland Clinic created a dedicated registry to expedite COVID19-related clinical research across our health system. Drawing on data from all patients who undergo COVID-19 testing, the prospective registry is using predictive

analytics to address three broad questions: (1) Who tests positive? (2) Why do some patients become sicker from COVID-19? (3) Which available treatment options are effective against COVID-19? In addition to fueling data research to aid individualized risk prediction, the registry supports clinical trials and collection and analysis of specimens for Cleveland Clinic’s enterprise-wide biorepository. These efforts already yielded a study in JAMA Cardiology showing no association between use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and increased risk of testing positive for COVID-19. In early May, the American Heart Association (AHA) awarded funding to Cleveland Clinic to serve as the coordinating center for the AHA’s new rapid response research initiative on COVID-19’s effects on the body’s cardiovascular and cerebrovascular systems. We also are involved in various multicentre

trials of proposed treatments for COVID-19. Our efforts include an investigator-initiated study of the IL-1 antagonist canakinumab for acute myocardial injury in patients hospitalized for COVID-19 with elevated troponin, C-reactive protein and brain natriuretic peptide.

On the road again We are excited to be getting back to what we do best: taking full and proper care of our fellow citizens with cardiovascular and thoracic disease. I suspect many patients will continue to use virtual visits when feasible, but many will need in-person testing for proper investigation of their health. We will be prepared to meet their needs in whatever setting is required. While there may be bumps along the way to society’s full return to its healthcare capacity, our profession’s resiliency in the past few months suggests we have a bright future ahead. n

Update on what is happening in the speciality - NADMEC November meeting Ter-Er Kusu-Orkar, NADMEC Chair

he national aortic dissection committee (NADMEC) is a body aimed at improving the education of aortic dissection in medical schools and foundation programmes. This committee was formed by myself after my involvement in research on valve sparing aortic root surgery after a type A aortic dissection (TAAD). I was disheartened by the poor prognosis patients have with this disease and sought to improve their prognosis in any way possible. After some digging, I found the Think Aorta campaign and noted their previous publication in the August 2019 SCTS bulletin. One of their aims was to educate younger doctors to adequately diagnose aortic dissection. I contacted the society and with the help of previous SCTS president, Mr. Graham Cooper, I was able to kick-start the society in January 2020. We now have an executive committee, as well as local and regional committee

members all over the UK. In order to achieve our aim of educating medical students and junior doctors on a national level, the breadth of our committee involvement is imperative. We hope to hold one local session in each medical school and one session in each region annually. These sessions comprise of standardised lectures given by a prepped tutor, with regional sessions involving communication and reallife stories from aortic dissection survivors. In order to develop this programme, we will measure the impact of these sessions using pre- and post- session questionnaires, as well as pre- and post- quizzes. In addition to this, we will be holding a November aortic dissection course that compromises lectures, surgical skills, cadaver anatomy and OSCE/Exam practice for junior doctors and medical students. It will be a very interactive day in which we hope to solidify the sessions

we have held during the year. We have secured funding from Think Aorta for these sessions and we are still looking for cardiothoracic surgeons who are interested in helping on this day, as well as a centre willing to host this event. We would also be extremely grateful for any sponsorship and we are interested in a long-term partnership to keep the committee running over the coming years. This is a very exciting and new movement that I hope will make a difference, it is not without its many challenges. But with the ongoing help of the SCTS, partners and yourselves, Junior doctors and medical students can begin their training better equipped to diagnose and manage aortic dissection. So if you are a medical student or junior doctor and you are interested in attending this meeting (described above), please email NADMEDUCATION@gmail.com. n

the 44 bulletin

Teaching and training – touching lives David J. O’Regan, Director of the Faculty of Surgical Trainers, Royal College of Surgeons of Edinburgh

raining is much more about what we say and how we say it. These are times of stress and uncertainty for everyone. How we relate to each other will be held up as examples and how we communicate with our trainees will have profound impact on how they feel. But this has always been the case and we can all be more mindful when communicating with our trainees and sharing their concerns. We need to progress beyond ticking boxes on appraisal forms and task orientated assessments as these are not markers of happy fulfilled individuals who have enormous potential and skill. We are in the business of realising their skills and giving them an opportunity to grow. This is the privilege and it should be the joy. We are stewards of people’s lives and that is our legacy as trainers. Aspirations and ambitions are easily crushed. I recall a trainee, now consultant, leaving an ARCP in tears because they were told they would never make it as they could not accomplish an anastomosis in under ten minutes? We hand out ones and fours, sometimes in the most impersonal and systematised fashion. The key attribute for a trainer is to believe in your trainee and respect the person as an individual. I have delighted in the skills and personalities of all my trainees over the years – some have been excellent thinkers, others deft of hand and some walking encyclopaedias. It is important to acknowledge the individual skills and personalities and together create value. Help them understand their purpose and realise their goals. It is important to involve them in

decision making and uncertainties because trainers are not infallible. There is more authenticity is exposing your own dilemmas and qualms. We are working in uncertain times and many trainees and medical students will be asked to work in unfamiliar settings. It is important to define their roles and limits of discretion but more importantly to have open channels of communication to ensure that all concerns are addressed with empathy and consideration. We need to be explicit about safety but more importantly invite feedback. The ISCP website affords an excellent tool for the trainer to use but this is poorly used – why? Trainees often offer excellent ideas for improvement. I was reprimanded by a trainee in September 2009 for using bone wax on the sternal edges ‘because that is the way we have always done this round here’. Together we adopted a tissue care bundles that has reduced ALL sternal wound problems to nearly zero. I recently reached out to a couple of trainees as they are on the front line and stepping up to meet the challenges COVID-19 presents – one was due to become a father within the month and he is worried about his wife, her pregnancy and their child. His family live in Iran where, allegedly, a COVID-19 related death is occurring every ten minutes. The other trainee I spoke to has inflammatory bowel disease and is on a regular prescription of steroids – they are understandably worried but not shielded. As teachers and trainers, we have a significant responsibility regarding our trainees and, by extension, those who depend on them, now and in the future. For me,

“The key attribute for a trainer is to believe in your trainee and respect the person as an individual.”

teaching begins with caring for, inspiring, and celebrating the successes of our trainees. By demonstrating these attributes to our trainees, holistically and respectfully, we hopefully inspire them to be the best they can be, in any situation. We must remember that the impact of our interactions extends beyond the clinical setting and into the homes and family lives of our trainees. Likewise, we must be mindful of the worries and concerns that they bring into the training environment – stress and heartache are not visible unlike the ‘POP’ for a broken bone. As teachers, demonstrating compassion and understanding goes a long way and has a wider impact and influence than what we might immediately see or understand. This similarly applies to the whole team – I reflect on a reply after asking at a team, as is custom, if there were any concerns or if anyone was troubled by anything; a member of staff came up to me in the anaesthetic room to tell me that they were appearing before an employment tribunal that afternoon. The job is hard enough as it is without having team members disenfranchised, disengaged, or distracted. Dealing with the ongoing impacts of COVID-19 has and will bring incredible challenges and stresses to all NHS staff. Whilst trainees on the frontline will be primarily concerned with treating patients and ensuring their safety, they will undoubtedly have underlying personal concerns about the impact upon their own training and progression and about their families, friends and loved ones. Therefore, please remember some of the key skills of being a good a teacher: listening; communicating; being present; self-control; and respect. These attributes are more important than ever and will help us all get through an incredibly difficult time. The Faculty of Surgical Trainers believes in leading education with passion. Be you and believe in your trainee. We are touching people’s lives. n

August 2020

Reflections of a thoracic surgical trainee during COVID-19 outbreak Ashvini Menon, Trainee

erhaps I was naïve but when I read about a virus outbreak at the other side of the world in Dec 2019, I didn’t really give it much thought. As a thoracic trainee, life continued as normal – Clinic, theatre, MDTs, interspersed with family commitments of childcare and the weekend extracurricular activities. Then the daily media started to give COVID-19 more importance – one by one, world leaders started to take note. To be honest, it wasn’t until the announcement of school closure and the halting of elective operations that the severity of the situation hit home! We were facing a nasty virus for which we simply weren’t the ones in control – there was no cure. As the COVID-19 virus started to wreak havoc in our healthcare, our department adapted to telemedicine and we were in full swing with telephone consultations and virtual clinics. Our rotas changed overnight and within a couple of weeks we had been re-deployed to the Intensive Care Unit (ICU). As cardiothoracic trainees, we have been endowed with ICU experience however there was an added sense of the unknown particularly being flooded with news reports from Italian and Spanish media about the bleak situation in the healthcare setting there. I recall viewing the Sky news video ‘It’s a war, it’s a disaster’ (the title says it all) from Cremona Hospital, Lombardy and asking myself will this be us in a few weeks? I need to equip myself clinically and emotionally to face this challenge. I felt the same trepidation as my colleagues – so what will I be doing on ICU? How long for? Will I have appropriate PPE? What about my training? Am I putting my family at risk? What about my booked holiday in July?! Our trust rapidly produced online COVID training packages and ICU training sessions were facilitated via Zoom sessions. My vocabulary expanded overnight – donning, doffing, FFP3, “Zoom teaching”, “hot” wards & “wobble” rooms. I diligently went through all the Moodle sessions on the hospital COVID teaching platform. There were COVID guidance emails being sent from every medical and educational body as well as the latest developments in the specialty, which kept me busy through the day.

I started shifts on ICU with eagerness to help and work through the challenges as well as a sense of fear of what might unfold in the next 12 hours of my shift. Yes, there are the clinical activities I foresaw – undertaking supervised assessments and triaging COVID/non COVID patients for ICU admissions, procedural interventions such as arterial, central and peripheral venous line insertion and insertion of intercostal drains. However, there were many tasks I adapted to quickly – mixing drugs, changing bed sheets, helping prone patients, “babysitting” a patient so a nurse can go for a break and simply just being there to chat to my fellow ICU colleagues at 4:30 am to allow them to “decompress”. Healthcare staff from various specialties and levels of experience were deployed to ICU. Despite our personal and professional differences and the layers of stifling PPE we came together supporting each other to fight this pandemic together. Our differences did not matter; we were in this together and we will come out of this the same. As the patient numbers increased our ICU began to spread encompassing other clinical areas, there were national shortages of drugs and renal support. Again, we came together and adapted to the situation making it possible to see the next day again. My COVID tears – I’ve had a few of them – The absence of family members at the bedside of a dying patient is a stark difference from business as usual in the ICU. So what have I learnt? Adaptability is a great asset to have as life is so unpredictable and things can change overnight for any of us. We are more adaptable than we give

ourselves credit for. If change is required, it can be done within hours rather than the months of meetings and bureaucracy that normally entails. We take for granted how important non-verbal communication is – interpersonal interactions are significantly more challenging when you cannot see people’s faces or hear them speak clearly due to hoods and masks. It also makes it more difficult to reassure the patients. We talk to them as we examine them – we describe what we’re doing. Now, with the masks, it makes it hard because you’re shouting; the patient can’t see that you’re smiling, it’s like they’re surrounded by space aliens, on top of being terrified about what’s going to happen. “Teamwork” is banded around in interviews all the time however this is the fundamental process that has got us to this stage and will take us into the post-COVID era. And finally, I have learnt that there are some excellent bakers within our hospital but my main overriding question is – will I still be able to go on holiday in July?! n

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MERITS: Multi-centre Evaluation of Renal Impairment in Thoracic Surgery, a collaboration of 17 thoracic units across the UK Vinci Naruka, ST1 Cardiothoracic Surgery Trainee, Royal Brompton & Harefield Hospitals Aman Coonar, Consultant Thoracic Surgeon

ortality is very low in thoracic surgery limiting its use as quality discriminator. Acute kidney injury (AKI) is a candidate measure because it is associated with increased rates of morbidity and mortality and is partly preventable. The incidence of AKI after thoracic surgery is not well documented. We designed a multi-centre study of AKI post-thoracic surgery (MERITS) aiming to determine if there was sufficient variation to use it as a performance metric and to find associations with patient demographics, type of procedure, length of stay and mortality.

We are proud to say that within few months MERITS collected 15,154 patients across 17 thoracic surgical units. This would have not been possible without the indispensable help of consultant leads, coordinators and SCTS STUDENTS. In these unprecedented times of a worldwide pandemic, it is clear that we are only as strong as we are united. Scientific collaboratives across the globe have strengthened; a sense of solidarity when there is a common goal in mind. Similarly, MERITS is a demonstration that collaborative work is feasible when centres

are united to answer the same question: what are the AKI incidence and outcomes for patients undergoing thoracic surgery? But how did we accomplish this? This article is an account of this journey. It all started with our pilot study at the Royal Papworth Hospital in early 2018 when we noticed a 15.1% incidence of AKI. This was higher than that reported by other studies in thoracic surgery. Why was our rate higher than the rates in other reports? Techniques, pathways and patients

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may differ as well as case mix. However, it is important to consider the extent and range of this problem. Our pilot study identified the following data as being robust and relatively straightforward to collect: submitted SCTS operation code, dates of birth, operation, discharge, death, gender, AKI stage 1, 2, 3, peak creatinine, pre-op and post-op renal replacement therapy. To build on this work and address some of the limitations, we developed MERITS. The primary goal is to have a pragmatic, high-quality multi-centre study to determine the contemporary baseline rate of AKI after thoracic surgery in multiple centres in the United Kingdom. In so doing, our goal is to identify the variation across a number of units. This would be useful for benchmarking, quality improvement and safety. The project was approved at the appropriate directorate meeting and registered within the Clinical Audit and Effectiveness Department at Royal Papworth Hospital, Cambridge (Registration Number: 1702). The following was the timeline: • March 2018 – 1st call & presentation at SCTS 2018 • April 2018 – protocol development. Regulatory approval as a multi-centre study • May-June 2018 – recruitment of centres and medical students • July-August 2018 – recruitment of biochemistry laboratories • 17th September 2018 – Launch of MERITS data collection • 7th July 2019 – collected 15,154 patients from 17 centres • August-September 2019 – validation of data points • October-December 2019 – analysis of data • March 2020 – presentation of results at SCTS – delayed due to COVID-19 All hospitals in the UK that offer thoracic surgery were invited to participate. MERITS collected all patients (age ≥ 18 years) undergoing any thoracic surgery under the care of participating consultants in the given unit in the time period from 01.04.2016 to 31.03.2017. To ensure equal distribution of information, an online site pack was designed and shared amongst the units. The site pack included: project registration, protocol with

“In these unprecedented times of a worldwide pandemic, it is clear that we are only as strong as we are united. Scientific collaboratives across the globe have strengthened; a sense of solidarity when there is a common goal in mind.” appendix, step-by-step guide for data collection, YouTube video on how to perform data collection and a passwordprotected template for the data collection sheet on Excel document. The protocol and site packs were presented in various conferences and meetings. To ensure efficient data collection, a local consultant or consultants acted as the lead(s) for each unit. Data collection and entry were performed locally by medical students recruited by the Society for Cardiothoracic Surgery (SCTS). They were supervised by a day-to-day coordinator (ranging from research nurse to cardiothoracic registrars) and a consultant cardiothoracic surgeon. This model worked really well as it involved keen medical students who would like to develop research skills and get involved in meaningful studies. By appointing coordinators, it helped to keep the momentum of the project and troubleshoot any issues encountered during data collection. The quick data collection was also contributed by the involvement of biochemistry departments. We realised each biochemistry department in England collects AKI alert stages 1, 2, 3 and peak creatinine since the NHS England Patient Safety Alert in 2014. To minimise error in collecting renal data, we asked each thoracic unit to contact their respective biochemistry departments and extract this already collected data. To maintain high standards, we worked closely with Cambridge University Biostatistics department for data analysis. At a confidence level of 95% with a margin of error of 1.5%, a sample size of

2,520 patients was required to estimate a UK rate. MERITS exceeded this, becoming one of the largest collaborations of thoracic units in the UK. Having baseline characteristics means that MERITS may generate hypotheses that can be explored in a more detailed study to identify risk factors and implementations for AKI. The outcomes will be useful in counselling patients, identifying patients at increased risk, benchmarking, and ensuring safety and quality improvement. We hope future collaboratives between cardiothoracic units in the UK will continue to work together toward a common vision and accomplish greatness. As Henry Ford quoted - “Coming together is a beginning, staying together is progress, and working together is success.” We would like to thank each and every person involved in MERITS. The following are the unit names and consultant lead. We thank you for your collaboration. MERITS Collaborators: Bart’s (Mr Steven Stamenkovic), Basildon (Mr Samir Shah), Birmingham (Mr Maninder Kalkat), Cardiff (Mr Vasileios Valtzoglou), Edinburgh (Mr Vipin Zamvar), Glasgow (Mr Alan Kirk), Hull (Professor Mahmoud Loubani), James Cook (Mr Joel Dunning), Leeds (Mr Nilanjan Chaudhuri), Manchester (Mr Kandadai Rammohan), Norfolk and Norwich (Mr Jakub Kadlec), Plymouth (Mr Adrian Marchbank), Royal Brompton (Professor Eric Lim), Royal Papworth (Mr Aman Coonar), Southampton (Mr Edwin Woo), St. Georges (Miss Carol Tan), UCL (Mr Martin Hayward). n

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The National PeriCCT Fellowship Scheme in Cardiothoracic Transplantation E. Khoshbin, Locum Consultant Cardiac and Transplant Surgeon (Former National PeriCCT Fellow) S. C. Clark, Consultant Cardiac and Transplant Surgeon, Director of Cardiopulmonary Transplantation Cardiothoracic Centre, Freeman Hospital Newcastle upon Tyne

The Need for the National Fellowship Scheme Prompted by a national concern that cardiopulmonary transplantation did not have a sustainable workforce, the UK Cardiothoracic PeriCCT Transplant Fellowship scheme was established in 2009 to train NHS surgeons to meet rapidly increasing demand. Over time this has become increasingly important with the goals outlined in the NHSBT strategic document Taking Organ Transplantation to 2020 aiming to increase

the rate of donors per million population from 19.1 to 26 and increase the donor heart and lung utilisation rate. Furthermore, the introduction of Max and Keiras Law on presumed consent and the greater use of mechanical circulatory support devices (MCSD) will inevitably result in an increase in surgical activity and huge demand upon surgeons to deliver. However, heart and lung transplant procedures are surgically demanding and often performed out-of-hours making this an unpopular career choice for some. Challenges for the transplant surgeon have increased in recent years with organ allocation systems prioritising the sickest patients and many will have had previous surgery or LVAD implantation. Transplantation though is an area of expansion in cardiothoracic practice when other elements of our specialty are in decline or under challenge, there are new technologies and developments which bring new and exciting areas for activity and research and for those seeking a testing but profoundly rewarding surgical practice, a career in transplantation can be highly attractive. The Fellowship scheme seeks to appoint those with these aspirations.

old and 14% over 55 years old. Only 6% are under 40. Most are job planned to spend 8-10 hours per week on this discipline alongside their routine and emergency commitments in general cardiothoracic surgery. Units report a likely recruitment need of 11 new Consultant posts over the next five years. This however maintains the status quo and does not account for the anticipated major increases (up to a predicted 50%) in activity that are likely through new legislation on donation in England to â&#x20AC;&#x153;opt outâ&#x20AC;? and the applications of new technologies to increase organ utilisation such as ex-vivo lung perfusion and heart donors after cardiac death. Furthermore, there is a trend towards surgeons taking earlier retirement, moving units, going abroad or ceasing on call duties which will significantly impact upon the national workforce. Therefore training competent, highly specialised transplant surgeons has never been more essential and is applicable to those thoracic surgeons wishing to pursue a career in lung transplantation or surgeons who wish to deliver both heart and lung transplantation and mechanical support.

Workforce Challenges

Currently, there are three 18-month PeriCCT surgical transplant Fellowships in the UK that provide comprehensive training in advanced heart and lung failure therapies to provide future transplant Consultants. These specialist Fellowships are offered in Newcastle, Cambridge and Manchester. The Fellowship is approved by the Joint Committee on

There are currently 36 cardiopulmonary transplant surgeons in the UK. Four are thoracic surgeons performing only lung transplantation. The most recent survey of the transplant workforce indicates that 44% of the current Consultant Surgeons are aged over 50 years

The Scheme in 2020

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Surgical Training (JCST) and the Speciality advisory committee (SAC) and funded through the Wessex Deanery.

Fellowship Goals The Fellowships have an agreed educational agreement which provides comprehensive training and experience in: • Organ procurement including training in the use of machine perfusion preservation systems. • Recipient heart and lung implantation. • Mechanical circulatory support such as durable ventricular assist devices and extracorporeal circulation. • Patient assessment and aftercare, including management of immunosuppression. Fellows are provided also with a minimum of one operating list per week to maintain their general cardiothoracic surgical skills. A specific educational grant is available to each Fellow to facilitate training in mechanical support and attendance at recognised conferences. Fellows are also invited to attend Cardiothoracic Advisory Group meetings to understand the national perspective, current issues and workstreams. A Quality Improvement Programme is also underway to further develop and enhance the programme to provide a mechanism to monitor progress externally and to allow Fellows to express any concerns or requirements.

Outcomes Since 2009, 14 Fellows have been appointed. Our recent survey indicated that the majority had completed general cardiothoracic training (CCST) prior to taking up the Fellowship (n = 11). The average length of Fellowship was 15 (SD = 3) months. The majority of respondents recommended the Fellowship although one was appointed just prior to the COVID-19 pandemic and has been adversely affected by the accompanying dramatic fall in transplant activity. Overall satisfaction with the programme over the last 11 years had a weighted average score of 7 out of 10 with the majority of Fellows feeling that this training period prepared them for the challenge. All but one was appointed at Consultant level in the UK in either a transplant or circulatory assist related post.

“Training competent, highly specialised transplant surgeons has never been more essential and is applicable to those thoracic surgeons wishing to pursue a career in lung transplantation or surgeons who wish to deliver both heart and lung transplantation and mechanical support.” Conclusions Cardiothoracic transplantation is a demanding but exciting discipline in cardiothoracic surgery. Training competent, highly specialised transplant surgeons has never been more essential given the increasing pressures on the service nationally and the expanding scope of new technologies and developments. The UK National Peri-CCT Cardiothoracic Transplant Fellowship has successfully addressed the national workforce deficit but challenges remain given the

present profile of the workforce and future demand for Consultants. Long term recruitment is important to consider given that the majority of current surgeons are in their fifties and with a predicted retirement age of 60 there will be a projected need for substantial recruitment to the discipline from 2023 onwards. Promoting applications to join the scheme is vital for the future and those passionate about the discipline who thrive on challenging decision making and surgery but work well within a multidisciplinary team are encouraged to apply. n

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Cardiac ACP Redeployment to ICU Transplantation Kathryn Hewitt on behalf of the Cardiac ACP team QEHB (Tara Bartley, Amy Millichope, Rachel Alldritt, Caroline Parry, Afia Sarkodie)

he Cardiac Advanced Clinical Practice (ACP) team from Queen Elizabeth Hospital Birmingham (QEHB) consists of qualified ACPs, trainee ACPs and also those in seconded positions. Like many teams around the country, the team faced the daunting challenge of being redeployed to the COVID-19 frontline, Intensive Care Unit (ICU) workforce. QEHB boasts the largest ICU in Europe with the ability to care for 130 COVID patients in the peak, decanting patients from sister hospitals in the area. To cope with this large influx of patients, extra capacity was created within ICU, doubling the amount of available beds, allowing for the surge of patients arriving at the front door. In order to cope with this increase in capacity and to allow for inevitable staff sickness, a repurposed workforce was created pulling staff from all areas within the hospital to work on the

frontline, amongst these were our Cardiac ACP team, redeployed regardless of prior experience in ICU. This article is an account of our team’s experiences and reflections of our time on the frontline. Once the executive decision was made to cease elective admissions for cardiac surgery, our ACP role initially adapted to support the medical team looking after general medical patients occupying our wards, both COVID negative and pending confirmation. This was a great way of exposing other medical specialities to the role and value of the ACP; assessing, diagnosing, treating and prescribing for patients not of our primary speciality, widening our own experience and testing our advanced decision making. During this time, the trust was undergoing major incident planning and after two short weeks we were informed of plans for redeployment to ICU.

The Cardiac ACP team at QEHB have varying experience, some being fully qualified ICU nurses, some having prior but limited ICU experience and others with no ICU experience at all. In order to prepare staff suitable for redeployment, the trust held an emergency ‘crash course’ for ‘Non-critical care staff in ICU’ running for three hours every day for a week. The course was run by the military supporting in ICU and although exciting and engaging, the underlying message of the intensity and complexity of the challenge to come was intimidating to most, experienced or not. “Nothing could have prepared me for the shifts in ICU during this COVID-19 crisis.” Just turning up to ICU that first shift was an eye opener. Learning to ‘don’ all the PPE was as if we were preparing for war. Despite this,

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morale was high, we were all in it together. Walking on to ICU the first time was intimidating, exhilarating, exciting and scary all at the same time. Patients were doubled in each bed space; two beds, two patients, two ventilators and multiple infusion pumps. This was going to be a challenge like none before. The plan was always to provide redeployed staff with one supernumerary shift in ICU, however due to joining the ICU workforce as the ‘peak’ was approaching the team was already stretched and was very much an ‘allhands-on deck’ approach. The cardiac ACP team were stretched and in an unfamiliar environment but drew upon advanced skills and clinical reasoning to get us through. Despite this, the challenge was like none other we had experienced. “My first night shift I was looking after two level three patients on my own. I was totally out of my depth.” During our ‘crash course’ in COVID ICU we were prepared for reduced staffing numbers and poor skill mix. We were informed that they were anticipating each patient would have a 1:1 with a non-critical care nurse with an ICU nurse overseeing two to six patients. Although we were lucky in that our ICU expertise wasn’t spread as thinly as 1:6, we were often the sole care giver for two level three patients with the ICU nurse looking after the same in the next bed space. “... both of the ICU nurse’s patients became increasingly ill … the ICU nurse had to solely focus on their patients. It became very apparent that we were alone.” It is more than fair to say the ICU nurses did a fantastic job at supporting the team around them as best they could and there was a real feeling of comradery with everyone mucking in as much as they could. Despite this, the complexity of each patient meant we had to adapt and learn quickly to become COVID ICU nurses, managing paralysed, sedated and proned patients, titrating medication for cardiovascular support and trying to give good holistic care at the same time. “... I apologised for not having time to take a CVC out, he replied with ‘you have kept both patients alive during your shift and that is all we can aim for at present.’ This was one of the sobering moments where you realised it was not physically possible to give the gold

standard care that you usually give to your patients, this is a pandemic and you have to just do what you can.”

as surgical nurses; admitting, treating and discharging patient’s home to their families for another lease of life.

Over the next few weeks, although distressing, we became more confident looking after these incredibly sick patients and soon we were supporting other less experienced staff finding themselves in the same position we were in just a few short weeks earlier. Key to adapting to a new environment, pandemic or not, is having awareness of your own limitations. As expressed in this article, our prior experiences differed and knowing when you were out of your depth and when to ask for help was essential to a successful redeployment, for yourself, the ICU nurse you are working alongside but most importantly for the patients we were looking after.

“Caring for fellow healthcare workers who had contracted COVID while exposed through lack of correct PPE was heart breaking. There are no words for how we felt about withdrawing treatment of our healthcare colleagues.”

“One of the worst experiences was having to withdraw care on a patient, and trying to support his family. It is definitely not the way you want to be delivering end of life care and this will stay with me forever.” Providing end of life care is one of the hardest parts of any nurse’s job, but doing this at a distance, over the phone or supporting families as they see their loved ones for the first time at the point of end of life, after weeks apart is incredibly hard. Advanced communication skills learnt in our roles as ACPs definitely helped with this but this never gets easier. With statistics suggesting a 50% mortality of the people admitted, working on ICU creates a personal challenge for each of us, particularly

During our time redeployed, there have been many articles published and conversations held regarding access to the correct PPE and BAME NHS workers. We will all recognise that at best, the PPE was uncomfortable, at worse it was restrictive and claustrophobic but at QEHB there were never any shortages. Although our specific advanced skills may not have been directly utilised, they did underpin the care we delivered and our interactions with the MDT. We will use this experience to underpin our future practice, it will always stay with us. n

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A potential study tool for the aspiring cardiothoracic surgeon Josiah Joseph, Medical Student

election into cardiothoracic surgery requires a demonstration of commitment, interpersonal and technical skills. Much of this is evidenced through a stellar clinical portfolio which requires time and dedication to build. For medical students and trainees, this poses a dilemma – should one study ardently in the library to excel at medical school and surgical exams, or participate in portfolio-development activities such as completing audits and scrubbing into theatres in their spare time? If only there was a way to prepare thoroughly for exams in the shortest time possible to reap the best from both options. Having researched various study techniques on my quest for efficiency, I believe I have found a method that students and doctors at all stages of cardiothoracic surgery can adopt for exam preparation and leisurely learning. The method is founded on two key concepts: active recall and spaced repetition.

What is active recall? Active recall is simply a process which involves actively retrieving information from memory during the learning process, in other words, it’s simply remembering! During active recall, the specific pattern in which neurons were originally fired as a result of learning is replayed, allowing the brain to recall information. Each time this information is recalled, neural connections of that memory are strengthened, allowing faster and easier retrieval of that information. These neural pathways can be likened to how we can navigate routes we have travelled often before more easily than routes we have taken less often. When we want to remember something, in an exam or a practical scenario, we do not have a trigger to help us retrieve this information. Active recall primes the brain to retrieve information without any prompts, reflecting realistic scenarios, whereas, passive

techniques, such as re-reading, highlighting or making notes, fire neural connections unidirectionally, and therefore do not have the same effect.

What is spaced repetition? Spaced repetition is a concept that involves strategically reviewing information at intervals over a period of time in order to retain information. It is optimised when used in conjunction with active recall. Spaced repetition is based on a graph called ‘the forgetting curve’, created by a psychologist called Herman Ebbinghaus. The graph shows how information is forgotten over time and the impact of reviewing that information before we forget it. The more a piece of information is reviewed, the more likely it is to be committed to long-term memory. For example, if I told you to remember an obscure fact such as the capital of Estonia is Tallinn, you may remember that for the next five minutes, but you are unlikely to remember it in a week. However, if I reminded you of that fact the next day and then three days after that and then asked you one week from now, you are more likely to remember. Using Ebbinghaus’ evidence-based estimations, a framework can be designed where information is reviewed just before it is forgotten. However, the idea behind spaced repetition is to allow the brain to forget some of the information (up to 80%), in order to make the brain work harder the next time you actively recall the information.

This increased strain to remember helps to encode the information with greater potency, allowing you to remember the information for longer. Spaced repetition can, therefore, be used to minimise the time needed to study by only reviewing information when it reaches the threshold of being forgotten.

How can I practically use these techniques? Active recall is a commonly used method and a lot of people unknowingly practise it already. For example, reading a piece of text and then stopping to try and recite what you just read from memory is a form of active recall. Online practice tests/quizzes and question books are also forms of active recall, however, my preferred method is to create flashcards. To make a set of flashcards, the content of the subject must be broken down into smaller manageable high-yield chunks of information. This is beneficial as different cards can be reviewed independently, allowing harder cards to be reviewed more

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Example of an Anki flashcard

frequently than easier cards. Additionally, measured metrics can be obtained from flashcards to help visualise your progress, allowing you to plan ahead and complete your learning before deadlines. Active recall sounds reasonable to accomplish, however, when coupled up with spaced repetition, the combination is not feasible to achieve right? Wrong! Previously, a messy, confusing diary would have to be kept to record when to review each of the cards, however, thanks to intelligent software platforms, spaced repetition can be applied automatically and effortlessly. ‘Anki’ is a free flashcard app that can be downloaded on a laptop/PC/phone. It allows you to make online flashcards and successfully uses a spaced repetition algorithm to help you review them efficiently. After each review, the app asks you to rate the ease with which the flashcard was completed; options include: again, hard, good and easy. Depending on how you rate the card, the software will automatically bring that card back to you using the spaced repetition algorithm, meaning flashcards

that are easier to remember will have longer intervals whilst flashcards that are harder to remember will have shorter intervals. This is particularly useful as each flashcard interval is personalised to your capacity. Additionally, you can find premade Anki decks online, that other medical professionals have created.

Conclusion In conclusion, a great way to combine active recall and spaced repetition is through the use of online flashcards that are reviewed at strategically spaced intervals. If this approach is not for you, the principle of active recall and spaced repetition is the take-home message. With a secure, timeefficient method of study, it becomes easier to build exceptional portfolios but also potentially improve emotional and physical health, which can only be accentuated when we have more time for loved ones and personal hobbies. The happiness and balance achieved from a healthier mind and body can positively impact our patients, whose wellbeing is our ultimate goal. n

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The cardiothoracic surgical team

My Cardiothoracic Elective at Hue Central Hospital, Vietnam Sam Jenkins, Medical Student

t the University of Sheffield, third year medical students are presented with an opportunity to undertake an elective module overseas. As an area of particular interest to me is cardiothoracic surgery, I organised a two week intensive clinical placement at Huế Central Hospital in Vietnam. Prior to my arrival, I was informed that I would be the first overseas medical student to undertake an elective in the specialty at Huế Central Hospital. I approached this experience with a degree of insight, having intercalated in cardiothoracic surgery the previous year. It is fair to say that my trip was initially tarnished by a degree of misfortune and poor timing. I was to fly out to Vietnam in January of this year, which coincided precisely with the outbreak of the coronavirus pandemic. To make matters worse, my connecting flight was scheduled via Tianhe International Airport, Wuhan, China, the epicentre of the

COVID pandemic. Many frantic phone calls later and I was thankfully transferred onto an alternative flight and made it to Vietnam without further disruption. Huế, known as the ‘Imperial Capital’, is the largest city in central Vietnam. There is a rapidly developing infrastructure with stunning buildings inspired by French architecture. On the outskirts lies the Citadel, a walled enclosure containing the former Imperial City which was constructed by Emperor Gia Long in 1789. As I ventured further out of the city, I was struck by the serene simplicity of the Vietnamese culture; the relentless preparation of vibrant foods to be sold on street stalls, children playing on nearby grasslands and families, often of multiple generations, gathered morning and night to share stories of their day. Huế Central Hospital boasts 125 years of history. In 1968, during the Vietnam

War, the hospital was bombed by US forces, necessitating its reconstruction in later years. Though devastating at the time, the reconstruction allowed the hospital to be developed into one of the most technologically advanced in Vietnam. The ‘Cardiovascular Thoracic Unit’, so named as surgeons are also trained in vascular surgery, is on the top floor of the Cardiovascular Centre, comprising four theatres and an intensive care unit. The wards below, host a mixture of male, female, adult and paediatric surgical patients. There were noticeably fewer nurses dispersed around the ward when compared to hospitals in the UK, as family members insist on providing basic care to inpatients. My day began at 7am with a briefing, shortly followed by the ward rounds. At 8am, theatre lists commenced. The vast array of surgeries performed on this unit soon became apparent, including but not limited to: valve

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replacements, coronary artery and common iliac bypass surgery, septal defect repairs, left atrial myxoma dissection, endarterectomy, kidney transplants and emergency operations. Patients with valvular heart disease were often younger than would typically be expected in the UK, deriving from complications of rheumatic fever. The expansive rural communities suffer poor access to healthcare and their low socioeconomic status deters patients from seeking medical assistance when required. The implications of this were prevalent; patients frequently presented with severe symptoms of cardiac disease and commonly required multiple valve surgery. On my first day, a patient was admitted with a dissected ascending aorta requiring immediate repair. In the absence of any health insurance, this emergency operation was delayed by 24 hours pending resolution of the financial difficulties. During my second week on placement, Professor Khanh Nguyen arrived at the hospital to provide specialist training and equipment to the team. Professor Nguyen, originally from Vietnam, trained at Great Ormond Street Hospital and now practices in New York, USA. I observed four of his operations and on my final day, was fortunate enough to assist in the repair of a VSD on a one-year-old boy. During this operation, Professor Nguyen approached by right axillary incision via the fourth intercostal space. Careful to avoid the phrenic nerve, the right thymus was removed before cannulating the aorta, IVC and SVC. The tricuspid valve annulus was dissected to visualise the VSD, whilst the pericardium was dissected and preserved in glutaraldehyde to later close the defect. My role during the operation was to apply suction, assist feeding the snares during cannulation and cut sutures when required.

Myself with 3 trainee cardiothoracic surgeons

Assisting in congenital cardiac procedure (bottom right)

“Surgeons in the UK subspecialise into cardiac or thoracic surgery, then into adult or paediatric surgery. In Vietnam, surgeons progress by demonstrating competency in all types of cardiothoracic and vascular surgery.” Despite my limited experience in the specialty, I noted some interesting differences between cardiothoracic surgery in the UK and Vietnam. Surgeons in the UK subspecialise into cardiac or thoracic surgery, then subsequently into adult or paediatric surgery. In Vietnam however, surgeons progress by demonstrating competency in all types of cardiothoracic and vascular surgery. Following post-operative discharge in Vietnam, patients attend a clinic led by cardiologists, meaning that cardiothoracic surgeons focus their time primarily on surgery and have limited involvement in the follow-up treatment of a patient. The surgeons are currently trying to change this, as they appreciate the significance of their involvement in the post-operative care of their patients.

The placement provided a unique insight into the specialty. I was able to assist in the repair of a septal defect and varicose vein procedure and observed a variety of new techniques, such as the Muller procedure for repairing varicose veins and the Bentall technique for repairing a dissected thoracic aorta. I was also introduced to Professor Nguyen’s nuanced technique of repairing congenital defects via right axillary incision. This approach produced a cosmetically superior outcome compared to sternotomy, whilst remaining safe and effective. In Europe, a small number of surgeons have adopted this technique, however it is not currently standard practice in the UK. My time at Huế Central Hospital enabled me to gain a deeper understanding and broader appreciation for the way in which cardiothoracic surgery is practised across the world. Undoubtedly, this has provided me with invaluable experiences which I will incorporate into the development of my future career. I extend my heartfelt thanks to the surgeons and staff at Huế Central Hospital, who generously offered their time and expertise to ensure my placement was so enjoyable. n

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Cardiothoracic surgery research during COVID-19 Professor Aung Oo, Consultant Cardiothoracic Surgeon and Lead Aortovascular Service, St Bartholomew’s Hospital Professor Julie Sanders, Director Clinical Research, St Bartholomew’s Hospital, SCTS Nursing and Allied Professional Academic and Research Lead

his year has been like no other we have experienced. On 30 January 2020, the World Health Organisation declared the outbreak of COVID-19 (SARS-CoV-2) a Public Health Emergency of International Concern, and officially announced on 11th March 2020 as a pandemic. At the time of writing, worldwide there were 5,899,866 cases of COVID-19, including 364,891 deaths, with the UK alone having 271,222 cases and 38,161 deaths. However, while the primary focus was on the pandemic itself and critical care, other clinical services were having to adapt and respond to the crisis. It was estimated that >28 million operations globally would be cancelled or postponed during the peak 12 weeks of COVID-19 (CovidSurg 2020, BJS). Certainly very early in March, especially in London, services were being realigned to cope with London being the UK ‘epicentre for COVID-19’ and critical care capacity was quadrupled within a matter of a few weeks. St Bartholomew’s Hospital also became the command centre for cardiothoracic surgery providing emergency and urgent cardiothoracic surgery across London and beyond. There was a distinct lack of data on surgical outcomes, specifically cardiothoracic surgery outcomes, during any previous epidemics/ pandemics and so at St Bartholomew’s Hospital we devised a series of studies to enable us to explore service provision and patient outcomes during the pandemic, mainly as the command centre for London. However, following discussion with the SCTS Audit committee, we offered these studies to all UK cardiothoracic centres that wished, or had capacity, to contribute, with invitations sent to all SCTS centre leads. We were delighted to have nine centres contribute to the cardiac surgery studies (Belfast, Cardiff, James Cook, Oxford, Wolverhampton, Leicester, Hull, Liverpool and Barts) and 19 centres for the aortovascular surgery studies (Hammersmith, Aberdeen, Coventry, Birmingham, Hull,

Stoke, Brighton, Harefield, Middlesbrough, Edinburgh, Leicester, Belfast, Newcastle, Sheffield, Southampton, Oxford, Blackpool, Liverpool and Barts). In summary, the studies were: • Cardiac surgery outcomes during the COVID-19 Pandemic: the UK experience. This study used linked national dataset and locally available data (National Institute Cardiovascular Outcome Research Adult Cardiac Surgery, Intensive Care National Audit and Research, and COVID-19) to describe and explore patients undergoing surgery and their short-term outcomes. From the nine centres we have 774 patients in the study with 53 of those having COVID-19. • Effects of COVID–19 Pandemic on the Provision of Cardiac Surgery in the UK a) Demographics and Outcomes of All Patients Referred for Cardiac Surgery (PLECS service) b) Outcomes of All Patients Currently Waiting for Cardiac Surgery c) Ability to Maintain Out-Patient Services d) Effect of COVID-19 on the Ability to Maintain General Cardiac Surgery Service • CardiacCovid study: This is a prospective observational cohort study to describe and explore the recovery process of patients undergoing cardiac surgery during the pandemic. We are exploring mortality, morbidity, health-related quality of life, eventspecific distress and depression pre-surgery, one week after discharge, and six weeks, six months and one year after surgery. As of May 31st at St Bartholomew’s Hospital we have 78 patients in the study. Other centres are exploring feasibility and capability of participating. • Aortvascular Surgery Studies: In this study, 189 patients from 19 centres were recruited of which 79 patients were treated for acute aortic syndromes. 13 patients with COVID positive, were treated with good outcomes.

To date this is the largest aortovascular patients population during the COVID-19 Pandemic recruited for study under the auspices of United Kingdom Aortic Surgery (UK-AS). The following areas will be assessed in this ongoing study. Effect of: a) Changes in access to outpatient treatment b) Changes in access to in-patient treatment c) Impact of modification of patient selection protocol on outcomes d) Changes in setting of Multi-disciplinary Team (MDT) meetings e) Local Covid screening protocol f) Restricted access of healthcare resources g) COVID-19 Pandemic on Quality of Life of patients with thoracic aortic disease We were also encouraging participating in COVIDSurg, an NIHR backed global surgery research collaborative, being run by the University of Birmingham, on all COVID-19 positive patients undergoing any form of surgery. The Cardiothoracic Interdisciplinary Research Network is leading a collaboration with COVIDSurg to specifically focus on cardiothoracic surgery, and Luke Rogers and Ricky Vaja have described this work elsewhere in the bulletin. At the time of writing four abstracts have been submitted to EACTS, detailing early outcomes, and the associated papers are in progress. We would like to thank everyone who has been working with us on the projects. At a time of great challenge and uncertainty it has been great to collaborate with other centres and to generate such a wealth of interesting data within such a short amount of time. n Reference:

CovidSurg Collaborative, Dmitri Nepogodiev, Aneel Bhangu (2020). Elective surgery cancellations due to the COVID‐19 pandemic: global predictive modelling to inform surgical recovery plans. British Journal Surgery. 12 May 2020. DOI: https://doi.org/10.1002/bjs.11746

August 2020

In virus veritas Antony Walker, Consultant Cardiac Surgeon

OVID-19 has washed in with tidal predictability. A modest, certainly not gentle swell nor the threatened tsunami of which we were warned. Cromarty, Dogger, Dover, SARS-CoV-2; moderate or rough but the forecast still threatening very high to phenomenal later. To continue the maritime metaphor, at the time of writing the loss of approaching 40,000 souls is nothing short of a total shipwreck. Sadly, visibility in this crisis has been poor and the British public have foundered on the hidden viral outcrop. The good ship NHS has weathered the storm, listing now from the tragic loss of crew, her mast splintered, and sail torn she heads off into the next wave. As doctors we have navigated for years using the basic constellations of the Hippocratic oath. Hopefully with humour, certainly with tongue in cheek and more than a salt spray of cynicism and satirical gybe-ho, I have used my time not-operating to plot a new, post-COVID course and oath. I swear by @ MattHancock, Messrs Whitty, Van Tam and Vallance that I will refer and adhere to your daily announcements and rules, no matter how often they may vary or appear at odds with my previous knowledge, learning or simple common and statistical sense. No matter how disparate your words are compared to my own experiences, I will stand tight lipped and allow the Gods to answer for me when questioned. I hold my teacher equally distant to my parents and indeed any elder or at-risk individual. I will teach my own sons, for they are more at risk, than my daughters for now both seem to laze about my house absent from their schooling. I will abandon established treatments in favour of erroneous modelling of new illness; taking advice and recourse from apps and media ahead of observation, fact and timeproven knowledge. I will ensure those suffering

cardiac or pulmonary ill humours (and many other illnesses) are over-looked to create capacity for those suffering the virus. Capacity that I will celebrate being never needed. Whilst I will never administer a poison, I will give up patients and tweet, post, share and generally disseminate widely the unscientific, un-investigated and unsubstantiated half-truths of the unknown viruses’ unknown cures and unknown treatments. Recourse to the knife will be done at great personal discomfort and threat but rewarded with applause and the banging of utensils. I will

(cough), may I be rewarded by the banging of gongs and receiving of letters. Yet if I break it may pestilence fall upon me. As we emerge from the surf, rubbing viral sized grains of sand from our eyes and blinking in the harsh, face-shield shrouded light of the new dawn. As we stand on fawn-unsteady limbs and look wide-eyed, nervously to the treeline. Let us stop, think, consider and implement what we have learned from our surviving the SARS-like scuttling. Let us get to the higher ground and safety of experience. Together we have all helped to keep HMS NHS afloat and sea-worthy; let us sure up the vessel with the beams and bulwarks of experiential learning before the next wave of predictable change bowls us over, leaving us floundering, gasping for air in the tide of inevitability. Never forget, “Good judgement comes from experience ...” Just as the waves clean the beach and smooth the sand so has this experience changed the visible surface of healthcare. Adoption of technology on board the NHS has occurred at meteoric rather than mollusc pace; new and novel collaborations have demonstrated the love and willingness to help, people have for the NHS; true colours have been revealed and the importance of ring-fenced protection of our services for the good of our patients realised; fake news, poor science and misinterpretation (deliberate or otherwise) have been revealed as weak navigational aids with which to plan our journey. The bounty of experience from this journey is held safe in the bay ready for future sailors and generations to study, interpret, learn and implement. From this experience captains have emerged, to learn, navigate and sail us into the future. I wish you all well, we remember those no longer with us in the “new world” and remember “to travel hopefully is a better thing than to arrive, and the true success is to labour”. n

“As doctors we have navigated for years using the basic constellations of the Hippocratic oath. Hopefully with humour, certainly with tongue in cheek and more than a salt spray of cynicism and satirical gybe-ho, I have used my time not-operating to plot a new, post-COVID course and oath.” not seek monetary reward for my exposure and discomfort; I may at times seek to retrain or distribute pictures of my bruised and disfigured features for further just and wide-spread publicity and reward. Into whatsoever house, or two-metre vicinity I enter, I will enter in appropriate attire and with appropriate behaviour. I will refrain from all intentional wrong-doing and harm, especially physical contact, sneezing and singing of hymns. I will observe rigorous handwashing and of course always remain, alert. Whatsoever I might see or hear in the course of daily briefing shall be tolerated and held in apparent esteem, despite my inner turmoil. Now if I carry out this oath, follow the rules and challenge not the doctrine; stand by the side of power at the lectern of truth

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Cardiothoracic Interdisciplinary Research Network (CIRN) Luke Rogers (CIRN co-chair; cardiac) Ricky Vaja (CIRN co-chair; cardiac) Edward Caruana (CIRN co-chair; thoracic) Akshay Patel (CIRN co-chair; thoracic) Thoracic; Associate Surgical Specialty Leads Akshay J. Patel & Edward J. Caruana, Supervisors - Professor Eric Lim & Mr. Babu Naidu Cardiac; Associate Surgical Specialty Leads Ricky Vaja & Luke J. Rogers, Professor Julie Sanders (SCTS Nursing & AHP Academic & Research Lead), Enoch Akowuah (Interim SSL), Professor Gavin Murphy (SSL)

Surgical Patients and Outcomes during the COVID-19 Pandemic The COVID-19 pandemic has resulted in widespread disruption, and overwhelmed healthcare services globally. The extent of this deviation from standard care for routine surgical patients, including those with potentially curable cancer, is unclear. Our understanding of the outcomes of patients undergoing surgery whilst suffering intercurrent infection with SARS CoV-2 remains limited. As such, there is uncertainty concerning how best to deliver safe surgical in the current era. There is high complexity and an elevated baseline risk across the majority of procedures performed in cardiac and thoracic surgery. Early data indicates that major surgery is an independent risk factor for disproportionately poor outcomes when performed with perioperative SARS CoV-2 infection. It is therefore essential that high volume data is collected in a timely manner, from across the global spectrum of healthcare structures, and analysed with regular dissemination in order to prospectively inform clinical decision-making. CovidSurg is an investigator-led, noncommercial, observational study that is investigating the impact of the COVID-19 pandemic on surgical patients across any

speciality. The NIHR Global Health Research Unit on Global Surgery based in Birmingham UK leads the study. It is designed to inform management during and immediately beyond the COVID-19 pandemic. There are two related studies in the CovidSurg project that are of relevance to a cardiothoracic audience: CovidSurg-Cohort (an observational study on the short-term outcomes of any surgical patient with confirmed or suspected perioperative SARS CoV-2 infection), and CovidSurg-Cancer (which seeks to document any variation from routine care for patients presenting to a cancer service with typically resectable malignancy, in addition to documenting outcomes). Patients may be registered in both studies. In many countries (including the UK), it can gain institutional approval as a service evaluation, meaning that patient consent is not required. Further information on this study is available at https://globalsurg.org/covidsurg/. The Cardio-Thoracic Interdisciplinary Research Network (CIRN) is partnering with the CovidSurg collaborative to lead subspecialty investigation, and enhance the relevance, participation and dissemination in cardiac and thoracic surgery across the globe. The work of the two subspecialties is being directed by two dedicated steering groups of international membership. All work will be published jointly under corporate authorship, with collaborators being indexed in PubMed as citable authors. The first two CovidSurg papers have been published recently in the British Journal of Surgery and The Lancet (available at this link https://globalsurg.org/publications/). The Lancet paper presents data for patients who had a perioperative diagnosis of SARSCoV-2, across all surgical specialties. In total 1,128 patients were included from 235 hospitals in 24 countries. Overall, pulmonary complications occurred in 51% of patients

and 30-day mortality was 24%. Risk factors for mortality were male sex, age of 70 years or older, ASA grades 3-5, surgery for malignant disease, emergency surgery, and major surgery. In the small thoracic surgery cohort of 35 patients, those with perioperative COVID-19 infection suffered a 43% 30-day mortality and a 66% risk of pulmonary complications. In patients undergoing cardiac surgery (n = 51), COVID-19 diagnosis was associated with a 34% mortality at 30-days, and a 94% risk of pulmonary complications. It is important to remember that these numbers only represent the small number of patients who do develop COVID-19 infection and reflect the early stages of the pandemic, where community prevalence was high and surgical programmes had yet to develop consistent means for detecting, preventing and mitigating possible infection in their patients. Importantly, the denominator was not recorded in this series of patients. Much work is still ongoing, and there is an urgent need to capture as accurate a picture as possible of patients who underwent any surgery, or should/could have undergone surgery for cancer with prognostic intent. This data will inform healthcare policy and or conversations with patients moving forwards. As data can be entered retrospectively and typically without patient consent, there is still plenty of time to get involved with contribution to larger multi-speciality analysis and with the important cardiac and thoracic projects. There has been extensive participation already from international centres in Europe and North America. These studies are reliant on collaboration and we would urge all eligible UK centres to join the cause. If interested, please register directly with the CovidSurg team via this link: https://globalsurg.org/covidsurg/ n

August 2020

Associate Surgical Specialty Leads appointed in Thoracic Surgery The Royal College of Surgeons of England (RCSEng) has appointed ‘Surgical Specialty Leads’ across the breadth of surgical specialties. These established academics are responsible for the development of clinical research networks and the delivery of meaningful multi-centre research, working alongside established Surgical Trials Centres. Since the inception of this ‘Surgical Trials Initiative’ in 2012, there have been great strides to bring surgical science the forefront of innovation in the United Kingdom. Under the leadership of Professor Gavin Murphy (Professor of Cardiac Surgery at the University of Leicester, and Surgical Specialty Lead for Cardiothoracic Surgery), the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) has established a dedicated Academic and Research Committee. A core aim of the Surgical Trials Initiative is to develop trainee involvement in surgical academia, by directly engaging trainees in all stages of research development and delivery. In 2018, two ‘Associate Surgical Specialty Leads’ (ASSL) were appointed in Cardiac Surgery: Mr Luke Rogers (ST4, South West Deanery) and Mr Ricky Vaja (OOP-R, London Deanery). Their work

to date has led to the establishment of the Cardiothoracic Interdisciplinary Research Network (CIRN) – a multidisciplinary collaborative of trainees and allied health professionals in the United Kingdom. Earlier this year, Mr Akshay Patel and Mr Edward Caruana were appointed to a similar role as ASSLs in Thoracic Surgery, where they will work together with Mr Babu Naidu (Consultant in Thoracic Surgery at Heart of England NHS Foundation Trust) and Professor Eric Lim (Professor of Thoracic Surgery at Imperial College London). Akshay is a ST4 trainee in the West Midlands, currently pursuing a PhD in cancer immunology under the supervision of Professor Gary Middleton at the University of Birmingham. Edward is a ST6 trainee in the East Midlands, currently pursuing a PhD in clinical trials research under the supervision of Professor Tim Harrison at the University of Nottingham. In striving to expand thoracic surgical research uptake nationally, we aim to integrate with the CIRN and the Thoracic Surgical Trials Network and are currently in the process of mapping the direction of our work in the medium term. We have

also been successful in getting the first thoracic surgical trial (TOPIC 2 - Thoracic Epidural vs Paravertebral Blockade for Post-Thoracotomy Pain) onto the Associate Principal Investigator Scheme, and will seek to expand the number of trials available for trainee engagement via this route. Details of this NIHR driven scheme can be found at this link: https://www.nihr.ac.uk/explorenihr/specialties/surgery.htm). The current pandemic has brought unprecedented changes to our practices, and diverted the focus of research initiatives worldwide. We have responded by shifting our focus to address questions that are unique and important at this current time. This work has included an attempt to gain an understanding of the multi-faceted challenges faced by trainee colleagues in the current era, and working with colleagues to extend emerging observational work (in the form of the CovidSurg and CovidSurg-Cancer studies, as well as the PanSurg PREDICT study) to specifically enrol thoracic (and cardiac) surgical patients diagnosed or receiving treatment during these months. As we look towards a new normal, and seek to settle in a post-COVID world, we would be very keen to hear from interested colleagues from all backgrounds, who may be seeking collaboration or opportunities in thoracic surgery research. Please email a.patel.2@bham.ac.uk or edwardcaruana@ nhs.net, or find us on Twitter. n

Cardiothoracic Surgical Training during the COVID-19 Pandemic The COVID-19 pandemic has brought about a disruption to our personal lives and professional development that is unlike any other that we have seen to date. Healthcare systems internationally have seen a paradigm shift in activity and practice, across all disciplines. We sought to establish the impact of this pandemic on the wellbeing, practice and progression of trainees in Cardiothoracic Surgery in the United Kingdom. A 31-item online questionnaire was delivered in mid-April 2020. Seventy-six (of 118, 64%) cardiothoracic surgical trainees responded, representing all training grades and programmes nationally. This survey highlighted trainees’ concerns about their physical and mental health, with a third having taken time off work in the first three weeks of the pandemic. There were significant concerns about the provision of personal protective equipment expressed by over half

of trainees; this despite two thirds having had direct clinical contact with COVID-19 patients, including in the operating room. Over half of trainees were reallocated, at least in part, to cover other specialty areas – including critical care and acute medical admissions. One third of the trainees described encountering ethical dilemmas related to the care of patients in these roles. Many trainees experienced a change in their working hours, often working long overall and taking on more antisocial hours. This redeployment, coupled with a reduction in clinical case load, resulted in a significant reduction in training opportunities – particularly at multidisciplinary team meetings and in the operating theatre. Over half reported that their day-to-day roles at that stage of the pandemic were contributing little to no educational benefit. This is expected

to cause widespread disruption to learning and progression, with the vast majority of respondents (88%) being concerned about the impact on their training. A significant proportion of trainees (32% to 71%, depending on the length of disruption) felt that the situation justified an extension to their planned training time. The timeline and destination of our emergence from the COVID-19 pandemic remains uncertain, with an acceptance that there may never be a full return to previously established norms. Timely sharing of concerns, experiences and expectations will inform healthcare and education policy, and influence practice in the pandemic era and beyond. The full text with details of this work has been published in The Journal of Thoracic and Cardiovascular Surgery, and is available at this link: https://www.jtcvs.org/article/S00225223(20)31275-7/fulltext?rss=yes. n

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Basic surgical skills workshop

SCTS Student Engagement Aman Coonar, Consultant Thoracic Surgeon

t has been a great experience to have started a new part of our society SCTS Students and to see how it has grown. The SCTS Student Engagement Program is into its seventh year and has grown in range, number of young people reached and scope of its activities. Around 10 years back cardiothoracic surgery saw declining recruitment and

Women in cardiothoracic surgery panel discussions (l-r: Catherine Sudarshan, Melanie Jenkins, Farah Bhatti)

competition from other surgical specialties which had a greater exposure in the medical school curriculum. There was also a move to ST1 recruitment. Our speciality wants and deserves the best young people to be excited about heart and lung specialities and to come into medicine. Around this time issues of diversity, inclusion and discrimination were also being addressed. We set out to expose young people to our specialty emphasising merit, team-working and inclusion. The SCTS and RSM cardiothoracic section, as well as other groups, already had a range of ad hoc events for students but at SCTS we wanted to go further. Building on those experiences, and also the energy of a group of students in Bristol, we ran our first cardiothoracic surgery student engagement day with talks and

workshops in the autumn of 2014. At that meeting we were surprised and also delighted when it exceeded our expectations in terms of young people attending, how far they were prepared to travel and the excitement that they had. Feedback was excellent. From there we started events at the SCTS annual meeting and included in that the Patrick Magee competition. Soon 6th form and other university students were also involved. Since then, with local student teams, we have had very successful events in Cambridge, London (Kingâ&#x20AC;&#x2122;s & Barts), Sheffield, Birmingham and most recently in Liverpool which was a combined effort from Manchester and Liverpool Medical Schools. We have also grown our sessions at the SCTS annual meeting and in the London 2019 annual meeting there was a large room overflowing with sixth form and university students from medicine, biomedical science and other areas.

August 2020

We have built an outreach system with representatives in all medical schools in the UK, foreign medical student affiliates, a thriving Facebook and Whatsapp community and we support any other events we hear about. We were looking forward to the annual meeting in Wales but as with everything else the COVID-19 crisis overtook us. When our meeting was cancelled we were amongst the first to respond by launching webinars for students now on COVID-19 related topics. Our first webinar, which included Simon Kendall President of SCTS, Vinci Naruka, cardiothoracic surgery ST1 from London and Nicola Jones ITU consultant from Royal Papworth, had several hundred delegates and was been viewed worldwide. The change to virtual meetings has been accelerated by the pandemic. In lieu of our meeting at SCTS 2020 we will hold a digital student engagement event on the 24th June 2020. We have also collected the entries for the Patrick Magee competition and will publish this as a digital book. This will both honour the programme and also recognise the achievement and success of all those students and teams who were accepted. During this journey we have emphasised that our exciting and rewarding speciality will do best by recruiting people based on their ability, enthusiasm, team-working and merit. To find those people we recognise that is best done by being accessible and inclusive. Our outreach program, whenever possible, tries to include local schools

“We have emphasised that our exciting and rewarding speciality will do best by recruiting people based on their ability, enthusiasm, team-working and merit. To find those people we recognise that it best done by being accessible and inclusive.” that might not have easy access to mentorships in medicine. We have also expanded our work into research and the SCTS students supported project MERITS- “Multi-centre Evaluation of Renal Impairment in Thoracic Surgery” recruited in excess of 15,000 patients from 17 centres in a few months. We have repeatedly emphasised the importance of teams and winning bids to host our meetings have included London (KCL and Barts), Liverpool (jointly with Manchester) and our next Winter meeting will be in Scotland organised by a combined group from Edinburgh, Glasgow and Dundee medical schools. As we face the challenge of COVID-19 and embrace the changes that it has accelerated, we look forward to the success of our speciality refreshed with the enthusiasm and excitement of capable young people. I wish my successors all the best with this project. n

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The Jack A. Roth Fellowship in Thoracic Surgical Oncology – an Invaluable Experience Across the Pond Gerard J Fitzmaurice, Consultant Thoracic Surgeon, St. James’s Hospital, Dublin, Ireland

s the inaugural recipient of the Jack A. Roth Fellowship in Thoracic Surgical Oncology from the American Association for Thoracic Surgery, I had the privilege of visiting the Department of Thoracic & Cardiovascular Surgery at the University of Texas MD Anderson Cancer Centre (MDACC), arguably the world’s

The University of Texas MD Anderson Cancer Centre

pre-eminent cancer hospital. Professor Ara Vaparociyan follows in the footsteps of Professor Roth and leads this internationally renowned quaternary referral centre that specialises in the management of all complex thoracic malignancies, in particular lung cancer, mesothelioma, oesphagheal cancer, and mediastinal tumours. MD Anderson originally developed from humble quarters during the Second World War to now stand prominently in the skyline of the Texas Medical Centre, a sprawling medical campus home to some of the world’s foremost hospitals. Steeped in history at every turn, my early morning walk to MDACC took me along Bertner Avenue, named after Ernest Bertner one of the original founders of the Texas Medical Center and also the physician who delivered Denton A. Cooley, founder of The Texas Heart Institute. And just a block away stands the Baylor College of Medicine, home to

the Michael E. DeBakey museum, attesting to the extraordinary cardiothoracic surgical ethos embodied in Houston. The thoracic service is based in the dedicated thoracic centre and is a true multidisciplinary team with close collaboration between surgeons, pulmonologists, medical and radiation oncologists, radiologists, and pathologists. As the inaugural Roth fellow, I was fully integrated into all clinical and academic programs of the department. I attended daily morning rounds, selected the most opportune surgical cases to attend which included RATS sleeve lobectomies, VATS anatomical lung resections, major chest wall resections and reconstructions, thymectomies (minimally invasive approaches and standard median sternotomy), and resection of major intra-cardiac metastasis. It was fascinating to follow patients from discussion at the MDT with ongoing surgical trials including NEOSTAR and BRIGHTSTAR and observe the extraordinary effects of these new treatment modalities. I also had the opportunity to attend outpatient clinics, with the ensuing discussions around perioperative and long-term management, while developing a key insight into the logistics of running a complex patient load. The weekly tumour board meetings, discussing management options for complex thoracic malignancies, were particularly valuable as were the discussions surrounding the wealth of ongoing trials. The weekly research meetings, journal club, morbidity and mortality meetings, and teaching sessions were highly informative and provided me with valuable seed ideas to bring home.

August 2020

A major component of the perioperative management of patients at MD Anderson revolves around the ERATS (Enhanced Recovery After Thoracic Surgery) program. There are a number of elements to this, however a key factor has been the introduction of liposomal bupivicaine (Experal) as a long acting local anaesthetic that has almost eliminated epidural use at the department. Discussion with all members of the multi-disciplinary team highlighted some initial reluctance to introduce this new concept through to eventual overwhelming adoption of the program once the excellent results became apparent. Interestingly liposomal bupivicaine is currently under review at the European Medicines Agency with a planned manufacturing facility in the UK. There are obviously other structural issues that are different to home, most notably scale. There are 38 operating rooms with a central administrative and anaesthetic control centre however there are no anaesthetic rooms – all patients are induced in the OR with a resultant delay in turnover that is not evident at home. However, theatres run very efficiently with an early start time – it was not unusual to have a knife-to-skin time of 7.45 am. There is also a frozen section laboratory in the theatre complex that facilitates rapid diagnosis and intra-operative staging as well as enabling surgical resection margin assessment in every case. The patient flow was also a product of the scale of the institution – patients were consented in clinic and admitted on the morning of surgery, generally from a nearby hotel, and most patients were extubated in theatre at the end of the case and transferred to the PACU recovery before transfer to the main floor. The PACU recovery area was also expansive and comprised 67 beds. The logistics of patient management meant that most patients were discharged to a nearby hotel as many patients came from far afield or to home if their residence was nearby, with ready access to the MD Anderson Emergency room as needed. Interestingly, the volume of cancer care at MDACC has enabled a large emergency room to function while only accepting reviews of current or previous MD Anderson patients. They also have a well-established robotic-assisted thoracic surgical program using the da Vinci Xi system with dual consoles that provides a key platform

Gerard J Fitzmaurice with Professor Jack A. Roth and Professor Reza Mehran after the presentation of a Stetson Cowboy hat at the Fellowship dinner

“It was fascinating to follow patients from discussion at the MDT with ongoing surgical trials including NEOSTAR and BRIGHTSTAR and observe the extraordinary effects of these new treatment modalities. I also had the opportunity to attend outpatient clinics, with the ensuing discussions around perioperative and long-term management.” for training. The overall approach to surgical training within the department was admirable, with the thoracic surgical fellow as primary operator in the majority of cases. Indeed, the department has a keen focus on continuing education and this enabled me to undertake a research project during my stay. We evaluated a new technique to aid in major chest wall reconstruction using pre-moulded titanium plates, with coverage using acellular dermal matrix, facilitated by 3D printing to plan the reconstruction. I also had the opportunity to spend some time in the interventional pulmonology department led by Professor George Eapen. This provided a valuable opportunity to gain an insight into aggressive airway management including post-inflammatory bronchial strictures,

bronchial stent management, cryotherapy, electrocautery, as well as EBUS and TBNA. Overall, this was an invaluable experience that provided a career inspiring insight into cancer management at a worldrenowned cancer centre and enabled me to develop key concepts that I can incorporate into my own practice. I cannot compliment the surgical staff in Houston highly enough – they were all extremely welcoming, engaging, and very keen to teach. And as with my friends and colleagues at the Liverpool Heart and Chest, I hope to have developed lifelong friendships with a fantastic group of surgeons that I aim to continue to engage with over the course of my career. Finally, to any current trainees ruminating on it, I would strongly recommend consideration of fellowship opportunities in the US. n

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Adapt, Innovate and Communicate! – A perspective from Southampton on running a thoracic surgical service amidst a pandemic Aiman Alzetani (pictured), Abdul Badran, Catherine Pritchard, Ben Johnson, Khalid Amer, Lukacs Veres, Martin Chamberlain, Edwin Woo

he current pandemic had challenged us in so many ways. As a large teaching regional centre catering for eight referring hospitals with their clinics & multi-disciplinary team (MDT) meetings, our local medical school students,

a busy research programme in addition to delivering specialty training for our juniors, the pressure to maintain these services has never been greater. Patient referrals may have slowed down but they never stopped therefore the need to carry on assessing and operating whilst protecting patients and staff has meant looking at innovative ways to minimise physical contact. The first step was maintaining our regular MDT meetings with our peripheral hospitals through remote access, then arranging our clinic appointments with patients through telephone/video consultations. Investigations were requested via local hospitals and virtual anaesthetic reviews were arranged as and when needed. Initially, operating was done at our NHS centre, University Hospital Southampton (UHS). Our cancer targets still had to be met even as the capacity to create space for the expected hundreds of COVID cases meant emptying out nearly 50% of our beds coupled with a reduced workforce due to the staff sickness. As of 16th of March, we cancelled all non-cancer / emergency work to use our beds more efficiently.

“Patient referrals may have slowed down but they never stopped therefore the need to carry on assessing and operating whilst protecting patients and staff has meant looking at innovative ways to minimise physical contact.”

As pressure to isolate against in-hospital and perioperative transmission, we started using personal protective equipment (PPE) very early. But with more information and guidance on viral spread, we had to look at a physically safe space for our elective work so on 7th April we turned to our local private sector for help and started doing two lists a week but ramped up to six within four weeks. We made sure that all patients were symptom free and self-isolating for 14 days and from 20th April, we were the first specialty to introduce COVID-19 testing 48 hours pre operation as an extra safety measure. Our nurses had to work extra hard to support patients’ anxiety with respect to having treatment at hospital. As the local pandemic scene was improving, we started repatriating services to our main site at UHS but kept activity in the private facility with the challenges of running a split site service. Our training had to adapt also as many medical staff were re-allocated and re-trained to look after the anticipated surge. However, we insisted that our specialist trainees should carry on their operating sessions and that it was protected in their new rotas even when it was in the private centre. The regional specialty teaching programmes have also moved to a remote format. With the ease of sharing screens, presentations that were often only considered as deliverable in a roomfull of audience have moved seamlessly to much larger audiences, utilizing resources and expertise that is often inaccessible to trainees as well as making interaction and discussion much easier. Teaching our medical students (who had to leave campus and clinical areas including hospitals) had to be addressed so the university asked all surgical specialties to help. A rolling eight week online

August 2020

program was developed with a full week for cardiothoracic surgery. We used Microsoft Teams for daily interactive sessions with real clinical scenarios, a practical session on knot tying and suturing and finished the week with a quiz! Our partnerships with industry have been utilized to use new technology in capturing intraoperative activity to facilitate discussion and even interaction remotely from students within the operating theatre and discussing intraoperative decision making in real time. We had excellent feedback from the university and we’ve been asked to carry on. This has also increased their awareness of CTS as an exciting and innovating specialty. Last but not least whilst the majority of research studies were paused and suspended (almost furloughed), our key cancer study TargetLung was allowed to carry but with a focus on contributing larger volume samples of background lung tissue – with pathologists unanimous approval – for Covid research. Our R&D and clinical managers had understood the value of these samples to help towards that.

So Plato’s proverb of necessity being the mother of invention has never been more true for our unit and the main element behind our successful transformation is our cohesive team approach based on years of good communication, seamless collaboration and lack of rigid hierarchical boundaries between medical, nursing, administrative and research staff. n

“Our cancer targets still had to be met even as the capacity to create space for the expected hundreds of COVID cases meant emptying out nearly 50% of our beds coupled with a reduced workforce due to the staff sickness.”

Cardiac Surgery Experience Abroad: Trainees Perspective Hannah Jesani, ST1 Cardiothoracic Surgery & Sanjni Bhudia, Medical Student

heumatic heart disease continues to remain a leading cause of cardiovascular morbidity and mortality globally. In July 2019, we had the privilege to accompany two UK cardiac surgeons to Nairobi, Kenya on a charity cardiac surgery mission. This annual mission of seven days

has been conducted since 2006 and over 230 open heart operations have been undertaken by these two surgeons. The age of the patients operated upon range from 3 to 20 years with 30% under the age of 10 years. All patients are rigorously followed up for longterm outcomes by the local cardiologists and allied staff. The philosophy of the mission is to train and utilise the local medical and nursing staff to enhance their skills. A vast majority of the local staff have had exposure abroad in various cardiac units. This concept has minimised cost and incumbents of an extended visiting

teams for the charity missions. We were privileged to participate in the 12th mission and would like to share our experiences. Every year preparation commences six months prior to the mission. Each visiting individual in the mission has to submit appropriate documents for the required registrations for practice and the Kenya Medical Council. Cost of the flights, accommodation, and meals are borne by the visiting team. Typically, a list of up to 35 patients is proposed for potential surgery. These patients travel from long distances with their family or carers, sometimes on their shoulders. On the first day, patients’ are reviewed with the local team. A brief history is presented and a transthoracic echocardiogram performed by a cardiologist and a management plan is formulated. The strategy ranges from medical treatment, percutaneous procedure >>

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“Surgical experiences through missions allow students and trainees exposure to surgical care in countries with challenging economic conditions. We truly benefitted from this memorable experience.” or surgery. Depending on resources, up to 24 patients are scheduled to undergo surgery over the following six days. The day would start by operating at 7am and not uncommonly finish at 9pm. I, Hannah, first travelled on this cardiac mission in 2011. During this mission, I observed the dedicated care of patients in severe heart failure. These patients were nutritionally compromised with stunted growth. The first sight of the chest opening and visualization of the dilated beating heart was extremely influential in my choice to study medicine. I embarked on this at Cardiff Medical School. During my foundation year I returned as a participating trainee member with full registration and approval. This experience further influenced my pursuit for training in cardiothoracic surgery. I witnessed operative strategy formulation in challenging circumstances where there is limited availability of investigative tools. I assisted in every operation undertaken throughout the week and was supported by seniors and local surgeons. I followed each patients’ progress following their operation. As a trainee there was an abundance of truly

incredible learning opportunities. Aspects such as clinical decision making, assisting, undertaking supervised procedures, cardiac pathologies, echocardiograms, surgical correction, instrument handling, monitoring, conduct of cardiopulmonary bypass, communication and team participation were very valuable. It was heartrending to witness a child carried into clinic due to severe breathlessness with no energy to eat, to seeing him devouring breakfast impatiently with an enormous smile on the first postoperative day. The momentous change to patients’ quality of lives through this mission has been a significant influence on me. However, there were equal disappointments when some patients were turned down for surgery due to time constraints, lack of funding and equipment. I, Sanjni, am currently a second-year medical student at University College London and my first experience of this mission in 2017 also confirmed my aspiration to study to be a doctor. Joining the mission for the second time in 2019 exposed me to clinical experiences that I would not have access to as a medical student. I was taught

on various aspects of patients’ treatment, from diagnosis to post-operative reviews, seeing a change in not only the patient’s physical health but also changes in their behavior and emotional state, was surreal. Observing the surgeries in the operating theatre gave me an insight into cardiac surgery that my peers have not had the privilege to witness. Seeing pathologies that I would not typically see in the UK further amplified the value of this experience. This mission has heavily influenced me to study cardiovascular sciences for my BSc intercalated year. We recognise reduced exposure to the cardiothoracic surgery speciality in medical school and minimal foundation year jobs to experience this field prior to applying for specialty training. Surgical experiences through missions allow students and trainees exposure to surgical care in countries with challenging economic conditions. We truly benefitted from this memorable experience and would highly recommend to all students and trainees with surgical intent, particularly in this speciality and encourage seniors to facilitate such opportunities for the trainees. Over the years, from the UK there have been notable missions undertaken by various teams in many corners of the world with commitments by the host nations and participants. Those seniors who have had these privileged experiences in their endeavours have acknowledged that although exhausting and mentally challenging, it is a humbling experience. The global demands in these developing environments have not diminished and broadening surgical experiences at all levels can enrich our speciality. There, however, needs to be some readdress to these activities with some guidelines from the Society for Cardiothoracic Surgery in Great Britain and Ireland. Issues among others are how these activities are acknowledged in job planning, appraisals, governance of both the team and the host medical institutions and their Councils. The ethos has to change from going to hospitals abroad to undertake surgeries without address on elements of training to obtain long-term independence to obviate the need for reliance on the visiting teams. There is also the need to identify and organise how such programmes benefit our trainees in the UK and those of the host nations. Perhaps collective participation by industries would address central funding though the offices of the Society as this is a major limiting factor for such ventures. n

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Pro-activity and preparedness: A medical student’s perspective on pursuing a career in cardiothoracic surgery Michalis Anestis Patsalides, Intercalating medical student

ardiothoracic surgery is a highly challenging and rewarding surgical specialty requiring multiple skills and perseverance through tough, high quality training. It is therefore unsurprising that the specialty is highly sought after by Foundation year 2 doctors ready to apply for specialty training and is very competitive. As a medical student considering cardiothoracic surgery as a career, two things became apparent to me through my exposure to the specialty. Firstly, medical students must be actively involved in their learning and chase learning opportunities throughout their degree and training. Secondly, it is important that medical students considering a career in cardiothoracic surgery start preparing early and gain as much insight into the specialty as they can. The need for active involvement in learning through placements was highlighted to me when I chose to undertake my third-year student-selected component (SSC) in thoracic surgery at Glenfield Hospital, Leicester. During four weeks of ward-based activities and operating room exposure, I had to accelerate up a steep learning curve not only in terms of skills but also in terms of attitude and professional behaviour. I made it my priority to chase every available learning opportunity. During my SSC in thoracic surgery I maximised the amount of time spent scrubbed up in elective thoracic theatre lists, optimising my surgical gowning and gloving technique; assisting in various types of operations; and learning new skills such as suturing techniques. These included rarer operations such as NUSS bar insertion for the correction of pectus excavatum (which one does not usually get to see during the medical school curriculum) which led me to appreciate the modern surgical techniques, instruments and materials used. Participation in daily ward rounds and documentation in the patients’ notes, as well as attending the Morbidity and Mortality meeting and various Multidisciplinary Team (MDT) meetings, were

learning opportunities providing well-rounded appreciation of thoracic surgery with regards to patient care and management. To further enhance grasping of the quality assurance and improvement domain in cardiothoracic surgery, I undertook an audit to evaluate the thoracic surgery service at Glenfield Hospital. This involved looking at the thoracic surgery theatre cancellations and determining the underlying reason for them. I came across a very interesting patient with Multiple Endocrine Neoplasia 1 (MEN1) syndrome who had undergone adrenalectomy and partial pancreatectomy as part of the management strategy. Recent Positron Emission Tomography (PET) scans had shown ‘cold’ pulmonary nodules which were slow growing. The case was fascinating and demonstrated the ‘weird and wonderful’ aspects of the specialty. However, all of the above would not have been possible without a team of consultants, trainees, nurses, and operating department practitioners who were always willing to help and demonstrate new skills, introduce me to interesting patient cases and consequently contributed towards my development. The experience I have gained during the thoracic surgery SSC was multifaceted and has led to improvement in multiple domains. I have become more skillful through hands-on work in one of the most challenging surgical specialties whilst enhancing my anatomical knowledge. Additionally, I made connections with intelligent and incredibly skilled people. These connections will be fundamental in my future career as they have provided me with valuable insight into the application and training process for the specialty and by guiding and motivating me to pursue cardiothoracic surgery as a career. Moreover, I was involved in all aspects of operating the Thoracic Surgery Service, including quality improvement, thus becoming even more insightful and aware of the processes required to run such a busy and successful service. The early-on exposure to the specialty

clarified the importance of starting to prepare early and plan ahead for applying to the specialty. By looking into the details published on the Health Education England – Wessex website (the centre which has been responsible for National Cardiothoracic Surgery recruitment since October 2010), a position to train in cardiothoracic surgery comes after a rigorous selection process with multiple selection criteria, including research and extracurricular activities and, invitation to interview. This was further enhanced by attending the SCTS Student Engagement Day in November 2019 at the University of Liverpool. The mixture of high-quality, informative lectures on the life of a cardiothoracic surgeon and how to apply for the specialty as well as the skills workshops, provided valuable understanding on the practical skills and professional attitudes expected of a cardiothoracic surgeon. But more importantly, they demonstrated the need for preparation and active practising of such skills and attitudes from early on in one’s career, even as early as the beginning of clinical years. This means that a medical student considering cardiothoracic surgery as a career should have come across and become accustomed to aspects of the specialty prior to applying. Ultimately, active involvement in learning, chasing learning opportunities, starting to prepare early, and gaining as much insight into cardiothoracic surgery as a specialty are inherently connected and are fundamental in attempting to apply for the speciality. These not only provide valuable experience and skills, but also equip the medical student with essential attitudes and behaviours that are highly sought after in potential cardiothoracic surgery trainees. Acquiring all those skills and attitudes has not been anything less than challenging. However, having them at my disposal has driven my pro-activity, improved my confidence and even increased my aspiration to be part of such a fascinating specialty. n

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Coronavirus - Trainee Representative Perspective Duncan Steele, ST6 Cardiothoracic Surgeon & Senior Cardiothoracic Trainee Representative Abdul Badran, SCTS trainee representative, Specialist Registrar Cardiothoracic Surgery

lthough plagues and pandemics have plighted the world before, cardiac surgery wasn’t around. The implications of perioperative infection with COVID-19 and how it affects our complex decision making in cardiac surgery is still not understood and may never be. Many Cardiothoracic Surgical departments have completely restructured or at the very least case numbers fallen. CTS trainees in the last few months have seen logbooks empty; referrals dry up and uncertainty escalate exponentially. Some have been affected by the pandemic in a terrible and personal way. Through my conversations with trainees, no two have been affected in the same way. This makes knowing how to fix things equally unique. During the last few months we have been inundated with enquiries from trainees whom have faced difficulties. Normally it has been when there’s been a disconnect or delay between hospital policy and the extraordinarily fast paced change. We’ve successfully helped trainees who have been told to use annual leave for symptomatic self isolation, trainees that have been told to go back to work despite remaining symptomatic and trainees who have been pressured to practice with inadequate PPE. What we’ve learned is the importance of discussing issues openly when they don’t sit right with you, rather than just blindly doing what you’re told. Even before COVID-19, trainees in cardiothoracic surgery struggled to get enough time in theatre. This can be seen in the quality indicator from the JCST survey where cardiothoracic trainees reported the lowest rate of achieving the targeted number of sessions

per week, just above 50%. Although worryingly this has to be taken in context though as many specialties aim at three rather than four half day sessions per week. JCST themselves have started using the twitter platform to raise awareness of the long term implications of the widespread stagnant training situation we find ourselves in by using #NoTrainingTodayNoSurgeonsTomorrow. I’m sure trainees around the country seen how they are valued and how furious efforts are going on daily to ensure negative impacts are minimised. It’s beyond naïve to expect training to have been unaffected by the pandemic and the real question is how will we as a specialty respond to the added pressures burdening our practice. Some deaneries have already had teaching sessions delivered online while some trainees have operated in private hospitals. Moreover, the difference between thoracic and cardiac surgery training has been noticeable. Thoracic trainees have seen less impact as cancer surgery has been prioritised, while exceptionally poor outcomes associated with COVID following cardiac surgery has been widely feared. Some of the most significant changes relevant to trainees so far have been: • ARCP outcome changes allowing extensions to training in addition to the normal extensions allowed during training • GMC curriculum changes suspended meaning the seven year syllabus will not start until August 2021 • Suspension on MRCS and FRCS with varied implications for progression

“It’s beyond naïve to expect training to have been unaffected by the pandemic and the real question is how will we as a specialty respond to the added pressures burdening our practice.”

• Suspended educational activities preventing trainees and trainers developing the required skills to progress We must also be mindful of the impact not only on physical health, but also mental health of trainees. In a recent survey of the trainee cohort across all years of training, over half had an increase in the number of regular or antisocial hours of work, possibly partly due to redeployment in ITU. Two thirds had concerns about their physical health and one third about their mental health. Given the often stoic approach surgical trainees are known for, these expressed concerns are very worrying. The impact of the pandemic on training may closely follow the economic implications. There has been a substantial pause and downturn. Some trainees re-allocated to intensive care will have been working in more tiring and stressful roles while case numbers sit static. Most of us are now sat wondering how we pick up the pieces and get everything back to normal. Will the recovery be V shaped or will fear and deskilling mean training follows an L shaped future? It is clear that the new normal is yet to come into focus and this includes, as trainees, our day to day lives on the road to becoming a consultant. It would make sense that our contribution to society is recognised as NHS surgeons and we all get our own parking space, desk and free tea and coffee. Furthermore, would it be too much to ask that we get paid for the longer hours we as cardiothoracic surgeons do above and beyond our rota’d hours? I’m certain that if we engage in change and be part of the process to improve the way we work then some significant and positive changes can be the legacy of this pandemic. Surgical training is simple though, learning about what can be done and why, then how to do it. We’re also certain we will come through this stronger with new and efficient ways of honing our craft. The new and exciting ways of using technology to streamline training should be embraced, as long as it doesn’t involve another family Zoom quiz. n

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The Medical Training Initiative sponsorship scheme by the Royal College of Surgeons, an International Surgeon’s experience Ramez AbuKhalil, Thoracic Surgery Department, Nottingham City Hospital

uring the final years of training, the hunt for advanced clinical fellowships following CCT or equivalent begins. Similar to my peers, I started exploring the pros and cons of each training destination. When seeking an advanced training in a certain scope of a certain speciality in particular, options become limited and long waiting times might be encountered. During the process and international advice seeking, the MTI scheme was brought to my attention by one of the Cardiothoracic Consultants in the UK. I was really surprised about the benefits of this programme and even more that it seemed like a hidden option that only a few know about amongst the international community. The programme gives an opportunity to international doctors who completed their training overseas to benefit from training in the UK, for a period of up to 2 years, accredited by the Royal College in their relevant speciality. The programme is designed to offer an equal opportunity of training to NTN’s and to monitor the training progress in a similar fashion through the regional TPD, assigned educational supervisor, clinical supervisors, adequate worked based assessments and ARCP’s. By the end of the programme, the Royal College issues a certificate of the accredited training fellowship provided that the trainee meets a satisfactory outcome during the training period. The process starts with a request of training from the international surgeon to a UK consultant in the same speciality. If the UK consultant is interested in training the international surgeon, the process can proceed. A key factor and the initial step for the programme is the submission of the application to the Royal College by the UK consultant who will be responsible for

educational and clinical supervision during the training. The consultant seeks approval of the local deanery as well, ensuring that such a post will not disadvantage the current trainees within the region while maintaining sufficient education and training content for the MTI fellow. The applicant then applies to the Royal College programme, where the main requirements would be the overseas specialist registration, CCT or equivalent, and a proof of English Language proficiency. When meeting the criteria, the Royal College issues a certificate of sponsorship which allows full registration with the GMC with a licence to practice. The process would generally take six months provided that all the requirements are met upon submission. The initial fear of working in a different health system with different guidelines rapidly vanished during my first month of the programme. The incredible support of my supervisors, colleagues, induction programmes, GMC welcome workshop, regional training courses and the Royal College was invaluable and allowed me to integrate smoothly within the team and the NHS. I have chosen to do my two year programme in the Thoracic Surgery Department at Nottingham University Hospitals, to allow a comprehensive exposure to a wide variety of elective and emergency procedures that would complement my previous training. After completing the first year of the programme, it was clear to me that it undoubtedly met my expectations and I was achieving my goals in a faster manner than I initially expected. In a 12 month period I performed over 200 major surgeries in almost all aspects of my speciality (including complex VATS/Open anatomical lung resections, tracheal surgery and endotracheal interventions, chest wall, diaphragm,

mediastinum and oesophagectomies). I was also given the opportunity to complete the basic robotic training, and will be working to develop this further in the next year. It is of no doubt that this opportunity of training in the UK expanded my knowledge and skills significantly, allowed me to gain insight into different approaches in the management of thoracic patients, and improved my management, leadership and teaching skills. I have managed to engage really well with the rest of the NTN’s and fellows and worked on different research projects and submitted four papers to the SCTS which were accepted for presentation in the annual meeting. I am confident that this fellowship would allow me to achieve all the Thoracic surgery competencies required by the ISCP curriculum and be a completely independent Thoracic surgeon. Furthermore, a significant advantage of training in the UK compared to its competitive destinations is the possibility to sit the FRCS exam and the ability to work towards specialist registration in the UK. Achieving that would be a valuable accomplishment that can have a significant impact on the future career opportunities worldwide. My hopes from this article is to serve as an eye opener for both international Cardiothoracic surgeons seeking advanced training, as well as Cardiothoracic consultants of the UK whom I feel that not many might be aware of this programme. Particularly, in a very small society like ours, the addition of international trainees can be a great asset to the NHS. I strongly encourage all SCTS members to share the knowledge of this programme with candidates whom they think might be interested in it, as well as cardiothoracic consultants who might not be aware of it and might be interested in training international surgeons. n

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SCTS-Ionescu Consultant Team Fellowship 2018: Bristol Royal Infirmary Elaine Teh (pictured), Sara Gomez, Eveline Internullo, Kaj Kamalanathan, Sarah Taswell, Douglas West, Gianluca Casali - Bristol Royal Infirmary

â&#x20AC;&#x2DC;S

hanghai, here we come!â&#x20AC;&#x2122; Excitedly we gathered early on 19 September 2019 to begin our journey to Shanghai. This amazing opportunity was made possible by the generosity of SCTS Education and Mr Ionescu.

The travelling team in the Bund, Shanghai

Our objective through this fellowship was to visit a high-volume centre, the Shanghai Chest Hospital, to gain insight into their protocol-based care, efficiency in perioperative care, managing high volume turnover and perspectives in ongoing development of services and techniques. Our secondary objective was to continue to build and strengthen our team. Shanghai Chest Hospital is the earliest hospital in China to specialise in Thoracic Surgery. It covers a wide range of thoracic specialty (lung, oesophageal and thymic). In 2018, they performed >15,000 cases; >12,000 lung surgeries, >800 oesophageal surgeries, 900 mediastinal

surgeries (60% via VATS) and 51 tracheal surgeries. There are 20 theatres in the hospital, performing between 5 to 8 cases in each theatre. When the volume started increasing, as a department, they carefully scrutinised their pathways and protocols, to find ways to improve efficiency and minimise idle-time in theatre. On the wards, mobilization is guided by distance-markers on the floor, along with supportive messages to cheer them on. Equally impressive is the simulation and training centre. The training centre is equipped with a robotic simulator, thoracoscopic simulators and a wide range of simulation for wards, theatres and ICU. This was made possible by collaboration with industry and Shanghai is now also a regional training centre for robotic thoracic surgery.

August 2020

of resources and time. For instance, the heads of Anaesthesia and Elaine Teh: Thoracics services of I was very impressed by the collaboration the Shanghai Chest and efficiency of the department. They came Hospital have realised together as a team, with a clear objective, to that the most precious carefully study their protocol and pathway in resource is the actual order to improve overall efficiency. theatre utilisation and have worked to rationalise Sara Gomez: and systematically move As a thoracic Clinical Nurse Specialist, the out of the operating Shanghai Chest Hospital has fully widened room all those immediate my perspective on the journey patients perioperative steps that experience on the day of surgery and has take time but don’t been an example of efficiency experiencing necessarily need to a large volume of cases per day. It has happen in theatre (e.g. been interesting observing the lung cancer insertion of cannulas, pathway from another cultural perspective central lines, anaesthetic and how this has an impact on the challenges blocks, extubation, being faced differently. As a team, the trip etc). Consequently, has encouraged us to reflect on our current the “induction room” practice and discuss ways to improve our and the recovery room efficiency. have been set up and implemented with appropriate staff and Eveline Internullo: equipment. The result is an impressive theatre Visiting the Shanghai Chest Hospital was a turnover of about 10 minutes. Although this mind-blowing experience. With its 14,000 outcome would not be reproducible as such, lung resections per year, it carries a case this philosophy and mindset is something that volume that is simply unthinkable in Western should definitely be looked into with a view to Countries. There are many differences optimize the use of theatre time and make the that immediately strike the mind: culture, most of available resources. lifestyle and work ethics of the healthcare professionals to start with, but also the Kaj Kamalanathan: clinicopathologic characteristics of the cancer From the anaesthetic perspective, I was really population itself – with a large proportion struck by the efficiency shown in turning over of resections for GGOs in relatively young patients and their pragmatic use of space non smoker women. As a result, although the with their induction areas. I was also really visit is exceptionally inspiring, many practices interested in their recovery area, which works and protocols are simply not exportable (or incredibly well to improve their efficiency. not applicable) to the NHS. I found very interesting the way they cope with these Sarah Taswell: exceptionally high volumes. The Shanghai As Lead Thoracic Nurse in theatres, Chest Hospital has seen its case volume my primary interest was teamwork and doubling in 3 years and this has generated communication and how they impacted theatre some impressive work on the optimisation flow and efficiency. I was also very excited to see the advances in surgery and anaesthesia and how they also affect the perioperative care pathway. Whilst it is important to appreciate the difference between the two hospitals and cultures, I feel there are aspects of their core values, efficiency, quickened turnover and The team in The Humble improved safety, that we can Ambassador’s Garden in Suzhou adopt within our unit.

Our personal reflections:

The Da Vinci robot in thoracic theatre during a mediastinal surgery

The recovery area in theatre where patients will be extubated

To have been able to see some of the innovative surgical techniques at the Shanghai Chest Hospital has been motivating to the team and I look forward to assisting in implementing them in our practice. Doug West: Being able to visit the Shanghai Chest Hospital provided a completely novel perspective on lung cancer surgery. Firstly, the volume of work and therefore the size of the unit is extraordinary by European or North American standards. This allows for the development of significant expertise and highly streamlined peri-operative processes. Time before surgery is used to site all monitoring lines and regional anaesthetic blocks, while post-op weaning and removal of the double lumen tube is done in a large recovery area. This maximises the utilisation of the operating room itself, making lists with six or more major cases possible. The clinical expertise made possible in this model has allowed the development of innovative techniques, for example in nonintubated tracheal surgery and anatomical lung resection. I was struck by how much we might be able to achieve with larger units and more protocol based care back in the UK. We have thoroughly enjoyed the trip and again, very grateful to SCTS Education and Mr Ionescu. We have shared our experience and thoughts with wider members of our team and aim to disseminate this within the Division in our ongoing mission to improve thoracic surgical care. n

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Challenges to Reduce Surgical Site Infection in Cardiac Surgery Melissa Rochon, Quality & Safety Surveillance Lead, Royal Brompton & Harefield NHS Foundation Trust, in collaboration with CIRN

urgical site infection (SSI) is the most important healthcare-associated infection affecting surgical patients. Through 2018 and 2019 an interdisciplinary steering group coordinated work by the Cardio – Thoracic Interdisciplinary Research Network (CIRN), National Cardiac Benchmarking Collaborative (NCBC) and Public Health England (PHE) performed a survey of variation in practice in the prevention of SSI in cardiac surgery patients. This work was presented at the February 2020 NCBC annual conference in morning and afternoon breakout sessions and was scheduled to be disseminated further at the SCTS 2020 annual conference in March before being curtailed by the COVID-19 pandemic.

National Cardiac Benchmarking Collaborative (NCBC) Breakout Sessions on SSI After presentations on the findings from the VIP surveys, the multidisciplinary discussions centred on the lack of consensus on the definition of SSI and the burden of data collection as well as looking ahead to new technologies to undertake prospective surveillance. One of the key challenges identified by CIRN in their Cochrane Review of interventions to prevent cardiac SSI is that the definition of SSI (ASEPSIS, EWMA, CDC, PHE or mediastinitis only classifications) varied between studies. The CIRN committee has agreed to use the PHE definition for the national SSI project, noting that this is in keeping with national surveillance strategies (Getting It Right First Time SSI Audit and PHE) in

England. Breakout groups in both sessions agreed that the PHE definition should be promoted via NCBC. In addition to consistency, data completeness for SSI surveillance was also problematic. The survey indicated that all 19 participating centres captured SSI during primary admission and 18 centres recorded SSI detected on readmission. In response to the survey results, the cost of undertaking prospective surveillance as well as ways of reducing data duplication by streamlining external submissions (eg. SCTS/NICOR and PHE) were also discussed. On reflection of the different practices in and between centres, the NCBC breakout groups agreed there was a need for SSI prevention guidance specific to cardiac surgery, and that SSI risk stratification would help target interventions. There was also broad support to raise awareness and a common approach to mediastinitis (an Amber incident) triggering duty of candour requirements and cessation of nonevidence-based practices such as extended antibiotic prophylaxis. The following action points were discussed as part of a broad SSI surveillance initiative, as well as within cardiac surgery: 1. PHE’s plans to launch SSISS web application in 2020 The majority of participating hospitals submit continuous surveillance data (88% for CABG and 81% for non-CABG cardiac surgery in the last calendar year). The new application is expected to improve efficiency, including reduced data entry time, faster record submission,

earlier release of reports through categoryspecific reconciliation, and streamlined communication between hospitals and the PHE SSI team. 2. Online training for healthcare professionals using digital images in wound care A Cardiac SSI Network project brought together specialist colleagues from Barts NHS Trust, Oxford University Hospitals FT, University Hospital Bristol NHS FT, Royal Brompton & Harefield NHS FT, Royal Papworth Hospital NHS FT University Hospital Southampton NHS FT to develop a free online course hosted by 3M Health Care Academy, called The use of digital images in wound care. The education programme is endorsed by the Royal College of Nursing and covers the processes involved in taking high quality digital images in accordance with expected professional standards and practice. 3. Photo at Discharge (PaD): a baseline image to bridge acute and community care The use of digital wound images prompted positive discussions in both the morning and afternoon talks. There are signs and symptoms of concern (such as sternal instability, fever, heat, pain or infection of deep tissue at the operation site) which would not be picked up via a standalone digital image. Nevertheless, attendees agreed that any service where wounds are reviewed should have the ability to take and upload an image to a secure patient record. A national 2019 Patient’s Association survey found that PaD is a tangible tool that patients could apply to their surgical wound care.

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“The actions arising from the NCBC SSI breakout sessions included encouraging consensus for defining SSI; increase uptake of post-discharge surveillance, ensuring that digital images are part of standard practice within the specialty.” 4. The use of images to improve post-discharge surveillance The median length of stay for both Cardiac and CABG surgery is 9 days, however, as the median time to infection tends to be closer to 14-15 days, postdischarge surveillance, such as the patient wound healing questionnaire, would provide additional data on the period after discharge (up to 30 days). Digital images, can be used as an assessment tool to identify problems with wound healing following discharge and prevent future readmissions as seen in the example of the PaD scheme.

be quick and self-explanatory. Secondly, medical photography can be highly sensitive so we must be able to control the storage of images end-to-end, and thirdly, the quality of images must be sufficient to be clinically useful. In supporting surveillance effectively, these challenges must be met. Rise, the ‘progressive web app’, essentially a website which also allows for a single click ‘install’ for engaged users wanting an application experience. See example here: https://youtu. be/9miOyCUdObE.

On the face of it, capturing an image and submitting it to a clinician to be reviewed is a simple enough task. Digging a little into the task reveals 3 areas of complexity. Firstly, many of the users who will go through this process will be single time users, meaning that the process must

Next steps The actions arising from the NCBC SSI breakout sessions included encouraging consensus for defining SSI; increase uptake of post-discharge surveillance, ensuring that digital images are part of standard

practice within the specialty. Within the Data and Information workstream of the National Wound Care Strategy Programme (NWCSP), to look at where there may be gaps and/or variation in managing or monitoring digital images taken by healthcare workers and patients, and the CIRN will be looking to link in with this subgroup. During the pandemic, many services have necessarily suspended SSI surveillance to focus on activities related to COVID-19. During these challenging times, there may have to be a change to the way some services are accessed and delivered, including remote patient review including surgical wounds. The proposed national CIRN-led SSI study has an exciting opportunity to coordinate efforts specialty surveillance strategies incorporating digital imaging. If you or your team would like to find out more about any of these initiatives, please email the CIRNetwork@outlook.com. n

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Silos to collaboration Sunil K Bhudia, on behalf of The RBHT Team* (and new Team)

ardiac surgery has come a long way and continues to improve. Further progress will be in smaller step changes. In order to reduce the time between the small step changes, surgeons and teams will have to think differently to optimise the changes. A move from working individually or in silos to collaborative working is the way forward. On many an occasion, to affect change in behaviour, a crisis situation catalyses the process. On 4th March, 2020 National Health Service England (NHSE) declared COVID-19 to be a ‘Level 4 National Incident’, a designation which permits NHSE to take control of all NHS resources. As part of the emergency measures introduced to deal with the outbreak, NHSE suspended all elective cardiac surgery in the seven cardiac surgical units in London. In the immediate aftermath of the ‘Level 4’ designation, the Pan-London Emergency Cardiac Surgery (PLECS) group was convened in order to coordinate the management of cardiac surgery across the London. It was recognized that cardiac surgical units located in hospitals with accident and emergency departments would be overwhelmed with COVID-19 patients and therefore unable to perform any cardiac surgery. Two units located in hospitals which do not have an accident and emergency department (Harefield Hospital and St Bartholomew’s Hospital), were tasked by NHSE with maintaining urgent and emergency cardiac surgical services for the London region, a population of approximately 9 million people, which also serves parts of the adjacent areas of the South-East and East of England regions with populations of 6 and 9 million respectively. All the cardiac surgical centres were represented in the group. At the outset, it was agreed that all elective surgery in the region would cease and that all the urgent and emergency surgery would be referred either to Harefield Hospital or St Bartholomew’s Hospital.

At Harefield Hospital we took up the challenge and embarked on collaboration with our sister unit, The Royal Brompton Hospital, and other cardiac centres in London, namely St Thomas’s Hospital and Hammersmith Hospital. The whole leadership team with the entire Harefield Hospital Team took a collective decision to change to an open mindset. Within a short period of time, infrastructure was put in place to hold virtual multidisciplinary team meetings across most of London and surrounding counties. Cardiology teams and surgical teams could present, discuss and refer urgent cardiac patients into the Hub on a daily basis 7 days a week coordinated from Harefield Hospital. The Hub is co-chaired by a surgeon and cardiologist. Expertise to manage any cardiac pathology is available. Patient pathways were modified to reflect national guidelines with safety and efficiency at the centre of decision making. The Harefield Hospital also managed high risk patients with COVID-19 infection. This encouraged collaboration amongst the various specialities within The Harefield Hospital to optimise resources and best serve patients in a safe environment. Patient pathways were modified given changing guidelines and protocols. This encouraged the team to be flexible and resilient. At The Harefield Hospital, we are a team of eightcardiac surgeons including transplant surgeons. We broke down barriers and teamed up with eight cardiac surgeons from our sister hospital, The Royal Brompton Hospital. With our human factors hat on, we created a buddy system to help settle surgeons in a new environment. We also ensured that surgical preference for each surgeon was available so that each surgeon in a new environment had least amount of changes in their routine to ensure optimum performance. Theatre allocation was equally distributed, and a sense of belonging provided. Patients

referred are pooled so that there are no delays in treatment and to improve resource utilization and efficiency. This was our second example of collaboration. Slowly but surely our throughput started improving with excellent outcomes given that we were only operating on emergency and urgent cases, including heart and lung transplantation. Our next task was to increase capacity, which we managed to achieve with space reconfiguration. With the increased capacity we pushed ourselves further and invited surgeons from St Thomas’s Hospital to collaborate and operate at The Harefield Hospital. We set out a patient pathway for new cohort of patients. Same human factors principles and buddy system employed with colleagues from The Brompton Hospital were utilized again. We learnt from previous experience and now we also facilitated respective junior doctors to come and assist in respective teams. This was our third collaboration. We did not stop there. We invited surgeons from The Hammersmith Hospital to come to The Harefield Hospital to operate. We followed the same steps as before but added yet another aspect. This time round we invited perfusionists from The Hammersmith Hospital to come and work with surgeons. This was our fourth collaboration. Our fifth collaboration is with King’s College Hospital. We were now in an extremely rich environment. Learning from each other, sharing facilities, sharing experience, sharing patients and most importantly collaborating. The net beneficiaries are the patients. *The RBHT Team – Toufan Bahrami, Fabio De Robertis, Jullien Gaer, Balakrishnan Mahesh, Shahzad Raja, Andre Simon, Ulrich Stoke, George Asimakopoulos, Tony De Souza, Mario Petrou, Cesare Quarto, Ulrich Rosendahl, Richard Trimlett, Rashmi Yadav, and Sunil K Bhudia. n

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2018 SCTS Education Ethicon Trainee Fellowship: One year training in Complex Aortic Surgery at St Barts Ana Lopez-Marco, Aortic Surgery Fellow, St Bartholomewâ&#x20AC;&#x2122;s Hospital, London

was in my final years of training in Cardiothoracic Surgery at the Wales Deanery, when I decided to apply for a national fellowship. I had completed the training programme in Cardiovascular Surgery in Spain in 2011. During my training I had a broad exposure to adult cardiac surgery and had performed over 350 cases as first operator. I developed an interest in Aortic Surgery during the early years of my Cardiovascular training in Spain, and with that in mind, I tailored my training rotations to maximize the exposure to this subspeciality area. After a competitive national selection interview process, I was awarded the 2018 SCTS Education Ethicon Trainee Fellowship to spend a year training with the Aortic Surgery Team at St Bartholomewâ&#x20AC;&#x2122;s Hospital (Barts) in London. St Bartholomewâ&#x20AC;&#x2122;s Hospital was founded in 1123 and has provided patient care on the same site longer that any other hospital in England. In 2015, The Barts Heart Centre opened, merging the services and staff from Barts, The London Chest Hospital and the Heart Hospital, forming the largest Cardiac Centre in the UK and in Europe on a single site. The AortoVascular Surgery team at Barts is led by Professor Oo with 3 Consultant Cardiac Surgeons: Professor Uppal, Mr. Yap and Mr. Adams. As a team, they cover the whole spectrum of aortic surgical procedures (root, ascending aorta, arch, descending thoracic and thoracoabdominal aorta), including aortic valve repair and minimal invasive procedures. A hybrid operating theatre allows endovascular and combined procedures on the same site. There is a specialized emergency aortic dissection rota covered by 9 Consultants Cardiac Surgeons, with Barts receiving over 60 emergency dissections in the last year. I was the first dedicated Aortic Surgery Fellow at Barts appointed competitively by the SCTS Education Ethicon Fellowship and I decided to make it count as my ST8 training year. I joined a rota of 8 non-resident trainees on a 1:4 oncall and a further 17

resident trainees and fellows of varying levels of experience. In addition to being on the rota for general cardiac surgery I was primarily responsible for all aortic patients in the unit, both preoperative and postoperative care including emergency referrals. A normal week would involve two or three days in theatre, an aortic outpatient clinic and an endovascular session every two weeks. During these 12 months I have had an excellent exposure to Complex Aortic cases, having been involved in over 130 cases, including 18 arches and frozen elephant trunk repairs, 5 descending thoracic aorta replacements and 22 thoraco-abdominal aorta repairs, as well as regular exposure to roots and ascending aorta replacements. I have also been exposed to valve sparing root replacements and mini-sternotomy approach for proximal aortic procedures (root, ascending and/or arch replacement). I have performed a total of 24 complete aortic cases as first operator, including 4 emergency repairs of aortic dissections and 10 arch replacements. I have had multiple training opportunities even with the most complex cases and I have gained confidence with redos, axillary cannulation, min-sternotomy and thoraco-abdominal exposure. Despite my rota allocations intended to maximize the aortic exposure, I also performed 20 adult cardiac cases independently. The recent collaborative link established between Barts the Aortic Endovascular service at the Royal Free Hospital led by Miss Tara Mastracci, has also allowed me to incorporate endovascular exposure and skills to the

Fellowship, by attending regularly Complex Aortic Endovascular procedures at the Royal Free since October 2019. In addition to the surgical skills, this Fellowship also allowed me to gain invaluable skills in the management of aortovascular patients from diagnosis to long term surveillance. I review all new referrals in our weekly combined surgical and anaesthetic aortic clinic. I have refined my diagnostic skills with a thorough and standardize approach to CT scans for the preoperative planning in clinic as well as preparation for MDTs. I have been co-coordinator of our bi-weekly Aortic MDT which discussed around 300 cases per year. I have gained extensive experience in the acute postoperative management of aortovascular patients, including blood pressure control, fluid management and spinal drainage. This has also included the management of patients on ECMO. Academically, the year has also been very productive, having presented at several National and International Aortic meetings: Barts AortoVascular Symposium, London Aorta, Bologna Thoracic Aorta Course, BISMICS, and IACTS and secured several presentations for this year SCTS Annual Meeting and Houston Aortic Symposiums. These presentations have also generated a few case reports and manuscripts. I lead the mortality meetings for the AortoVascular service. I recently coordinated a Quality Improvement project to analyse the current results of emergency type A aortic dissection in the unit and standardize the unit approach. From the personal point of view, I thoroughly enjoyed being part of such a big team and I can confidently say I made some friends for life during the long working hours. Having now completed the UK training program, I am confident that this experience has prepared me well for the next steps in my career as a Cardiac Surgeon with an Aortic interest. I would definitely encourage any of the current trainees with an Aortic interest to consider Barts as one of the preferred options for an Aortic Surgery Fellowship. n

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SCTS-Ionescu Consultant Travelling Fellowship 2018 Fraser Sutherland, Consultant Cardiac Surgeon

was fortunate to be awarded the Marian & Christina Ionescu Consultant Travelling Fellowship by the Society in 2018 The fellowship provided funds for me to spend one week at Shiga University of Medical Science, Otsu, Japan studying elective aortic arch surgery under the direction of Professor Tohru Asai a very accomplished cardiac surgeon with a particular expertise in arch surgery. However, during my short stay I also took the opportunity to study his technique for skeletonisation of the right gastroepiploic artery (and bilateral internal thoracic arteries) for off pump total arterial revascularisation, which is also a subject of great interest to myself and colleagues in Glasgow. The fellowship was used to visit a leading centre for aortic arch surgery in Japan with a track record of having successfully performed over 400 cases and average skin-to-skin operating time in the region of 3½ hours which I consider to be

Anastomosis of left subclavian artery in cadaver lab

very impressive. The principle objective for this fellowship was to compliment my existing skills with a better understanding of how best to obtain exposure of the distal arch for end-to-end anastomosis and to improve my technique for reimplantation the branch arteries using a 4 plexus graft or equivalent, thus allowing myself and colleagues in Glasgow to improve the provision of elective aortic arch surgery to patients in Scotland. Like most adult cardiac surgeons, the most frequently encountered aortic pathology in my practice is aortic dissection and despite that the focus of this fellowship was to study elective arch surgery, I was confident that skills learned through this fellowship would be transferable to more challenging cases such as repair of Type A dissections where the primary tear is located in the distal arch or beyond. Additional objectives included my desire for a more contemporary understanding of recovery expectations following elective aortic

arch surgery than is prevalent in the UK, especially ‘fast track recovery’ in elderly patients, a subject about which Professor Asai and his team have published4,5. A final objective was to build stronger professional relationships between UK surgeons and international colleagues. Prior to leaving the UK, I arranged a cadaver lab. At a local university using the Thiel embalmed technique which affords a soft and pliable fixation of tissues. In previous work I have found this method of cadaver fixation to be well suited to training cardiac surgeons in new procedures6. I practiced the exposure and implantation of arch grafts using a range of standard and minimally invasive surgical instruments and retractors (Fig. 1). The experience gave me a flavour for what to expect and left me with some clear learning objectives and technical questions for my host. I departed for Japan at the beginning of September 2018. Soon after my arrival Typhoon Jebi struck the south of the country. All services were suspended for 24 hours after which normality seemed to resume. Otsu was spared the worst of the damage but the infrastructure serving access to Osaka airport was severely damaged and the airport was closed for several weeks forcing me to seek an alternative route home. I attended surgery with Professor Asai at two hospitals and studied hours of high quality video footage in his office between surgeries (Fig. 2). A meeting was arranged with the chief perfusionist which enabled me to understand practical details of their selective antegrade cerebral perfusion (SACP) technique, examine routinely used disposables and discuss how best to manage various perfusion scenarios that can arise during delivery of SACP (Fig. 3). During my stay, I was asked to deliver a lecture on “Transcervical Approach for Surgical Aortic Valve Replacement (SAVR) and

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Transcervical Approach for Transcatheter Aortic Valve Implantation (TAVI)”. Upon my return to UK I took steps to harvest the benefits of this experience for the wider good. The cardiac team in Glasgow is already very well equipped with the skills and equipment to perform complex aortic surgery. Nonetheless, I set about writing a standard operating procedure for elective aortic arch replacement based upon what I had learned, developed a detailed perfusion protocol for delivery of SACP and discussed practical implementation of these protocols with anaesthetic/surgical colleagues and the wider scrub team. Our first patient had actually suffered a Type A aortic dissection with a primary tear in the distal arch and warranted urgent surgery. He successfully underwent total arch replacement and went on to make a full recovery. Subsequent patients have followed a similar course and during this time I have worked closely with colleagues from other disciplines to orchestrate robust multi-disciplinary team (MDT) meetings to discuss such cases. The team feels very enthusiastic about the future. I do believe that building strong professional relationships and learning from leading surgeons from other countries is extremely valuable to our speciality. I sincerely thank my host, the Society and Mr Marian Ionescu for the generous fellowship and support that enabled me to visit this centre in Japan and to realise all of my goals. n References: 1) Dapunt O E, Luha O, Ebner A, Sonecki P, Spadaccio C, Sutherland FWH. First-In-Man Transcervical SAVR using the CoreVista System. Innovations 2016;11(2):84-93. 2) Dapunt O E, Luha O, Ebner A, Sonecki P, Spadaccio C, Sutherland FWH. New Less Invasive Approach for Direct Aortic TAVR using Novel CoreVista Transcervical Access System. JACC Cardiovasc Interv. 2016;9:7503) Spadaccio C, ElKaswary, Sutherland FWH. New Minimally Invasive Surgical Approach for Excision of Left Atrial Myxoma. Gen. Thorac. Cardiovasc. Surg. 2017;65(10):605-8. 4) Suzuki T, Asai T. Fast-Track Total Arch Replacement in Principles and Practice of Cardiothoracic Surgery Ed. Firstenburg ISBN 978953-51-1156-6 INTECH Open Access Books 5) Korazumi H, Mikamo A, Kudo T et al. Aortic Arch Surgery in Octogenerians: Is it Justified? Eur. J. Cardio-Thorac. Surg. 2014;46:672-7. 6) Spadaccio, C, Sutherland Y, Sutherland FWH. Thiel cadavers: the ideal simulator for training in novel cardiothoracic procedures. Presented to the Royal Society of Medicine, Cardiothoracic Section. London 2015.

Reperfusion of brachiocephalic trunk during aortic arch replacement

Professor Tohru Assai (left) hosts a meeting with his chief perfusionist and Mr Fraser Sutherland (right)

“I set about writing a standard operating procedure for elective aortic arch replacement based upon what I had learned, developed a detailed perfusion protocol for delivery of SACP and discussed practical implementation of these protocols with anaesthetic/surgical colleagues and the wider scrub team.”

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SCTS-Ionescu NTN Travelling Fellowship 2019 – Adult cardiac surgery at The Prince Charles Hospital, Brisbane, Australia Eshan Senanayake

as it a dream? Having returned back to Birmingham, it now sure feels like it. My fellowship in adult cardiac surgery at The Prince Charles Hospital (TPCH) in Brisbane, Australia (Feb 2019 – Feb 2020) has provided me with great fulfilment clinically and personally, and it has also provided me and my family with a full year of fantastic out-doors Australian living. I am eternally grateful for being awarded the SCTS-Ionescu NTN Travelling fellowship in 2019, which has helped fund this fellowship, and I would like to take this opportunity to sincerely thank Mr. Marian Ionescu and the SCTS for creating this opportunity. During ST6 I was acutely aware that there wasn’t much time left before the next step of being a consultant; the key question I had was if I was ready to be a consultant? First and foremost I wanted to get the basics right! This led me to arrange a fellowship that allowed more independent operating within the generality of cardiac surgery but also give me the scope to sub-specialise in my area of interest within the fellowship year. I decided to do this as an OOPE after passing my FRCS (C-Th). I had firmly decided to go abroad for a fellowship. After a lot of research and speaking to colleagues here and abroad there was little hesitation that Australia was going to be the preferred destination to provide both a comprehensive training experience and also for a better quality of life. The Prince Charles Hospital (TPCH) in Brisbane, Queensland, is one of the biggest public units in Australia offering all aspects of cardiac surgery; > 1000 conventional cardiac cases/ year, aortic surgery programme, heart & lung transplantation, mechanical support, and

ACHD programme. The state of Queensland has the best quality of life Australia has to offer (I say this with bias now, but I’m sure many will agree) with year round sunshine, extremely mild winters (with baby blue skies), easy access to both the Goldcoast and Sunshine-coast and, of course, the Great Barrier Reef (should be on everyone’s bucket list). Therefore the decision to target TPCH was easy! TPCH was able to offer me in principle a fellowship with greater independence as a first operator and scope to develop in aortic surgery and transplantation. With this knowledge I took a great leap of faith and committed to this fellowship. I had to formally apply through their national recruitment process in June 2018, with an intention to start in Feb 2019 (to stay in line with their recruitment schedule). Having secured this fellowship and obtaining all the

mandatory regulatory approvals, my family and I were ready to embark on this journey. We arrived in Brisbane in the middle of January 2019. It was the height of the Australian summer; sun was shining, it was 30°C and parks were full of families enjoying the great outdoors. Prior to starting work we headed to the coast to experience the awesome coastline, enjoy the sunshine, play on the beach and swim in the fresh Pacific Ocean; the kids, my wife and I all loved it and as far as lifestyle goes, we had made the right choice! This lifestyle continued throughout the year in Brisbane. The Prince Charles Hospital is set within its own acreage with manicured lawns and driveways lined with palm trees. The cardiothoracic surgery department is a big unit with 10 consultants (8 cardiac, 1 thoracic and 1 mixed practice). There was a lot that was different from the NHS. The feel was a

“The Prince Charles Hospital is set within its own acreage with manicured lawns and driveways lined with palm trees. The cardiothoracic surgery department is a big unit with 10 consultants (8 cardiac, 1 thoracic and 1 mixed practice). There was a lot that was different from the NHS. The feel was a hybrid between the American and old British systems.”

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hybrid between the American and old British systems. Cardiac and thoracic surgery had a ward each with excellent level of nursing care (despite three 8 hr shifts per day). The service was mostly consultant led. The wards were manned by interns and residents. The middle grades consisted of registrars with variable experience. To my surprise, there were no nurse/surgical care practitioners! Electronic medical records were not established. Intensive care was managed purely by intensivists with no cross over with cardiac anaesthesia. Oncalls were based on a 1st and 2nd oncall tiered system (as a senior registrar I had no resident nights). There was a strong firm based structure with two consultants in each team with their two registrars and a resident/intern. Each consultant would have 1-2 operating lists per week and a clinic. The registrars and interns would rotate firms every 3 – 4 months. There was an unwritten expectation that work starts 06:30-06:45 for pre-consultant ward rounds followed by theatre which often started by 08:30 (knife to skin). Clinics were generally a later start. Each list always had 2 cases scheduled irrespective of complexity; routine list would finish by 16:30. The day would end after a close of play ward round. Each day had three parallel cardiac theatres and on some days a 4th thoracic theatre generating between 5 – 6 cardiac cases each day, all moving through a 9 bedded ITU. Cancellations were extremely rare! My time at TPCH was truthfully a thrilling rollercoaster with very high highs and some lows. Starting in a new country, hospital and department with very different working practices, getting used to the systems and the people was a very steep learning curve. I was most certainly put to the test, clinically and professionally. In hindsight, every day was an assessment and like me, they too had taken a leap of faith in me and I had to prove myself ! Having the FRCS (C-Th) went a long way, but I couldn’t slip up. Everyone’s anxiety is heightened in theatre. During the first few weeks every aspect of my surgical capabilities were tested; assisting, conduits (they used a lot of radial arteries), setting up a case, to performing the case. The pressure was always on. Very soon, I was doing cases starting with coronary surgery. On reflection, expectations were set within the first few cases I performed. Once this standard was deemed acceptable, the anaesthetic, theatre staff and surgical consultant body were extremely encouraging

to do more cases. The type of pressure changed; I was outside the protection of being a trainee and as a fellow being able to do cases, I was expected to perform at that level with acceptable outcomes. I would consider my first rotation the settling in phase. Having progressed to perform cases under minimal supervision; there were logistics that needed to be overcome. With no SCPs I was reliant on junior colleagues for assistance. Understandably not every case was suitable and unlike in the UK, it was rare for trainees/ fellows to do both cases on the list (due to the perceived time efficiency factor). During this first rotation I also started on the transplant retrieval rota. This was my first step in tailoring my fellowship towards heart and lung transplantation – a key component of this, having never done it before, was organ procurement including organ assessment and optimisation. After a very short period of training and supervision I was on the retrieval rota, independently assessing and harvesting organs from across the country, and this included procurement of hearts with the TransMedics Organ Care System (this too was a very steep learning curve). Once the organ was delivered I got involved with the organ implantation – they were long days! This aspect of my duties continued throughout my fellowship with increasing commitment towards retrievals and implantation. During my second rotation, I was given free reign to operate on any surgeons’ list, whilst being attached to the senior surgeon of the unit (fulfilling this duty was essential) whilst meeting my commitments to retrieval and transplantation. Although this sounds good on paper, it was logistically very difficult to action. The senior surgeon would have three lists per week; undertake all the difficult and high-risk cases, including multiple redos and major aortic surgery. Hands-on training was minimal and with the greatest respect I absorbed this period of observational training; I learnt technical finesse, surgical strategy, efficiency, decisiveness, all executed with such flare, even in difficult and high-risk cases. These skills I will retain and use throughout my career. Whilst in Australia, I spent some time at the epi-centre of heart transplantation – St. Vincents Hospital, Sydney. I experienced first-hand their DCD and TransMedics OCS programme and how the entire unit is set up around heart & lung transplantation; during the week I spent

there, they implanted two hearts and two lungs (in 48hrs)! The third and final phase of my fellowship was the ultimate high. I worked within a great team of surgeons, performed the majority of the cases under distant supervision and had exposure to the full gamut of cardiac surgery; from coronaries, redos, mitral surgery, through to double and triple valve procedures, heart failure surgery including ventricular assist devices and adult congenital work. On most weeks we operated 4 days/week. This phase was undoubtedly hard work with greater responsibility at all levels, but with high personal reward; I think it’s fair to say it was truly a win-win period for all concerned. I worked with a wide group of people in a high volume unit. The theatre team were extremely efficient with short turn-around times. The cardiothoracic scrub team were truly fantastic. The perfusionists were a small committed team. The cardiac anaesthetists were versatile & adaptable. The surgeons were cohesive and supportive. The ward had skilled staff able to handle patients with infusions; patient left intensive care sooner. The middle-grades were enthusiastic and committed. The Queensland government and TPCH looked after their staff and were well remunerated. The CTS department retained their staff and were happy to work! A number of these domains can theoretically be translated to the NHS, but would require a series of changes to take effect. My time abroad has also re-enforced my belief in the NHS – the service provision for cardiac surgery is very good but there are areas for further improvement; I am now acutely aware of what these areas are. On reflection I have achieved most of my objectives during my fellowship; an experience abroad within a different healthcare system, performing a wide array of cases under minimal supervision and experience in retrieval & transplantation. Without a doubt this fellowship has strengthened my character and enhanced my surgical skills; qualities I will use throughout my career. My family and I have also had a great year in the sun, sea and sand and we have seen an amazing part of the world; this we will always fondly cherish. Once again, I would like to take this opportunity to sincerely thank Mr. Ionescu and the SCTS for creating this opportunity to apply for the NTN travelling fellowship award, which has immensely helped me with funding this fellowship at TPCH in Brisbane. n

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SCTS-Ethicon Surgical Trainee Fellowship 2019 – Minimally Invasive Cardiac Surgery in Aalst, Belgium Syed M Rehman, Post-CCT Minimally Invasive & Robotic Cardiac Surgery Fellow

was privileged to have the opportunity to complete a post-CCT fellowship in minimally invasive cardiac surgery under the mentorship of Dr Frank Van Praet at OLV Ziekenhuis in Aalst, Belgium. This was generously supported by an SCTS-Ethicon Surgical Trainee Fellowship. OLV’s MICS programme was established by Dr Hugo Vanermen over twenty years ago where the department has been a pioneer in the fields of endoscopic mitral valve and robotic cardiac surgery. They also have a proud history of training international fellows, including surgeons from the UK, who have subsequently successfully established their own MICS programmes.

Preparation I initially contacted OLV in December 2016 with the hope of commencing a fellowship in August 2018 after obtaining CCT. I was oﬀered a fellowship to start in August 2019 following review of my application. I was lucky to have the start date subsequently reviewed to February 2019 at three months’ notice. Therefore, it is important to have all the paperwork completed and to be registered with the Belgian equivalent of the GMC early to be able to take the opportunity of an unexpectedly earlier start date. The process is prolonged for doctors with a non-EU medical degree, so this

may be of relevance to those with a UK medical degree following Brexit! The local language is Flemish but there is no language requirement for the fellowship and all the staﬀ comfortably and happily communicate in English. I was fortunate to have thorough experience of mitral valve surgery from my training in Southampton and an ST7 OOPT fellowship in Rennes, France, which also included minimally invasive mitral valve surgery. This provided the ideal preparation for a fellowship with Dr Van Praet, whose case mix consists predominantly of complex mitral, redo, concomitant tricuspid and AF ablation cases, including several international referrals.

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Department of Cardiac Surgery at OLV Ziekenhuis The department is staﬀed by four consultant cardiac surgeons. Dr Van Praet performs the endoscopic mitral and robot-assisted MIDCAB cases. A relatively smaller number of such cases are performed by another consultant and three of the four consultants routinely perform J- sternotomy aortic valve surgery. Although the focus of the fellowship is MICS, the department covers the full spectrum of adult cardiac surgery, including complex coronary (total arterial revascularisation and oﬀ-pump), valvular, complex aortic (root repair and arch surgery), heart failure (ECMO, VAD and transplantation) and transcatheter (TAVI and MitraClip). The activity level is up to approximately 800 adult cardiac cases per annum.

Fellowship Experience As a fellow, every day I would review the patients on ICU and then attend the operating theatre. I was always scrubbed for the MICS cases and otherwise had exposure to the wide range of conventional operations. I was also involved in the discussion of pre-operative planning for MICS and complex cases. My on-call commitment was one week in three nonresident. In terms of operative experience, I was scrubbed for a total of 413 cases, including complex sternotomy cases (triple valve, valve-sparing root, arch, VAD and transplant, redo and endocarditis).

OLV Ziekenhuis in Aalst, Belgium

The MICS experience was as follows: • 110 cases • 67 endoscopic including mitral, tricuspid, AF ablation, myxoma, repair of PAPVDSVASD and redo (previous endoscopic or sternotomy) • 22 J-sternotomy AVR • 21 robot-assisted MIDCAB The volume and complexity of cases that I was exposed to over one year provided a comprehensive understanding of the key issues of: • minimal access exposure • cannulation, cardiopulmonary bypass and cardioplegia strategies • techniques of endoscopic instrument use • pre-operative selection and intra-operative strategy • management of intra-operative and postoperative complications Of note, it was incredibly useful to gain experience of using an intra-aortic occlusion device during the first six months of the fellowship before the device was temporarily withdrawn from the market. I found this to be a particularly elegant alternative to cross-clamping the aorta, which has been used successfully in the majority of 3000+ cases in Aalst and is especially useful in the redo setting. It was also useful to have the prior experience of assisting in endoscopic mitral surgery in France to appreciate diﬀerences in technique between the two centres. Apart from the incredibly valuable clinical experience, there were plenty of educational and academic opportunities. Dr Van Praet runs a four-day cadaveric simulation course for endoscopic mitral surgery for which I was honoured to be on the faculty on the three editions during the year. I also had presentations at the AATS Annual Meeting in Toronto, the Minimally Invasive Techniques in Adult Cardiac Surgery EACTS Academy Course in Frankfurt and the C3 Meeting in Vienna.

Furthermore, I hope to have two papers published from work during the fellowship. In addition, there is the state of the art ORSI academy near Aalst which provides endoscopic and robotic simulation training.

Conclusion I, like every UK trainee, have spent the majority of my training learning how to operate through a sternotomy. Therefore, it was an eye-opening and humbling experience to learn how to operate in a way which requires a very diﬀerent skill set and approach. It was also a privilege and a priceless opportunity to stand opposite Dr Van Praet and discuss the ins and outs of MICS over the course of a year. I would encourage anyone to seek foreign experience to learn about a new system and culture, alternative philosophies and strategies and to broaden one’s horizons. It has been a pleasure to work with Dr Van Praet and his team and to develop friendships and opportunities for future collaboration. I am confident that this fellowship has equipped me with the expertise to help set up an MICS programme, which was my key objective and which I believe is crucial to the progress of cardiac surgery in the UK. To have as productive an experience as possible, I would ideally recommend this fellowship to surgeons who have obtained CCT and have the desire and passion to develop the field of MICS. Finally, I would like to thank the SCTS for their invaluable support through the SCTS-Ethicon Surgical Trainee Fellowship, without which this transformative experience may not have been possible. n

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SCTS-Ionescu Nursing & Allied Health Professional Fellowship 2019 Professor Julie Sanders, Director Clinical Research, St Bartholomew’s Hospital, SCTS Nursing and Allied Professional Academic and Research Lead

ll health care professionals have a duty to ensure patients, their relatives and communities receive high quality evidence-informed care, and it is widely acknowledged that patients in research-active environments have better outcomes. Overall, there is a shortage of nursing and AHP (NAHP) researchers in the UK – while 5% of the medical profession is in a research-focused senior academic position, this is true for only 0.01% of the current NAHP workforce. However, in the UK there are also very few NAHPs specialising in cardiothoracic surgery research and equally around the world this is also the case. Both my day job (Director of Clinical Research, St Bartholomew’s Hospital, Barts Health NHS Trust, London and Clinical Professor of Cardiovascular Nursing at

Queen Mary University of London (QMUL)) and SCTS role (NAHP Research and Academic lead) involve increasing NAHP research capacity and capability. Since one in five of all scientific papers are co-authored internationally, and due to the lack of UK NAHP researchers in this field, international collaboration is vital. In the preceding 12 months I had been developing a collaboration with Professor Suzanne Fredericks, a nurse scientist researching issues in cardiovascular surgical nursing practice and the graduate program director at Ryerson University, in Toronto, Canada. The SCTS Ionescu Travel Fellowship was awarded to provide an opportunity for me to visit Professor Fredericks to explore the research infrastructure at Ryerson University

and discuss in more detail joint-working opportunities. The specific aims of the Fellowship were to a) explore the research education opportunities in Canada and locally at Ryerson University, b) learn about the cardiothoracic research being undertaken at Ryerson University, c) understand the clinical opportunities for research, d) plan a programme of collaborative work, including the opportunity to offer an ‘exchange programme’ both from a clinical and research (PhD and post-doc) perspective so that nurses can gain exposure and experience from an international perspective, thus increasing their learning and experience opportunities. During the seven-day visit I met with academics at the University (Professor Suzanne Fredericks and Dr Souraya Sidani (Director Intervention Research) and the Associate Director of Research Dr Margareth Zanchetta), nurse practitioners and cardiac surgery nurse researchers at Toronto General Hospital (Dr Barbara Bailey, Ms Sherali Soldevilla and Ms Anda Bozetu), patients and relatives from the Aortic Dissection Canada group (Mr and Mrs Cinnamon and Mr and Mrs Harrington), the manager (Ms Naushaba Degani) of Performance Management at Health Quality Ontario (NICOR-like organisation in Canada), the President of the Canadian Council of Cardiovascular Nursing (Ms Brenda Ridley) and the Editor of the British Journal of Cardiac Nursing (BJCN, Ms Aysha Mendes), who is based in Toronto. In addition to commencing and developing key relationships with individuals and organisations several initial outcomes were achieved from the visit: a) It was agreed that a formal research collaboration would be formed between Ryerson University and St Bartholomew’s Hospital/QMUL and a

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Memorandum of Understanding (MOU) would be devised, b) a collaborative research project, including student exchange, relating to frailty and outcome after cardiac surgery would be planned, as this is a clinical and research priority in both Canada and the UK, c) an international NAHP cardiac surgery research network would be established, d) a six-paper series highlighting and celebrating the role of nurses in cardiac surgery care, with a focus on international perspectives, will be commissioned by the BJCN. Considerable progress has been made against these which include the completion of the MOU, a project grant including student exchange has been developed and will be submitted in January 2020, and the BJCN six-paper series has been devised collaborating with three international colleagues in Canada, the USA and Australia. The first paper has been submitted which is expected to be published in February 2020. The remaining papers, focusing on clinical, clinical academic, student and patient perspectives of cardiac surgery will be published approximately every other month throughout the year with the final paper, exploring cardiac surgery delivery in low income countries, being published in December 2020. Finally, it has been agreed that the international NAHP cardiac surgery research network will be hosted at QMUL, which will be further developed during 2020. This will provide a (growing) directory of international cardiac surgery NAHP researchers, highlighting research interests and expertise and opportunities for sharing experiences and collaboration. The SCTS-Ionescu Travel Fellowship provided a fantastic opportunity to meet organisational leads and potential collaborators to enable progression of plans to build international NAHP cardiac surgery research capacity and opportunities. This has obvious personal and organisational benefit in terms of building NAHP research, as well as direct opportunities for linking SCTS NAHP academic and research endeavours internationally. The SCTS Cardiothoracic Interdisciplinary Research Network (CIRN) is not replicated in Canada and Australia and so is viewed by international colleagues as a valuable initiative they would like to participate in, potentially resulting in the international expansion of the SCTS CIRN. I would like to sincerely thank the SCTS and Ionescu Family for the wonderful opportunity the Fellowship provided. n

â&#x20AC;&#x153;The SCTS-Ionescu Travel Fellowship provided a fantastic opportunity to meet organisational leads and potential collaborators to enable progression of plans to build international NAHP cardiac surgery research capacity and opportunities.â&#x20AC;?

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SCTS-Ethicon Surgical Trainee Fellowship 2019 for Robotic Thoracic Surgery Muhammad Asghar Nawaz, Consultant Cardiothoracic, Robotic and Transplant Surgeon

“Robotic is not the future but the present of the Thoracic Surgery”

niportal VATS / RATS is the future of thoracic surgery and perhaps we will be executing surgery without entering the ribcage routinely e.g. subxiphoid in the near future and eventually via the natural orifice (endobronchial resections) in the distant future. Minimal access surgery has always been my keen interest and I have been trying to

get onto the robotic route few years down the line until I spoke to Joel who kindly supported my application. At the time of application, I had achieved the highest number of lung resections among my cohort of trainees in the country and was also performing uniportal VATS lobectomy independently following a brief training fellowship in Shanghai. The above two emails have been the life changing moments in my career to achieve my goals. In fact, 2019 was a marvellous year when I got;

1. my CCT / Specialist register 2. awarded the Ethicon Scholarship for Robotic Surgery 3. awarded the very unique and first of its kind the ‘post-CCT National Pulmonary Transplant Fellowship.’ (So I have the privilege to do the dual national fellowships simultaneously) 4. atop all, appointed as Consultant Cardiothoracic, Robotic and Transplant Surgeon in Dublin.

My Journey After a robust national competitive process at SCTS March 2019, I was awarded the Ethicon scholarship for robotic surgery. Although based in Manchester for the post-CCT national transplant fellowship, my job plan included at least one dedicated thoracic list per week that I was allowed to use for the robotic surgery. I had some basic exposure to DaVinci Xi, thanks to Mike Shackcloth and Steve Wooley in Liverpool for this. Joel Dunning, a thorough gentleman and innovative

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surgeon was my supervisor and mentor for the robotic surgery. I travelled to James Cook University Hospital Middlesbrough on alternate weeks for the robotic cases. Although tiresome this has been an excellent and rewarding journey in my career. As the transplant fellowship was quite busy, I drove a few times to Middlesbrough either after retrieval or lung transplant, as I did not want to miss the opportunity to operate the robotic cases. After going through some online and simulation modules and assisting with a few robotic cases, Joel exalted me to the console while he assisted. My first case was right S6 segmentectomy for lung cancer and it was an amazing experience and it felt like I reached my destination although soon I realized this is just the beginning. Following on I performed a lobectomy and also the diaphragm repair. I have to give credit to Joel for being such a patient, polite and pleasant mentor who guided me through each operation. Joel is an innovator so we discussed some brilliant ideas and also tested some of his new instruments. As part of the transplant fellowship, I visited TGH Toronto the worldâ&#x20AC;&#x2122;s busiest pulmonary transplant center in January 2020 to have transplant experience for a few weeks. I was so glad to know that TGH also have robots, so I contacted Dr Yosofuku and spent my time in robotic theatres when there was no transplant activity. During this time, I liaised with wellknown and worldâ&#x20AC;&#x2122;s prolific robotic surgeon Robert Cerfolio who also kindly granted me the robotic observership at his state of the art robotic center NYU Langone, New York, United States. It was such a fantastic and fascinating experience of my career where I saw a variety of routine anatomical lung resections including robotic lobectomy, segmentectomy and complex operations like robotic chest wall resections and robotic sleeve resections. Cerfolio runs his theatres very efficiently and I acquired a few tips to establish a successful robotic program. I met another surgeon, who according to Rob Cerfolio, is a world-class surgeon and I echo Cerfolio for Mike, he is very competent in robotic complex cases. I also had the opportunity during this observership to sit on the console with these great surgeons. Cerolioâ&#x20AC;&#x2122;s center also performs robotic cardiac and out of interest I went into robotic cardiac theatres to see robotic LIMA harvest, robotic mitral repair and redo robotic mitral surgery. This enormous exposure took my

shyness away and I felt more confident and comfortable in doing the robotic cases now. Here is a notion for surgeons interested in learning the robotic surgery. The Intuitive has developed a pathway to technical and clinical skills whereby you learn core system and advance technology training (30 hrs simulation + 2 days wetlab) and then progress to peer-to-peer clinical skill advancement. Phase I: introduction to the da Vinci technology; includes test-driving the system, reviewing videos and observing live cases. Phase II: da Vinci technology training; includes online learning, simulation and hands-on training at Intuitive. Phase III: initial case series plan; operating with support from proctors typically one case/week. Phase IV: continuing development; expanding skills through mentoring, surgeonled programs and simulation. I just want to wipe this argument off comparing Open, VATS and Robotic surgery. Robotic technology has undeniable advantages including wrist like maneuverability, 7-degree freedom, 3D

HD view, no steep learning curve, excellent mediastinal work, better lymphadenectomy and performing complex operations as dexterity is replicated e.g. sleeve lobectomy. Robotic is the future of thoracic surgery and the technology is only getting better. During the next 5 years, the VATS (operating by chopsticks) rate will go down by 10% and robotic will be up to 50%. Even the cost is not a valid argument as intuitive monopoly will be over when the market will be flooded with the Medtronic, Ethicon, Versius and Google robots. Robot is very safe and in case of error it usually is a human error not a robotic error. Presently, I am performing simple robotic cases to establish but have the aspiration to do complex robotic operations to make the best use of robot e.g. sleeve resections where my transplant experience will also come into benefit. I would like to thank the SCTS committee and Ethicon for awarding me this prestigious scholarship through which I had this wonderful experience. SCTS video for this is available on the link below https://www.ctsnet.org/home/manawaz. n

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Royal Papworth Hospital Team

SCTS-Ionescu Consultant Travelling Fellowship 2019 Marius Berman, Consultant Cardiothoracic and Transplant Surgeon, Surgical Lead for Transplantation and Mechanical Circulatory Support, Royal Papworth Hospital, Cambridge

he incidence of cardiogenic shock (CS) is raising in United Kingdom with up to 2300 cases post STEMI per year. Despite advances in early reperfusion, CS remains the most common cause of in-hospital mortality after acute MI with rates exceeding 50% for nearly 2 decades. Despite growing evidence supporting early recognition of CS, haemodynamic monitoring, tailored escalation of mechanical circulatory support (MCS) and centralized care, there is variation in patterns of care which might contribute to persistently high mortality rates. In addition, other frequent pathologies such as

post-partum cardiomyopathy, myocarditis and acute pulmonary emboli are potentially reversible acute conditions which could immensely benefit from an immediate multidisciplinary (MDT) targeted therapy. I work as a consultant cardiothoracic surgeon at Royal Papworth Hospital. I have a special interest in transplantation and MCS. Over the years, I recognized the importance of multidisciplinary work approach to complex scenarios in order to achieve better results. I have always felt that the surgeon has a key contribution to make in cardiogenic shock, particularly their early involvement – not just for technical reasons

but also for decision making. We presented at SCTS 2019 our results regarding interhospital transfer of patients in cardiogenic supported by veno-arterial extra corporeal membrane oxygenation (VA-ECMO) and published an overall 60% survival1 of this patient cohort, which, if left without adequate treatment, has 100% mortality. However, as this is not a commissioned service, the referral, process and pathways were on an ad-hoc basis. We recognized the need to extrapolate the vast experience acquired within our trust in treating complex patients into a ‘’shock-team’’ approach. The concept

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experience first-hand the process and interact with their counterpart I decided to explore having additional colleagues travelling with myself. After carefully managing the grant budget, aiming for group transport, reasonable priced flight tickets and accommodation, the grant has facilitated the travel of 8 team members and an additional self-funding colleague. The visiting team consisted of: • Nurse Consultant, ECMO specialist – Mrs. Jo-Anne Fowles • Perfusionist – Jonathan Cox • Heart Failure consultant cardiologist – Dr. Anna Kydd • Interventional consultant cardiologist – Dr. Steve Hoole • Three Consultant Intensive care – Dr. Antonio Rubino, Dr. Chinmay Patvardhan and Dr. Ganesh Ramalingam • Two Cardiothoracic & Transplant surgeons – Mr. Pedro Catarino and Mr. Berman Marius

was elegantly described by Tehrani et al.2 from Inova Heart and Valve Institute, Falls Church, Virginia, US. The team consists of 4 individuals; intensivist, interventional cardiologist, heart failure cardiologist and cardiac surgeon. Their study suggested that a standardized team-based approach improves CS outcome. My successful application for the Ionescu Individual Travel Fellowship was to learn from a major “hub and spoke’’ system, such as the Inova, how to implement a modern multi-disciplinary shock team approach. I approached Dr. Tehrani and Dr. Murphy and established a visit to their center. Inova is a major US “healthcare system”, the constituents of which extend beyond the typical tertiary UK NHS trust into secondary and even primary settings. It showed us how better integration through these levels can benefits this sort of “hub and spoke service”, and should be achievable in our NHS. Within our trust, the buy in and support were phenomenal. Recognizing that the chances of a successful implementation of the program resides that others will

INOVA Institute visit consisted of a fully comprehensive 2 days program which gave a detailed overview in: • Background of the program • Team coordination • Heart failure team involvement in CS • ECMO in cardiogenic shock • Mechanical circulatory support • Right ventricular failure and infiltrative cardiomyopathies • Hub and spoke model of care for CS • Observe and take part in case presentations • CS challenges and opportunities • Q and A with fellows • Hands on Impella simulator • ECMO team meeting • Gender differences in CS and coronary artery disease • Each team member had ample opportunities to exchange views with their counterpart • How to build a CS database • Sharing of protocols and pathways • Tour of the intensive care • Tour of operating complex and observe live case management of acute CS

Cardiogenic Shock Algorithm Exclusion criteria: • Alternate causes of shock: sepsis, anaphylaxis, haemorrhage, and neurological. • Non-ischaemic cardiogenic shock (e.g. PE, pneumothorax, tamponade) • Active bleeding • Recent major surgery • Known LV thrombus Circulation present, EF <30% No mechanical complications

SBP <80mmHg SBP >80mmHg

LHC ± PPCI

SBP <50mmHg Peri-arrest

Impella / ECMO Early RHC

CARDIOGENIC SHOCK? Low threshold for activation Contact switchboard: “Activate SHOCK team*”

Early MDT discussion

STEMI? Yes, PPCI activated

Cardiac arrest? CPR ongoing

• Witnessed arrest • Age <65 years • CPR <60 minutes • No known cancer or chronic disease with poor prognosis • ET CO2 >1.3 kPA • Primary arrest rhythm VT/VF

Shock criteria:

Acute HF Failure? Cardiogenic shock without STEMI: • RHC • MCS if indicated • LHC if indicated

Perform haemodynamic assessment** Exit strategy decision within 24hrs

Fig 1. Royal Papworth Hospital ‘’Shock team’’ Algorithm

*On call SHOCK team: PPCI consultant Transplant surgeon Critical care consultant Heart failure consultant

• SBP <90mmHg/MAP <50mmHg OR SBP >90mmHg/MAP >50mmHg with support (inotropes ± IABP) • Cl <1.8/min/m2 PCWP > 15mmHg CPO < 0.6 W PAPi <1.0 • Impaired end organ perfusion OR clinical/radiographical evidence of pulmonary oedema • Sats. <50% or lactate >2mmol/L No absolute contra-indications to heart transplantation

Mechanical Circulatory Support Peripheral/central

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The engagement and enthusiasm for sharing their knowledge and expertise was second to none. We have founded new bridges of knowledge, exchange and friendship and I am personally grateful to our new friends; Dr. Tehrani, Dr. Murphy, Dr. Sinha, Dr. Truesdell, Dr. Psotka, Dr. Singh, Dr Osborn, Dr. Desai, Mrs. Rosner and Dr. Batchelor. We are also indebted to Dr Chris O’Connor, President of the Inova Heart and Vascular Institute, whose support was extremely helpful for this visit, and whose challenge to set up a joint research project we intend to take up. We have learned about the advantages of early activation of the shock team having a shared plan which is constantly reviewed. The escalation or de-escalation of the therapy is discussed and based on understanding the importance of haemodynamic data. Inova’s key haemodynamic protocol pillars were the CPO (cardiac power output) and PAPi (pulmonary arterial pulsatility index) which were used as a universal language within Inova, or, referring centres. As over 50% of CS Inova patients were referred from outside, we have learned how they disseminated their management algorithms to referring cardiologist, intensivists

and surgeons. By having a 24/7 access to CS hot line, Inova has successfully piloted implementation of regionalised care systems which resulted in improved survival. They have shown also the successful implementation of mobile CS teams that travel to spoke hospitals to initiate MCS, stabilise patients and transport back them to hub institution. On our return from the visit, we have finalised our internal pathway for “shock team’’ activation to manage acute CS (Fig. 1). and built a bespoke database. The pathway was widely disseminated within the trust and so far it was implemented on 2 occasions, achieving the first goal of our visit which was an early activation of the “shock team’’ and joint continuity of care. Once first step is established, similar to commissioned national VV-ECMO services, I believe that it is critically important to implement coordinated regionalised systems of care to reduce practice variation and centralise the care of CS patients to high volume tertiary centres able to offer

Hands on Impella device placement (Dr. Patvardhan)

full spectrum of medical and mechanical support, in a multidisciplinary care. In conclusion, expressing both my own and my colleagues’ views, we all thought that this visit was very beneficial on multiple levels and we are grateful to Mr. Ionescu for his kind support which is already benefitting patients care. n References:

1. Transfer of patients with cardiogenic shock using venoarterial ECMO. Ali J., Vuylsteke A., Fowles JA. et al. J Cardiothorac Vasc Anesth. 2020 Feb;34(2):374-382 2. Standardized Team-Based care for Cardiogenic shock. Tehrani BA., Truesdell AG., Sherwood MW et al. J Am Coll Cardiology 2019; 73: 1659-69

SCTS-Ionescu Exceptional Fellowship Award 2019 – The Advanced Practitioner’s Approach to Aortic Surveillance Kathryn Hewitt, Cardiac ACP QEHB

n 2019 I was fortunate enough to be awarded a SCTS Ionescu Exceptional Fellowship Award to explore the Advanced Clinical Practitioner’s (ACP) approach to Aortic Surveillance currently in the UK and in two more established centres; Mount Sinai NYC and Hospital

of the University of Pennsylvania (HUP) Philadelphia USA. I would like to thank both the SCTS and Mr Ionescu for this inspirational opportunity. We are all aware of the devastation that can come with aortic conditions, the potential life-altering sequelae that can occur

following surgical intervention and therefore the importance of good quality surveillance both pre and post operatively. Many centres approach this in different ways, with full surgical follow-up, referral back to the medics or a mix of the two, often resulting in poor record keeping and a loss of patients to

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follow-up. My aim of this fellowship was to explore centres with established ACP follow-up clinics and identify the skills required to do this successfully with a view to implement this at QEHB and also to share with other centres through the SCTS. Back in April 2019 I kick started my fellowship at home in the midlands for the Regional ECHO Meeting held at New Cross Hospital, Wolverhampton. The meeting focused on the role of imaging in various aortic conditions including teaching on identification of aortic root phenotypes. This informative meeting was not only a great way to emphasise the pivotal role of imaging in surveillance of all aortic conditions and but also a fantastic learning experience and something I would be very interested in attending in the future. June 2019 brought about the Liverpool Aortic Symposium which was two whole days of presenting and teaching from inspirational UK surgeons and also international speakers including some of the biggest names in aortic surgery. The symposium hosted multiple discussions on surgical techniques and held many take home messages on the importance of good quality surveillance post operatively particularly presenting statistics from across the globe on reoperations post emergency and elective surgery. For example, 25% of patients following repair of acute Type A Aortic Dissection will require re-intervention (planned or not) within 10 years. There was also an inspirational ‘Marginal Gains’ Lecture focusing on the life and work of QEHB’s very own Professor Bonser, applauding the work he achieved within aortic surgery and transplant but with a take home message that yes, we have great advances in surgical care but we need to identify opportunities to bring holistic care up to speed and educate and empower our patients to improve their quality of life. In a forum of surgeons, it was refreshing to hear talk of holistic care and something I am keen to

implement within surveillance clinics. Thanks to my colleagues in New Cross Hospital for sharing two great contacts, September 2019 I was able to take my fellowship state side stopping first at Mount Sinai Hospital in NYC to spend time with Dr Ani Anyanwu, an Attending Cardiac Surgeon who was a UK trainee. The aortic program at Mount Sinai was put together in 1985 and was the largest in the nation, headed by Dr Greipp who has left a huge surveillance programme in his wake. During my time there I spent time with their lead Advanced Practice Provider (APP) Joel Estabillo who explained their current surveillance was performed by APPs under the watch of attendings and included both clinic appointments and telephone review assessing both pre and postoperative test results, identifying pathophysiology and referring on as necessary. Joel explained that standalone APP clinics are something they are looking to move towards in the future.

cardiac surgeon with almost 600 research items and over 23,000 citations and was able to teach me a great deal on aortic conditions themselves and how to identify pathophysiology on imaging. He explained his expectations of the APP’s he works with, that they are to be educated in anatomy and physiology, assessing and diagnostics, and highly trained in imaging such as ECHO’s and CT scans including 3D replicas. The outpatient APPs become experts in these particular skills and are responsible for all surgical review, opinion and surveillance of aortic conditions referred to them. I was fortunate to be taken under the wing of Melanie Freas who recently completed her doctorate on bicuspid aortic valves. I was able to shadow Melanie and the whole team sitting in on the impressive clinics run solely by APPs with no medical practitioner present. These clinics are essential to review patients and identify if and when they meet criteria for surgery, thus freeing up surgeons to operate. They also allow the patients to discuss holistic concerns and anxieties they may experience pre or postoperatively. I would like to thank Ani Anyanwu, Joe Bavaria and Melanie Freas for their hospitality and guidance during my fellowship and for being so supportive and welcoming. I look forward to working in collaboration in the future. This past year has helped educate and enforce an opinion of the necessity of ACP-led aortic surveillance in providing a fully informed, holistic service for our patients, educating them on signs and symptoms to look out for to identify the need for reoperation or sequelae following aortic surgery, improving quality of life and reducing mortality. We are looking to implement ACP-led clinics for aortic surveillance in QEHB in the near future and I have taken aspects of this concept forward into my MSc dissertation which I look forward to sharing with you in the future. n

“Dr Bavaria is a hugely decorated cardiac surgeon with almost 600 research items and over 23,000 citations and was able to teach me a great deal on aortic conditions themselves and how to identify pathophysiology on imaging.” After a weekend in NYC I then travelled down to Philadelphia to begin my two weeks at HUP. HUP was identified as my main centre for achieving my goal of identifying skills required to implement an ACP-led surveillance clinic because I knew they were already successfully managing this on a large scale. Cardiac surgery at HUP is very much a multidisciplinary approach utilising APPs in both inpatient and outpatient settings which is essential as it is currently the most active aortic centre in the region. My contacts at HUP were Dr Joe Bavaria, Attending Cardiac Surgeon specialising in aortic disease and Dr Melanie Freas, Advanced Nurse Practitioner also specialising in aortic disease. Dr Bavaria is a hugely decorated

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ESC Cardiac Development meeting 2019

Exceptional SCTS-Ionescu Non-NTN Surgical Fellowship 2018 Adrian Crucean, Specialty Doctor in Congenital Heart Surgery and Consultant in Cardiac Morphology and ECLS

y name is Adrian Crucean and I work at the Birmingham Women and Children’s Hospital Foundation Trust as a Specialty Doctor in Congenital Heart Surgery and ECMO, and Consultant in Cardiac Morphology. I am also an SCTS member. Our hospital is a tertiary referral centre for some of the most complex patients with congenital heart disease in the country. It frequently deals with referrals from abroad and with second opinions requested by other major centres. There is a busy surgical programme and I am also the curator of an extensive archive of human heart specimens with CHD (congenital heart disease) housed

by the Trust. Winning the Exceptional SCTS-Ionescu surgical fellowship for non-NTN cardiac surgeons brought multiple benefits to me, my collaborators and to the clinical and academic environments we work in. It allowed me to visit the Division of Cardiothoracic Surgery of Toronto’s Hospital for Sick Children in Canada, a beacon of excellence for clinical, teaching and research endeavours. I participated at the Hands-On Surgical Training course run on 3D-printed hearts and tutored by Glenn Van Arsdell and David Barron, at the 2nd Contemporary Course in Cardiac Morphology and visited their advanced

3D-printed Heart Lab. We are now collaborating with them on analysing and producing 3D-printed hearts for some of our most complex patients with CHD. The fellowship supported my participation at the American Heart Association meeting in Philadelphia. Upon my return I shared the most interesting presentations and findings with my colleagues. I have also participated at a wellestablished course in cardiac morphology, the Weinberg’s advanced boot camp in CHD at the Children’s Hospital of Philadelphia. Similar to the visit in Toronto, this not only enhanced my surgical skills but also my understanding of cardiac morphology,

August 2020

it created opportunities for further collaboration in creating virtual reality hearts and exploring complex lymphatic and venous studies, especially in patients with univentricular physiology. The SCTS grant allowed me to continue my work as a member of the International Society for Nomenclature of Paediatric and Congenital Heart Disease regarding the new ICD11 classification and the first ICHI linked with WHO initiative while collaborating with experts from around the world at our last meeting in Montreal, Canada. It is a privilege and a significant responsibility to be among a selected group of professionals who are engaged in a complex work redefining how we understand and treat the cardiac malformations. I have to be up-to-date on multiple areas and to delve into the minutiae of concepts and common parlance that we take for granted in our everyday clinical work. The opportunities for networking and â&#x20AC;&#x2DC;meetings of the mindsâ&#x20AC;&#x2122; are extraordinary on such occasions. Moreover, the SCTS grant allowed me to continue the work with the University of Birmingham as an honorary senior clinical lecturer and supervisor of the Intercalation Year in Clinical Anatomy and Imaging. This resulted in various teaching and research projects, for example in the study of cardiac embryology, of ventricular septal defects and thoracic vascular rings. The work has been presented at national and international meetings by the students themselves who also published their work in highly ranked journals like EJCTS.

Students presenting at ESC Development meeting, Malaga 2019

The fellowship also allowed me to further continue my work as a member of the Cardiac Development Group in the European Society of Cardiology. I was able to participate at the Annual meeting in Malaga, Spain where ISNPCHD meeting, Montreal 2019 I was joined by two of our Intercalation students who actually presented our work at the meeting. Furthermore, I was also able to participate as a faculty and deliver 4 talks at one of the largest imaging meetings in the world â&#x20AC;&#x201C; the EuroEcho gathering Visiting Mr D Barron at Sick Kids Toronto of the ESC in Wien, Austria. This required the safe transport of human hearts there alongside the audio-video equipment. I organised the meeting of the West Midlands CT Surgery Regional Training programme at our hospital and delivered cardiac morphology sessions at the EACTS Academy in Windsor, Wessex Congenital series in Southampton and the East Midlands Congenital Heart Centre Network meeting in Leicester alongside other presentations at local and regional meetings. It is understandably difficult to encompass the wide range of benefits drawn from being awarded the SCTS scholarship. As a non-NTN but fully trained cardio-thoracic surgeon belonging to the SAS group, at times it is a challenging position to be in. Hence, I congratulate the Society for expanding its embrace towards doctors in my position. Not long ago I would have not envisaged being able to take on so many roles in my clinical, teaching and research work. It just goes to demonstrate that with the right support from the Trust and with recognition and substantial grants from our national professional body one can expand on an initially sometimes limited clinical

role. As a curator of one of the very few fully functional cardiac archives in Europe, it is a privilege for me to use it for teaching a wide variety of health practitioners, from medical students and nurses to cardiology, intensive care and CT surgical trainees and consultants. It is now starting to being used for research projects requiring collaboration with universities and other international academic institutions. The SCTS grant supported not only these actions but also allowed me to maintain and improve my surgical skills, to challenge my knowledge, improve, exchange and enrich it. I can now use multiple sources to imagine better ways of understanding congenitally malformed hearts and I can share this to my colleagues in our everyday work. Potential for research collaborations has opened up. Ideally, regularly visiting other cardiac units of excellence should be part of our appraisal and the SCTS just allowed me to plentifully undertake that. As medical professionals our goal should be not only to understand and apply the knowledge of our field but, ultimately, to create new content and disseminate it wisely and widely. Through this scholarship the SCTS proved that such a strategy is within the reach even for the nonNTN doctors of its ranks. Thank you and I hope this encouraging vision of the Society will continue to grow. n

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SCTS-Ionescu Medical Student Fellowship 2019 Manveer Rahi, Academic Foundation Trainee

ello, my name is Dr Manveer Rahi. I am an academic foundation trainee working in the Cardiothoracic Surgery Unit at the Royal Infirmary of Edinburgh. Between April and June 2019, I visited Auckland City Hospital and Starship Children’s Hospital in New Zealand to undertake a placement in cardiothoracic surgery. The Auckland City Hospital is a publically-funded hospital which serves a population of 530,000 residents of the Auckland district, including Māori and Pacific societies.1 The Starship Children’s Hospital Cardiac Surgery Unit is the only paediatric cardiac surgery department in New Zealand and therefore receives patients from the entirety of New Zealand and the Pacific islands.1 I was fortunate to receive a travelling fellowship from the SCTS to help fund this opportunity.

Objectives I have a longstanding interest in paediatric cardiac surgery which began when I shadowed in paediatric cardiac theatres aged 16 and I hope to apply for the ST1 run though in cardiothoracic surgery in the near future. I had several objectives for this elective, these included: - to gain an improved understanding of the range of procedures performed in adult and paediatric cardiac surgery. - to improve my hands-on surgical skills. - to further my understanding of New Zealand health system and the challenges it faces.

Discussion The placement at Auckland City Hospital and Starship Children’s Hospital was filled with thought-provoking, interesting Auckland, New Zealand is a vibrant multicultural city and home to the Auckland City Hospital and Starship Children’s Hospital

and complex cases. During this elective, I was exposed to a range of postgraduate topics within cardiac surgery, setting the foundation for further learning and development. I was fortunate to scrub-in for all adult surgeries that I attended. This was a valuable experience to log thirty cases for my surgical logbook, engage with surgical teams and to practice basic surgical skills such as knot tying and suturing. Being scrubbed-in also presented the opportunity for me to revise my cardiac anatomy with the help of the registrar. This was a particularly useful experience as it served as a foundation on which to better understand subsequent operations. Having an improved understanding of correct cardiac anatomy was valuable when trying to appreciate the complex anatomical changes seen in paediatric and congenital heart surgery. I was also able to broaden my understanding of a number of postgraduate topics on cardiac physiology, such as the relationship between pressure, resistance and flow and the importance of these variables to maintain adequate perfusion. I was able to shadow within a number of complex congenital cardiac cases, which exemplified the fascinating, technically demanding and, at times, stressful nature of congenital cardiac surgery. One particularly interesting case was that of a young patient presenting for the Fontan procedure as they were born with an array of congenital malformations including dextrocardia, pulmonary stenosis and a hypoplastic right ventricle. This univentricular system resulted in inadequate perfusion to the lungs and the patient underwent an atrial septectomy and right-sided bidirectional Glenn creation at 3 months old to create a left-right shunt and permitted the child to live a relatively symptom free infanthood. In meeting the families of children with complex heart conditions I was able to understand some

August 2020

of the difficulties of having a child with an illness, including the emotional toll and travelling hundreds of miles for clinic appointment, but I was also able to appreciate the immense value that surgery can provide to the patient and their family. Finally, I learnt about the high incidence of rheumatic fever in Māori and Pacific island populations. In New Zealand 95% of new rheumatic fever cases between 2000-2009 were seen in Māori and Pacific populations with there being a strong association with low socioeconomic status.2 Cardiac valve surgery to manage rheumatic cardiac disease has a substantial economic cost for the New Zealand health system.3 On further research, I discovered that the New Zealand government runs the Rheumatic Fever Prevention Programme, which includes improved housing schemes, sore throat clinics and awareness campaigns for at risk populations. I have been struck by how many of the large initiatives to reduce rheumatic fever incidence are still in their infancy, with very few schemes having data

on their impact on disease incidence. I will continue to take an interest into the effect of these primary and secondary prevention schemes upon rheumatic fever incidence and the economic cost for the New Zealand health system.

Thanks to the SCTS and Mr Ionescu I was able to work with a team of amazing and dedicated staff; learn from some of the most talented surgeons in the world and understand Cardiothoracic from a new perspective. I was also fortunate to travel New Zealand a little and sample some of the beautiful culture the country has to offer. I will take the contacts and experiences that I have made and I hope to create new links between my local cardiothoracic unit and those in Auckland. I was fortunate to be awarded a travelling fellowship grant from the Society of Cardiothoracic Surgeons (SCTS) to help fund my elective. I am hugely grateful to the SCTS for selecting me for this prestigious fellowship.

I wholeheartedly recommend my junior colleagues to apply for this and similar opportunities with the SCTS. Finally, I would like to thank Mr Ionescu for his incredibly generous donations each year that help aspiring cardiothoracic surgeons, such as myself, along with established cardiothoracic surgeons to undertake incredibly enriching experiences that benefit the community of cardiothoracic trainees, surgeons and our patients. n References:

1) Auckland District Health Board. Annual Report 2017 | 2018 [Internet]. Auckland: Auckland District Health Board; 2019. Available from: https://www.adhb.health.nz/assets/Uploads/ ADHB-Annual- Report-2017-18-FINAL.pdf 2) Milne RJ, Lennon DR, Stewart JM, Vander Hoorn S, Scuffham PA. Incidence of acute rheumatic fever in New Zealand children and youth. Journal of paediatrics and child health. 2012 Aug;48(8):685-91. 3) Milne RJ, Lennon D, Stewart JM, Vander Hoorn S, Scuffham PA. Mortality and hospitalisation costs of rheumatic fever and rheumatic heart disease in New Zealand. Journal of paediatrics and child health. 2012 Aug 1;48(8):692-7.

New Consultant Appointments - February 2020 to August 2020 Name

Hospital

Specialty

Starting Date

Pradeep Kaul

Royal Papworth Hospital, Cambridge

Adult Cardiac & Transplantation

March 2020

Ramesh Kutty

Alder Hey Children’s Hospital and Liverpool Heart & Lung Hosptial

Congenital

May 2020

Silviu Buderi

Royal Brompton Hospital, London

Thoracic

May 2020

Other Appointments Name

Hospital

Appointment

Starting Date

Jalal Bin Saeid

Liverpool Heart & Chest Hospital

Locum Consultant Cardiac

January 2020

Habib Khan

King’s College Hospital, London

Locum Consultant Cardiac

January 2020

Antonios Kourliouros

John Radcliffe Hospital, Oxford

Locum Consultant Cardiothoracic

January 2020

Gunaratnam Niranjan

Liverpool Heart & Chest Hospital

Locum Consultant Cardiac

January 2020

Mohamed Umar Rafiq

Royal Papworth Hospital, Cambridge

Locum Consultant Adult Cardiac

January 2020

Swetha Iyer

Royal Papworth Hospital, Cambridge

Locum Consultant Adult Cardiac

February 2020

Sherif Mansour

Glenfield Hospital, Leicester

Locum Consultant Adult Cardiac

February 2020

Nicholas Walcot

John Radcliffe Hospital, Oxford

Locum Consultant Cardiothoracic

February 2020

Niamh Keenan

St. James’ Hospital, Dublin

Locum Consultant Cardiothoracic

March 2020

the 96 bulletin

2019/20 Ionescu Nursing/AHP Fellowship – Lung Ultrasound in Cardiac Surgery Critical Care Jonathan Johnston, Advanced Clinical Practitioner, Sussex Cardiac Centre, Brighton “For the things we have to learn before we can do them, we learn by doing them” – Aristotle

e are a group of nine advanced clinical practitioners (ACPs) working at the Royal Sussex County Hospital in Brighton on the cardiac intensive care unit. We were the grateful recipients of one of the Ionescu Fellowships in 2019. Our plan was to travel to other critical care environments that are recognised for their use of point of care ultrasound scanning as part of their daily routine. To put this in context, our clinical supervisor Dr Robert Kong had become interested in the idea of the ACPs performing lung ultrasound on post cardiac surgery patients as they do in other critical care areas.

Lung ultrasound is known to readily identify lung problems known to occur regularly after cardiac surgery: Pneumothorax, Pleural Effusions, Pulmonary Oedema and Consolidation among others. It was felt that as this is now generally accepted as an accurate diagnostic tool for these common complaints it would be useful and efficient to be able to screen for these without relying on the radiology team. In addition, it will reduce the amount of radiation our patients are exposed to. We then embarked upon a clinical learning programme with Dr Kong, who over six months, was able to teach us the basics of lung ultrasound as well as some of the theory underpinning it. However, he felt that consolidation of this learning should involve exposure to other centres.

Udine Hospital

Our fellowship allowed us to develop a program with Dr Luigi Vetrugno from Udine Hospital in northern Italy. Dr Vetrugno had been using point of care ultrasound in his department for many years and had published a lot of papers on its application in critical care settings. Therefore, we organised that he visited Brighton and for as many of us as possible to travel to Udine for hands on experience. The programme was designed to cover the basics of lung ultrasound and to offer exposure to in situ clinical teaching by the bedside, in order to offer the troubleshooting advice that is needed when learning new practical skills. In June 2019 Dr Vetrugno attended Brighton and delivered an excellent full teaching day to our group followed by a more informal teaching session over food in the evening. This was hugely valuable and prepared us greatly for our respective trips out to Udine. Dr Vetrugno was able to cover the physics of ultrasound in some detail as well as some practical teaching about probe placement, identification of anatomical structures and how to recognise different pathologies using evidence-based techniques. In the evening he was able to explain how our trip to Udine would work and what to expect as well as how his team build point of care ultrasound into their everyday practice. This was very exciting to us as this is what we wanted to get out of the fellowship. In September - November 2019 six of our team were able to travel to Udine for practical sessions with Dr Vetrugno. The sessions were excellent and we were all struck by the size and quality of Udine Hospital. The unit we attended was actually a general ITU but there were ample opportunities to learn about lung ultrasound that were directly relevant to our practice.

August 2020

They had a fantastic approach which was very much scan first. They would scan almost every patient on the ward round. However, it was very efficient as everyone was well trained and conducted the scans with a lot of skill. We spent two full days on the unit with Dr Vetrugno with informal teaching in the evening as in Brighton. This was a great model as there is so much that comes up during the day but with very little time for questions. After this we came back to Brighton with enthusiasm and tried to implement lung USS as much as possible. Patients who were breathless or fatigued were scanned straight away and in five minutes we were able to include or exclude some of the serious lung pathologies mentioned above. The department started to rely on us for scans too. Suddenly we were being asked ‘Can we do a quick scan on bed 4 ...’ we felt this was a good sign that the programme was working and that being on the unit visibly doing scans with competence had started to cement what we had learned in Udine. In January, Dr Vetrugno returned to offer final comments and covered what we had learned and was pleased to hear how

“We learned so much on this fellowship that continues to inform our daily practice and invoke discussion within the team. We were able to get hands on experience in another centre to see this practice really working in situ.” we had begun to implement lung USS in our unit. He also delivered a fantastic lecture on point of care echocardiographs for our future interest. We learned so much on this fellowship that continues to inform our daily practice and invoke discussion within the team. We were able to get hands on experience in another centre to see this practice really working in situ. But, perhaps most importantly we made a good friend. As a team, we are extremely grateful to Dr Vetrugno and his team for the way in which

Obituary: Jitendra Rathod I t is with profound sadness that we inform you of the passing of our beloved late colleague – Mr Jitendra Rathod, Associate Specialist – or Jitu as he was known to his friends. He passed away on 6th April 2020 in Intensive Care, University Hospital of Wales, Cardiff after testing positive for COVID-19. He was well known throughout the UK cardiothoracic community and beyond having worked in many units and having always made an indelible, positive impression. Jitu qualified from Grant Medical College in Mumbai in 1986 and went on to complete his Masters in Surgery. In 1989, he went on to practice surgery in Pen, Maharashtra. He came to the UK in 1991 and worked in Newcastle,

they welcomed us to their unit and took the time to teach us. We would also like to thank the SCTS and Mr Ionescu for their support with this project without whom it would not have been possible. We can strongly recommend this fellowship to other teams, learning by immersive experience as we have, has been invaluable. In the future, we plan to train in focussed echo scanning and create educational programmes for future ACPs with discussion of the possible addition of basic lung ultrasound to the SCTS advanced course. n

From the team at the University Hospital, Cardiff

Glasgow, Bristol and Alderhey before coming to Cardiff in 1993. Jitu then went on to train in Cardiothoracic Surgery in one of the premier institutions – Christian Medical College, Vellore. In 2003 he went to Bahrain before finally returning to Cardiff in 2006 to work a further 17 years in University Hospital of Wales. Anyone who had the pleasure to meet and know him can agree that Jitu was noted for his humility, kindness and gentle nature which endeared him to all members of staff and patients alike. Jitu could brighten up any room with his adorable and cheeky smile. He was an incredibly dedicated professional who cared deeply for his patients. Many of us had the privilege to work alongside him for many years

and are indebted to him for his support and mentorship. He was generous to a fault, often sharing his homemade lunch and his wealth of knowledge and experience with junior staff. His dedication to teaching and training was inspirational, typified by a recent enthusiastic presentation at Grand Round. Outside of work he loved classical music and had a passion for astrology. He smiled in the face of trouble, and was very proud of his family, constantly concerned for their wellbeing. He is survived by his wife, Sandhya, and their two sons, Pranav and Amay. Our thoughts and sympathy are very much with them at this difficult time. We would like to express a big thank you to the frontline staff who cared for Jitu and provided the exemplary compassionate, high quality care that he deserved after all his years of service. Through the darkest of hours one can always find light. For us it has been reminiscing over the cherished memories of our dear colleague and reminded us that the light that he brought us lives on in our memories. n

the 98 bulletin

Crossword

Set by Samer Nashef

1 7/26 9/15 10 11 12 13 15 17 19 22 23 25 26 27 28

Please email solutions by 30/09/20 to: sctsadmin@scts.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE The first successful solution received will win either a bottle of champagne or fine olive oil. Congratulations to Jonathan Hyde for winning the January 2020 Bulletin crossword competition (right) who has selected a bottle of champagne.

Across Hold out to spike policeman’s shoe (10) Wolves matured in a box (8) Monica heard Nikki? (8) Runs a piece about gourmets (10) Polish and almost wealthy, getting a distinguished title (6) Unrestricted love to die penniless outside (4-4) Please remove my blindfold, hmmm? (3, 2, 3) See 9 Famous person tucking into chilli con carne (4) Jane Austen’s life, a memoir starts appearing in London, perhaps (8) An outfit cuts retrogressive political symbol (8) Tempt conservative to shift right in full (6) Brown primarily chosen as PM after Blair’s invasion levelled Iraq twice? Yes! (10) See 7 Hey, frames for pictures? Sweet! (4) Why poor Serge is stuffed with eats (10)

Down

2 23 admits initially entering into spirit of fun (7) 3 A dark, poor place in Africa (5) 4/21 Isn’t MacDuff in a hole? There’s a source of material (8, 6) 5 Constabulary admits flipping coin: heads for evil in disguise (8, 7) 6 Defeat royal device for data delivery (6) 7 As a contribution to a rising economy, no dues paid in name (not real) (9) 8 Start off at 17, from having a change of heart to toe the line (7) 14 Network-covered home towards the back not a feature of 4,21 (9) 16 Favourite able queen uncovered dye mixture (4-4) 18 Two PCs deployed to contain a Jersey product (7) 20 See 24 21 See 4 24/20 They’re needed to get on board with Kent artistic production (5, 7)

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