The 2017 IntraClude fellowship in minimally invasive cardiac surgery

Bilal H Kirmani, Consultant Cardiac Surgeon, Liverpool Heart and Chest Hospital

In August 2017, having just completed my national training, I became the first minimally invasive fellow funded by Edwards LifeSciences. In doing so, I undertook the first formal industry funded minimally invasive cardiac surgery fellowship in the United Kingdom, working with Joseph Zacharias in Blackpool.

The idea, of course, raised eyebrows. A minimally invasive fellowship in the UK? In Blackpool?! Innovations in cardiac surgery are seldom welcomed with open arms and the concerns were predictable and pragmatic. Would there be a great enough volume? In the current climate for UK surgeons, would I be allowed enough hands-on experience to make progress? Was there even sufficient expertise nationally to start training our own? These seemed legitimate questions to ask before embarking on six months of post-CCT training and I knew that the answers could only ever be found by attempting a UK based fellowship. In the privileged position of having a substantive post to go back to after the six months were over, I felt I had nothing to lose.

During my twenty four weeks at the Blackpool Victoria hospital, I participated in 115 cases, of which just under half were minimally invasive. Crucially, for a British trainee, I wanted to keep my general cardiac skills “ticking over” and was therefore provided ample opportunity to undertake general cardiac cases with some unsupervised lists: coronary artery bypass grafts (including some total arterial and off pump grafts), open mitrals with arrhythmia surgery and re-do endocarditis patients.

More importantly, however, I was incrementally exposed to complex minimally invasive aortic, mitral, tricuspid surgery and endoscopic conduit harvest. From very little experience of minimally invasive surgery, I progressed to independent setup including the introduction, deployment and management of the IntraClude intra-aortic clamp and the access to the mitral and tricuspid via the right chest. This naturally graduated to intra-pericardial dissection, atrial closure and eventually valve assessment and placement of annular sutures.

Concurrently with the totally endoscopic mitral surgery (predominantly with the IntraClude, but also on occasion with a clampless fibrillating heart) I was also trained to undertake minimally invasive aortic valve replacement via a right anterior thoracotomy (ART). Having already undertaken some hemi-sternotomy aortic valve replacements at my alma mater in Liverpool, this was an additional experience that I had initially been sceptical about. Convinced by Joe to give it a chance, I did perform one and was pleasantly surprised by the access and the patient’s prompt and painless progress to discharge (see picture of patient on day 4).

We were sometimes operating on two minimally invasive cases a day. This seemed to provide me with the volume required to build experience quickly – perhaps not the volume that might have been possible in the large German or North American centres that usually host British fellows, but with plenty of hands-on in setting up and components of the operations.

Where I wasn’t in theatre, there was strong academic direction from the consultants. During the six months I spent at Blackpool, I had six national presentations and four international presentations accepted. One of these caught the eye of a key European minimally invasive surgeon who proctors and lectures widely on the IntraClude and is currently being adapted for a multi-centre international study on the technique.

Whilst in Blackpool, I also recruited patients for the UK Mini-Mitral Trial during clinics and was actively involved in the research process for this. This collaboration with Enoch Akowuah at Middlesbrough led to my involvement in another planned randomised controlled trial in cardiac surgery and my invitation to deliver a talk at the SCTS University this year at the national conference in Glasgow. The academic and research opportunities, not to mention the networking, from this short fellowship have, without question, been excellent.

“But did you actually get to do any minicases?” I have been asked several times since the fellowship ended. Yes, I did. Aside from the procedural parts that many international fellows aren’t allowed to undertake, such as placement of neochordae or annular sutures in mitral valves, I did a redo-tricuspid using a totally endoscopic approach; a right anterior mini-thoracotomy aortic valve replacement and progressed to independent, unsupervised endoscopic vein harvest. In addition to the crucial skills of identifying, managing and setting up these cases, this fellowship has provided me with the foundations I need to help me realise my goals. To my mind’s eye, that’s an excellent result from the first formal minimally invasive training fellowship in the UK. With the exponential increase in interest in Minimally Invasive Cardiac Surgery I hope more trainees can look to doing their fellowship in the UK with the help of industry partners. n

I performed a hemi-sternotomy aortic valve replacement and was pleasantly surprised by the access and the patient’s prompt and painless progress to discharge