SCTS Bulletin Issue 10 by Open Box Media & Communications

the

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Issue 10

August 2021

values

culture

audit

innovation

trust end of life care

ethics

principles

CPR integrity

leadership

resilience

consent

confidentiality

unit specific outcomes

mortality bioethics respect autonomy

concerns

honesty

patient safety

communication

DNAR

Society for Cardiothoracic Surgery in Great Britain and Ireland

morality

listening

dilemma

I Confess That I Have Lived Welcome ST1 The Montgomery Case and Nights and I Have Lived Days p36 Cohort 2021 p44 the Notion of Consent p47

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August 2021

the

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In this issue ... 5 6 9

From the Editor Indu Deglurkar

SCTS Virtual Annual Meeting 2021

SCTS Nurses and Allied Health Professional Report 2021

16 17

SAC Report Marjan Jahangiri

From the President Simon Kendall Improving Patient Outcomes Narain Moorjani

Maninder Kalkat

Bhuvaneswari Krishnamoorthy

Audit Update: Developing A Modern Unit Quality Assurance Programme in Adult Cardiac Surgery Doug West

Academic and Research Sub-Committee Update

Eric Lim, Mahmoud Loubani

National Thoracic Research Improvement Initiative

SCTS Education Report

Sri Rathinam, Carol Tan

SCTS Education Tutors’ Report 22 Debbie Harrington,

George Asimakopoulos

Ionescu Annual Fellowships 2021 24 Sri Rathinam, Carol Tan SCTS Forum Nursing and Allied 28 Professional Research Update

New SCTS Student Education Committee Announcement

33 34

Women in Cardiothoracic Surgery

I Confess That I Have Lived Nights and I Have Lived Days

Luis Sergio de Moura Fragomeni

Ishtiaq Ahmed, Momna Sajjad Raja, Sahil Modi, Yasmin Dhuga

All Change for Monitoring of Results in Cardiothoracic Surgery

Keith Buchan

50th Anniversary of Ionescu’s Pericardial Heart Valve Concept

Dual Consultant Operating

Non-NTN Ionescu Fellowship in Advanced Cardiopulmonary Failure Strategies Sharp Memorial Hospital, California, USA

Uday Trivedi, Andrew Goodwin

Invitation to a Wedding: A Thoracic ANP Journey During COVID

Justin Pahelga

Deborah Harrington

Hybrid workshops: “The best of both worlds”

Sunil Ohri, Suvitesh Luthra

David Quinn

New Roles and Appointments SCTS-Ionescu NTN Travelling Fellowship 2019 Elaine Teh

SCTS/Ethicon Fellowship 2021 – Lung 60 Transplantation and ECMO in Toronto

The 2021 National Recruitment for Cardiothoracic Surgery Jeremy Chan

Muhammad Izanee Mohamed Mydin

Welcome ST1 Cohort 2021 44 Devan Limbachia

Thoracic Surgery Resident Association 62 (TSRA) Collaboration and Current

Unsuccessful in ST1 Cardiothoracic Surgery 46 National Selection, What is Next?

Abdul Badran, Jason Trevis, Clauden Louis, Yihan Lin

New Consultant Appointments – February 2021 to August 2021

Jeremy Chan, Amer Harky

The Montgomery Case and the Notion of Consent Sarah Murray

Duncan Steele, Abdul Badran

SCTS Annual Meeting 2021: Student Engagement Day Report

National Cardiac Surgery Clinical Trials 49 Initiative National PPI Group

We are committed to sustainable forest management and this publication is printed by Buxton Press who are certified to ISO14001:2015 Standards (Environmental Management System). Buxton prints only with 100% vegetable based inks and uses alcohol free printing solutions, eliminating volatile organic compounds as well as ozone damaging emissions.

57 58

Sophie Mason, George Liu

Women in Cardiothoracic Surgery 48 India Premjithlal Bhaskaran

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

Anglia Ruskin University Cardiology and Cardiothoracics Society International Virtual Reality Conference 2020

Trainer Awards in Cardiothoracic Surgery 2021

Society for Cardiothoracic Surgery in Great Britain and Ireland

Heart Research UK Aortic Dissection Masterclass, Keele Anatomy & Surgical Training Centre

Javeria Tariq, Karen Booth, Farah Bhatti OBE

Nigel Drury

Veena Surendrakumar, Ashvini Menon, Richard Steyn

Congenital Heart Disease Priority Setting Partnership

Julie Sanders

Rules of (Virtual) Engagement

Society for Cardiothoracic Surgery in Great Britain and Ireland

United States Pathways of Training

Obituary: 64 Raymond Lambert Hurt 1922-2020

Steve Edmondson

66 Crossword

Sarah Murray

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August 2021

From the Editor Indu Deglurkar, Publishing Secretary, SCTS

The art of communication is the language of leadership.

s a professional body, the SCTS has explored the art of new forms of communication via the use of virtual media for the first time in conducting the Annual meeting which was highly successful. The hard work and efforts of the Annual Meeting Team and the organising committee was hugely appreciated. The virtual AGM saw the landmark move towards Unit specific outcomes with greater emphasis on the patient pathway and the SCTS Equality, Diversity and Inclusion strategy was unanimously supported by the membership. Our President Simon Kendall outlines the SCTS Toolkit, patient pathways and addresses the imbalance existing in the career progression of surgeons in training and allied health professionals and the need for equitable training opportunities. In this summer edition of the Bulletin, we introduce for the first time all the budding surgeons appointed to ST1 posts and extend a warm welcome to the world of Cardiothoracic Surgery. We have received many articles as usual but two were particularly striking and revolve around the very core of our practice. The Nuremberg Code of 1947 ruled that it is mandatory to obtain voluntary and informed consent. Singularly, this is the most important development in medical ethics and human rights. Informed consent

constitutes the core of the Nuremberg Code and its influence on global human rights law and medical ethics has been profound. The patient has as much authority as the treating Physician, unlike the Hippocratic ethics in which the patient relies on the Physician to determine their best interests. Beyond that, the Helsinki Declaration was adopted by the World Medical Association in 1964 and has undergone seven revisions outlining ethical principles of medical research involving human subjects. Sarah Murray’s article on consent refers to the landmark case ruling, Nadine Montgomery v Lanarkshire Health Board

as we endeavour to provide holistic care. We face ethical dilemmas all the time-ie doing the right and the wrong thing at the same time. We make rapid decisions based on the information available weighing potential risks and benefits of resuscitation. As Surgeons, we are determined to restore life and feel physically and emotionally defeated by death. When faced with clinical and ethical dilemmas, our technical and communication skills are tested to the limit. Prolonging life and restoring consciousness are appropriate medical goals but who decides what is an appropriate goal or what constitutes futility? The health care provider? The patient or the family? A consensus of experts? The initial decision about these very difficult questions often have to be made during a cardiac arrest by the senior health care provider including the decision to terminate resuscitative efforts. The articles on Consent and the resuscitative dilemmas illustrate the importance of communication and the need for it to be a part of the training curriculum. Thank you all for the excellent articles and I look forward to hearing any suggestions to improve the Bulletin. We would like to thank our Publishers Mark Lamsdale, Rachel Gold & Matt Hood for their tireless efforts creating our Bulletin. Wish you all a relaxing and happy summer break. n

“Informed consent constitutes the core of the Nuremberg Code and its influence on global human rights law and medical ethics has been profound. The patient has as much authority as the treating Physician unlike the Hippocratic ethics in which the patient relies on the Physician to determine their best interests.” (2015) in the UK Supreme Court 15 years after the incident. The doctrine of informed consent, joint decision making and discussion of alternative options is now a legal requirement. The information given to the patient must be comprehensible, calibrated to the patient in question without bombarding them with technical information which may be difficult to understand. Patients are no longer the passive recipients of the care of the medical profession. Fragomeni’s article illustrates how our roles are complex and multi-faceted

indu.deglurkar@wales.nhs.uk

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From the President Simon Kendall

• To move the focus of the cardiac surgical audit from the individual surgeon to the outcomes of the unit and include the whole patient pathway. • To approve the SCTS strategy for Equality, Diversity and Inclusion • To support the writing of the SCTS Toolkit about Transforming the Care we deliver for the benefit of patients, allied health professionals and surgeons in training.

We were delighted to receive 100%, 100% and 93% support respectively for these proposals. Here is a brief update on their progress:

The SCTS Toolkit This is now published and available to all on our website. It describes the need for change and to share some of the exemplary practice and models of care from around the nation. At present, patient care and patient experience are inconsistent; the opportunities for clinical career progression for allied health professionals (AHP) are extremely variable; surgeons in training have a lack of access to theatre to learn and hone their skills and furthermore a tension in units which colleagues should have priority for theatre sessions. Introducing change is most challenging and has been achieved in units due to local need, local resource and always due to outstanding clinical leadership. Coming out of the pandemic, the limits on NHS funding will make change even more challenging and the toolkit describes the common obstacles and the proven solutions. These changes will take three to five years to implement and we hope the toolkit will help colleagues find the bespoke models of care that will be applicable to their own unit. The anticipated result will be:

t our virtual SCTS Annual Business Meeting in April we were delighted that more members than ever could attend. It was a step forward that we could make the meeting more interactive to the point it was possible for members to hold an informative and constructive discussion in the ‘chat’ section whilst the business was being conducted. As leaders we presented three agenda items hoping for approval from the members:

“Introducing change is most challenging and has been achieved in units due to local need, local resource and always due to outstanding clinical leadership. Coming out of the pandemic, the limits on NHS funding will make change even more challenging and the toolkit describes the common obstacles and the proven solutions.”

Improved patient care and experience; Consistent opportunity for clinical career progression for allied health professionals,

with defined competencies, roles, titles, qualifications and remuneration. This will allow 24/7 care to be delivered by AHPs which will allow a reduction in the number of the middle grade surgeons, the senior of whom can become non-resident when they are on call. With a reduction in this tier of surgeons they will have more opportunities to attend theatre sessions, and these opportunities can be shared equally between trust appointed surgeons and the national appointed surgeons in training. An ambitious project, but if we take a step back and consider the consequences of doing nothing then we would not be supporting our AHPs nor the surgeons in training, who are the future of our specialty.

Equality, Diversity and Inclusion In the last Bulletin, Narain, as Honorary Secretary, shared the proposed strategy for SCTS. The wisdom of his article has been reinforced by the recent publication of the Kennedy report for RCS England (https:// www.rcseng.ac.uk/about-the-rcs/aboutour-mission/diversity-review-2021/ ). It is sobering to read and it is my observation that its recommendations have been well received especially by women and BAME colleagues. White male colleagues accept the report but too often follow their approval with the word ‘but’. The anecdotal descriptions of prejudiced behaviour are most uncomfortable reading, followed up by Ms Susan Hill’s article in the RCS Bulletin ‘Its Time for Surgery to Speak Out’ of her own experiences of prejudiced and sexual harassment (https://publishing. rcseng.ac.uk/doi/10.1308/rcsbull.2021.48). We devoted a plenary session to this agenda and it was inspiring to hear the presentation of Brigadier Nicky Moffat of what has been achieved in the army under her extraordinary leadership.

Narain concluded the session quoting Benjamin Franklin: “Change will not occur until those who are unaffected are as outraged as those who are.” As a white male I cannot stress this enough to everyone to really understand what Equality, Diversity and Inclusion means to our specialty, our professional lives and our personal lives. To further stress this point, I was humbled to hear two colleagues share that the best thing about their role are the complex and challenging operations but the worst thing about their job is being isolated and not included in the conversation by their male colleagues. We can do so much better and we can put this right.

Cardiac Audit – the end of Published Surgeon Specific Outcomes? April 1st was the beginning of the new three-year audit cycle focusing on the outcomes of the unit and whole patient pathway. The data collection for each patient episode is fundamentally unchanged but the new era requires a questionnaire to be completed, taking around 10 minutes, to share the progress each unit is making against the standards. Many of these standards are detailed in the recent publication in collaboration with ACTACC, BCS and BCIS, Guidance For The Structure & Function Of Cardiac Multidisciplinary Meetings. The fundamental difference is the need for a multidisciplinary meeting to review the defined clinical outcomes every three months, so if there are any negative trends they can be supported to improve. In this way no unit should reach the end of the audit cycle with any negative variance. We are most grateful to Uday Trivedi for the significant amount of work to put this structure in place. It is most encouraging having contacted every unit that they are all most positive about the proposals and they have clear plans to implement this strategy. They clearly understand that we have been trusted to move away from individual outcomes, and that to repay that trust we need to be providing safe patient care and quality assurance within the audit cycle itself.

This will be such a step forward to the previous process where we are only now just at the point of contacting units and individual surgeons about the positive and negative outliers from the 2017 to 2020 audit cycle. Fourteen months since the end of the cycle and only now highlighting the variance. The pandemic has disrupted the steady state of the audit with a significant reduction on the number of the cases and also a perceived change in the risk profile of those case. This disruption to the statistical model may well make publication of individual surgeon outcomes obsolete, but it will remain important we work with NICOR to monitor outcomes and help units if variance occurs. With Andrew Goodwin’s leadership, NICOR are providing the tools that will enable real time monitoring of outcomes, and if units can return their data in a timely manner this can be done against contemporary benchmarks.

Importantly ... This edition of the bulletin further reinforces the depth of talent, commitment and enthusiasm in our specialty. It is not possible to give the recognition and praise that is due to all that is being achieved. However, there are two exceptions to mention.

Firstly to thank Clinton Lloyd for his dedication and extraordinary commitment to create our new SCTS website. It has phenomenal capability and we now need to use it effectively to make it the ‘hub’ of SCTS. And secondly to commend the extraordinary resilience and achievements of the Annual Meeting Team. Maninder Kalkat, Cha Rajakaruna, Daisy Sandeman, Sunil Bhudia, Isabelle Ferner and Tilly Mitchell. Even as a past meeting secretary myself I cannot imagine the disappointment of having to cancel an AGM at such short notice as we had to do in 2020. They have picked themselves up and embraced the virtual format learning from other organisations. If that wasn’t challenging enough they then saw the next iteration further postponed due to the 2nd/3rd wave and finally were able to put on an outstanding Virtual AGM. The feedback has been most positive and they now have the conundrum for Belfast how much will be real and how much will be virtual – one example of the challenge of our new world after Covid. May you all have a good summer and that through the year we can go on to make progress on all these progressive agendas for our specialty. n

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August 2021

Improving Patient Outcomes Narain Moorjani, Honorary Secretary

s well as enhancing the working lives of practitioners delivering care to patients undergoing cardiothoracic surgery, the SCTS’s primary objective is to promote excellence in the practice of cardiothoracic surgery by continuously improving the quality of healthcare that our specialty delivers to patients in an open and accountable manner. The past 12 months dealing with the COVID pandemic has allowed us to reassess the way care is delivered to patients undergoing cardiothoracic surgery and in line with this, the SCTS has recently introduced or is planning to introduce a number of initiatives to help to improve patient outcomes.

Unit specific outcome monitoring After many years of debate, the SCTS has recently introduced probably the most significant change in adult cardiac surgery outcome monitoring for over 20 years. Bringing it into line with the outcome monitoring programmes in thoracic surgery and congenital cardiac surgery, adult cardiac surgery outcomes from April 2021 will be published on a unit-level basis, as opposed to the surgeon-level reporting that we have all been used to over recent years. Importantly, the outcome monitoring programme will also assess other markers of the patient pathway and experience, including morbidity following cardiac surgery (such as post-operative rates of stroke, acute kidney injury, deep sternal wound infection and return to theatre for bleeding), as well as measures of process (such as rates of day of surgery admission, hospital length of stay and wait for inhouse urgent surgery). As the project evolves and matures, further outcomes

measures will be assessed to best define optimal delivery of patient care. The premise behind the changes is that the care of patients undergoing cardiac surgery is delivered by a team of cardiothoracic surgical practitioners and specialists, including cardiologists, anaesthetists, intensivists, perfusionists, surgical care practitioners, nurses and allied health professionals, as well as surgeons, and it is important to recognise the role that these professionals play in a successful outcome for these patients. Hence, as cardiac surgery is a teambased specialty, the monitoring of outcomes should reflect this. In addition, it has been described that the spectre of individual surgeon mortality publication may produce risk aversion and thereby potentially deny high-risk patients the opportunity for surgical intervention. The introduction of dual consultant operating in April 2020 was in part recognition of this to allow these cases to be attributed to the unit rather than the individual surgeon, and hence ensure that these patients were given the opportunity. Further details of the dual consultant operating concept can be found later in the Bulletin. In addition, success for a patient is more than just survival. Hence, it is important that any assessment of outcomes considers morbidity following cardiac surgery, as well as factors that influence the patient experience and patient pathway.

Enhancing clinical effectiveness through MDM standards The SCTS has developed standards for multi-disciplinary team meetings (MDMs) to offer a framework of how MDMs should run and how they can be used to

improve patient outcomes. These have been produced in collaboration with the British Cardiovascular Society (BCS) and Association for Cardiothoracic Anaesthesia & Critical Care (ACTACC), using a structured approach, based on evidence and guidelines, to support the decision-making process for each individual patient. They will help units to introduce best practice from around the country in relation to MDMs for revascularisation, aortic valve disease, mitral valve disease, endocarditis and high-risk cases, thereby assuring that all units have a consistency of MDM structures, consider all patients in appropriate MDMs, discuss patients in a timely manner, and have quality assurance and audit of decisions and outcomes. This guidance is also pivotal in supporting the adult cardiac surgical audit moving its focus to outcomes for the unit and on the entire patient pathway.

Shared learning and dissemination of good practice In parallel with these initiatives, the Society is planning to develop a Patient Safety Working Group, where BORS representatives will be encouraged to anonymously submit (via an SCTS portal) case reports in cardiac, thoracic, congenital and transplantation surgery of near-misses, no-harm incidents or serious adverse events, where there are potential learning points of relevance to national practice. These case reports will have been appropriately handled locally and a series of recommendations will have been produced. The working group would assess the reports to extract any important learning points, which can then be disseminated via the SCTS >>

Meeting Secretary: Maninder Kalkat

Lay Representative: Sarah Murray

Trainee Reps.: Duncan Steele, Adbul Badran

Honorary Treasurer: Amal Bose

Education Secretaries: Sri Rathinam / Carol Tan

Nursing & AHP Chair: Bhuvana Krishnamoorthy

Appointed Members: Rajesh Shah Juliet King Kandadai Rammohan Babu Naidu Steve Woolley Joel Dunning Leanne Harling David Healy Mark Jones

Appointed Members: Steven Billing Shakil Farid Thanos Athanasiou Mobi Chaudhry

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

Trainee Representative: TBC

NAHP Representative: Kathryn Hewitt Lisa Carson

Education Lead: Deborah Harrington George Asimakopoulos

Co-opted Members: Emma O’Dowd (BTS) Ian Hunt (Commissioning) Richard Steyn (Trauma)

Trainee Representative: Oliver Harrison Jennifer Whitely

NAHP Representative: Xiaohui Liu

Education Lead: Sri Rathinam Carol Tan

Audit Lead: Doug West

Executive Co-Chair: Simon Kendall

Executive Co-Chair: Rajesh Shah

Audit Lead: Uday Trivedi

Co-Chair: Aman Coonar

Co-Chair: Enoch Akowuah

Deputy Audit Lead: Serban Stoica

Trainee Representative: Joesph George

NAHP Representative: TBC

Education Lead: Attilio Lotto

Audit Lead: Carin Van Doorn

Unit Reps.: Chuck McLean Andrew Parry Mohammed Nassar Osama Jaber Andreas Hoschtitzky Phil Botha Tim Jones Conal Austin Mark Redmond Branko Mimic Martin Kostolny

Executive Co-Chair: Narain Moorjani

Co-Chair: Rafael Guerrero

Trainee Representative: Abdul Badran

NAHP Representative: Emma Matthews Amy Chadwick

Education Lead: Espeed Khoshbin

Website Lead: Aisling Kinsella

Audit Lead: Jorge Mascaro Marius Berman

Appointed Members.: Marius Berman Stephen Clark Phil Curry Fabio De Robertis Aisling Kinsella Jorge Mascaro Rajamiyer Venkateswaran

Executive Co-Chair: Rajesh Shah

Co-Chair: Steven Tsui

Co-opted Members: Andrew Goodwin (NICOR)

NAHP Representative: Hemangi Chavan Nisha Bhudia

Congenital Cardiac Surgery Lead: Carin Van Doorn Deputy Congenital Cardiac Surgery Lead: Serban Stoica

Thoracic Surgery Lead: Doug West Deputy Thoracic Surgery Lead: Kandadai Rammohan

Adult Cardiac Surgery Lead: Uday Trivedi Deputy Adult Cardiac Surgery Lead: Umberto Benedetto Regional Deputy Adult Cardiac Surgery Leads: Indu Deglurkar (Wales) Zahid Mahmood (Scotland) Alastair Graham (Northern Ireland)

Co-Chair: Doug West Executive Co-Chair: Simon Kendall

Elected Trustees: Carin Van Doorn, Mobi Chaudhry, Enoch Akowuah, Aman Coonar, Betsy Evans, Andrew Parry

Perfusion Reps.: Phil Botha, Chris Efthymiou

President Elect: Rajesh Shah

President: Simon Kendall

Congenital Cardiac Surgery Lead: Attilio Lotto Transplant Surgery Lead: Espeed Khoshbin NAHP Representative: Bhuvana Krishnamoortthy Trainee Representatives: Duncan Steele Abdul Badran Consultant Lead: Prakash Punjabi Shahzad Raja Trust Appointed Doctors Leads: Zahid Mahmood (Cardiac) Kandadai Rammohan (Thoracic) Student Lead: Farah Bhatti Karen Booth Accreditation Lead: Shafi Mussa Communication Lead: Vivek Srivastava

Surgical Tutors: Deborah Harrington George Asimakopoulos

Co-Chairs: Sri Rathinam Carol Tan Executive Co-Chair: Rajesh Shah

Co-opted: Andrew Goodwin (NICOR) Luke Rogers (ASSL) Ricky Vaja (ASSL) Serban Stoica (Congenital Audit) Ed Caruana (ASSL) Akshay Patel (ASSL)

Medical Student Lead: Rishab Makam

Trainee Representative: Marius Roman Azar Hussain

NAHP Representative: TBC

Congenital Cardiac Surgery: Massimo Caputo Nigel Drury

Thoracic Surgery: Babu Naidu

Adult Cardiac Surgery: Enoch Akowuah Gianluca Lucchese

Executive Co-Chair: Narain Moorjani

Co-Chairs: Eric Lim Mahmoud Loubani

Audit Co-Chair: Doug West Congenital Co-Chair: Rafael Guerrero Innovation Co-Chair: Hunaid Vohra Exam Board Chair: Rana Sayeed Cardiothoracic Dean: Neil Roberts

Co-opted Members

NAHP Representative: Una Ahearn ACTSCP president

Appointed Members: Rajesh Shah Narain Moorjani Ishtiaq Ahmed Alex Cale Massimo Caputo Roberto Casula Joel Dunning Hazem Fallouh Rafael Guerrero Shyam Kolvekar Kelvin Lau Nicolas Nikolaidis Karen Redmond Stephan Schueler

Executive Co-Chair: Simon Kendall

Co-Chair: Hunaid Vohra

Meeting Lead: Daisy Sandeman Cardiac Lead: Kathryn Hewitt Thoracic Lead: Xiaohui Liu Audit Lead: Hemangi Chavan Education Lead: Bhuvaneswari Krishnamoorthy Regional Tutors: Libby Nolan Michael Martin Namita Thomas Sophia Wang Transplantation Emma Matthews Innovation Lead: Una Ahearn Patient Liaison: Amy Chadwick Zoe Barrett Brown Membership Lead: Jane Dickson Communication Lead: Jeni Palima Pharmacy Lead Nisha Bhudia Critical Care Lead Anna Gesicka Perfusion Lead: Noel Kelleher Lisa Carson Physiotherapist Lead: Zoe Barrett Brown Occupational therapist Lead: Amy Chadwick Surgical Care Practitioner Lead: ACTSCP President

Chair: Bhuvaneswari Krishnamoorthy

Research Co-Chairs: Eric Lim / Mahmoud Loubani Tutors: Deborah Harrington, George Asimakopoulos Transplantation Co-Chair: Steven Tsui SAC Chair: Marjan Jahangiri

Honorary Secretary: Narain Moorjani

Women in Cardiothoracic Surgery Co-chairs: Karen Booth Narain Moorjani

Equality, Diversity & Inclusion Co-chairs: Narain Moorjani Indu Deglurkar

Meetings Team Meeting Secretary: Maninder Kalkat Deputy Secretary: Cha Rajakaruna Associate Secretary: Sunil Bhudia NAHP Representative: Daisy Sandeman Conference Organisers: Isabelle Ferner Tilly Mitchell

Communications SCTS Website: Clinton Lloyd Bulletin: Indu Deglurkar

Professional Standards Sarah Murray Rajesh Shah Bhuvaneswari Krishnamoorthy Noel Kelleher Doug West

Emma Ferris

Tilly Mitchell

Isabelle Ferner

the 10 bulletin

August 2021

website, Bulletin, BORS meetings, and newsletters emailed to members, with the aim to prevent similar incidents occurring elsewhere in the country and to improve patient safety. The working group would also collaborate with other organisations involved with patient safety and clinical improvement, such as GIRFT, Confidential Reporting System for Surgery (CORESS) and NHS Improvement. In addition, the working group will be used as a vehicle to share best practice and quality improvement projects, such as happened during the COVID pandemic with dissemination of national and international guidelines, as well as lessons learnt from different units.

Innovation through good governance Whilst it is important that cardiothoracic surgical practitioners concentrate on clinical outcomes, it is also imperative that that we continue to innovate and evolve our specialty, and to remain leaders in the field. With this in mind, to ensure that patients receive contemporary and most up to date care, the Society has recently developed an Innovation Sub-Committee, with the purpose of providing a leadership role in supporting innovation in all aspects of cardiac, thoracic, congenital and transplantation surgery. This includes both technological innovations (such as minimally invasive or robotic surgery) and non-technological innovation (that improve processes and patient pathways). The responsibilities of the sub-committee will focus on facilitating an environment where the development of innovative techniques and the adoption of new procedures in cardiothoracic surgery is encouraged and allowed to flourish. In addition, the sub-committee will produce examples of best practice and quality improvement projects in innovation in cardiothoracic surgery, as well as develop protocols and guidance documents to support the introduction of new procedures. The sub-committee will work with Specialist Commissioning Groups, BISMICS and industry partners to support the safe introduction of innovation.

“The premise behind the changes is that the care of patients undergoing cardiac surgery is delivered by a team of cardiothoracic surgical practitioners and specialists, including cardiologists, anaesthetists, intensivists, perfusionists, surgical care practitioners, nurses and allied health professionals, as well as surgeons, and it is important to recognise the role that these professionals play in a successful outcome for these patients.” Through these different initiatives and a process of collaboration with all practitioners involved in the delivery of care to patients undergoing cardiothoracic surgery as a team-based approach, this will allow us to improve the clinical outcomes and patient experiences through marginal and sometimes not-so-marginal gains. In particular, the Society would

like to thank Uday Trivedi, Umberto Benedetto, Andrew Goodwin, Enoch Akouwah and Hunaid Vohra, who have helped develop some of these projects on behalf of the SCTS. As members, we would value your support of these initiatives and welcome any other ideas as we continue to strive for excellence in cardiothoracic surgery. n

the 12 bulletin

SCTS Virtual Annual Meeting 2021 Maninder Kalkat, SCTS Organising Committee

he SCTS Annual Meeting eventually materialized from 9th to 11th May, more than two years after the last one in London in 2019. The uncertainty and restrictions surrounding COVID repeatedly forced the organising committee to cancel and postpone the meeting. After much deliberation and consultation, it was decided to move the meeting to a virtual platform. There, of course, was much anxiety, trepidation, and uncertainty about this alternative to a much anticipated conventional get together at the annual conference. The thin attendance at other virtual meetings was a matter of great concern to the committee. In addition, the contracts with the various planned venues

had to be re-negotiated for cancellations and postponements. The tough decisions made ahead of time, gentle diplomacy and perseverance paid off, with no financial penalties imposed on the SCTS. The realisation soon dawned on the organising committee that planning of the virtual meeting was a completely different exercise and not only did it test the resilience of the team to the maximum, but gave an opportunity to learn, collaborate with various groups (industry, event managers and the Royal College) and to bond with each other as never before. At the outset, the aim was to deliver an Annual meeting with high quality educational content, an opportunity for young and budding surgeons, nurses and students to present their work and a platform for the delegates to interact in an easy, user friendly and conducive environment. For this matter, the virtual online platform was developed aiming to have an effortless login and seamless access to various sessions by the delegates. Considerable brainstorming took place to

encourage people to register, ensuring active participation for three days and for them to get value for the time and money they would spend. Despite the trend and advice from various quarters, we resisted the temptation to make the meeting completely free. The registration fees were reduced by two thirds with significant discounts for various groups. The publicity campaign was augmented in the last few weeks before the meeting with email blasts, a regular presence on social media and airing of interviews by various speakers. The cumulative effect of all these actions was more than a thousand people from various disciplines registering for the meeting. The industry stood steadfast with SCTS, resolute to work together for the successful conduct of the conference. A virtual exhibition hall was created with input from the representatives, industry seminars were facilitated and measures to improve the interaction with delegates were explored. The regular reminders during the meeting to the delegates to visit the industry stalls and “scavenger hunt” had a desirable impact, but nothing will compare with the bonhomie and glitter of the live exhibition hall. Well done to Claire Stewart for winning the scavenger hunt and receiving an iPhone 12. There was some apprehension about the failure of internet and related issues, speakers inability to join and most importantly for the organising team to connect with each other and the event management people. An inventive concept to conduct the meeting from a hub was mooted. This hub was created at the Royal College of Surgeons at Edinburgh with high tech support, excellent bandwidth and manned by Richard Steyn, a thoracotechnocrat. To give the semblance

August 2021

“The virtual meeting was a completely different exercise and gave an opportunity to learn, collaborate with various groups and to bond with each other as never before.” of a real meeting, senior officers from SCTS shared the stage with the wider virtual delegates. The President awarded a life time achievement to Mr William Walker in person, with a backdrop of the large SCTS banner in an opulent hall of the Royal College.

The reformatted plenary sessions attracted a good number of attendees numbering about 300 - 350 and the individual sessions attracted about 100 delegates. In addition to the education and professional developments, the meeting also enhanced the physical and mental health of its participants. A virtual 5K run on Saturday afternoon was well attended and the winner, Neil Roberts, finished in an impressive 20 minutes. The Virtual quiz on Sunday was full William Walker receives the of fun and wit and a serious effort Lifetime Achievement Award to win the prize was witnessed. from President Simon Kendall In the end, the spirit of collaborative learning, The Ionescu University on Sunday, sharing experiences and coming together the Scientific Annual meeting on Monday as one big family, a united Cardiothoracic and Tuesday was perceived as a great success, community working selflessly for the patient reflected by the number of registrants was held high. numbering more than a thousand and on an Looking forward to a conventional average 750 people attending on each day. annual meeting in Belfast in 2022. n

CALL FOR ABSTRACTS Abstract Submission opens: 1st September

SCTS ANNUAL MEETING 2022

Sunday 13th – Tuesday 15th March

#SCTS2022

Abstract Submission deadline: 5th November Registration opens:

1st December

SCTS

Society for Cardiothoracic Surgery in Great Britain and Ireland

the 14 bulletin

SCTS Nurses and Allied Health Professional Report 2021 Dr. Bhuvaneswari Krishnamoorthy, SCTS Nursing and AHP Lead

his is my first report as your NAHP Lead for our Society, and it is my honour to write this report, full of happiness and sorrow. I would like to thank all of you who have put in so much effort during this pandemic, working tremendously and my heartfelt condolences if you have lost family and friends. I have separated my report into a few sections to give more clarity and inform the members about what has been going on for the past six months.

Annual conference I would like to thank my fellow subcommittee representative for the annual meetings, Mrs. Daisy Sandeman who pulled together our first virtual annual meeting with her meeting team. She has done an amazing job and I was so happy to see many of the NAHP speakers and members attending the meeting from their doorsteps or at work. I would like to thank everyone for taking time during this crisis and for supporting our annual meeting. Special thanks to Isabelle Ferner and Tilly Mitchell and team. Hopefully, we will meet face-to-face or in a blended approach in 2022.

Education Once again, many thanks to all members and non-members attending our virtual webinar series for the past year. We have successfully conducted 18 webinars ranging from chest physiotherapy to non-medical prescribing in CT surgery. More than 650 delegates have attended these webinars worldwide and these webinars are freely available on YouTube after the event. We have successfully conducted a one-day virtual online thoracic course which was well received with lots of discussion. Many more are to come. We will be continuing online education until early next year to reduce our members’ work-related pressure after the pandemic.

Unit representative engagement sessions I have managed to speak to six unit representatives and look forward to speaking to others in due course. I understand your work commitments, but if you can spare a half hour of your valuable time, it will be more than enough for me to explain the exciting opportunities ahead. I would like all unit representatives to take part in our NAHP educational activities, to write one annual report and to participate in local level taster sessions.

Being inclusive I strongly believe in being part of a team and to create a wider team with different likeminded people who thrive for our NAHP stream success. My main goal is to promote and support members to get what they want from our society such as professional support, education, dissemination and much more. I have set up and interviewed for 21 NAHP professional sub-committees to sit on 13 SCTS core sub-committees. More

details and their name are listed on the table. Please note there are four committees vacant and it will be completed in a couple of months. I have faith in our members that we will get an exciting team with brilliant, innovative ideas to create a strong foundation for our junior NAHPs.

Awards I am excited to announce that in October 2021 we are going to advertise for 12 SCTS NAHP team awards. Please look for an advertisement and apply on behalf of your team. These awards will be selected by an independent panel executive and will be awarded at our 2022 annual meeting.

Surgical Care Practitioners The Royal College of Surgeons (England and Edinburgh) have joined up to rewrite a new surgical care practitioner curriculum to standardise the education of our trainees. This new curriculum will set standards across

“Once again, many thanks to all members and non-members for attending our virtual webinar series for the past year. We have successfully conducted 18 webinars ranging from chest physiotherapy to non-medical prescribing in CT surgery. More than 650 delegates have attended these webinars worldwide and these webinars are freely available on YouTube after the event.”

August 2021

the United Kingdom. Both colleges have also set up voluntary registration for SCPs to be registered and working towards statutory registration with GMC/DOH. I would like to thank all the members and non-members who have signed the petition to highlight these problems to the DOH/RCS.

New website with easy access Our new website has a dedicated NAHP section with lots of educational materials and videos with easy access. I would like to thank my fellow sub-committee representative Mrs Zoe Barrett-Brown who worked tirelessly with Mr Clinton Lloyd to put things together in our NAHP section.

Ionescu Fellowship winners

Future

I would like to congratulate Mr Janesh Nair (Wythenshawe hospital) and Miss Sophia Wang (Royal Brompton hospital) who were successful in the April 2021 Ionescu fellowship round. I would like to stress to all members to please apply for this exciting opportunity to obtain £5000 per person to visit a centre to learn or develop a new programme in your workplace. It is vital for us to benchmark and learn new methods which provide better patient care and satisfaction. The project does not need to be patient oriented, but it should make a difference to your organisation and promote excellence in your area of practice.

We will be focusing on NAHP professional based online forum discussions, webinars and virtual one day courses on a monthly basis to provide more education. I will be engaging with all unit representatives to promote our SCTS NAHP stream among junior staff members in CT centres across GB. “Together we can make a difference. Being part of our NAHP stream will strengthen us and our future generation. Please join us without any hesitation and trust me to make that change which you always wanted to see. Love you all.” n

NAHP Committee Membership 2021 Lead 1

Lead 2

Adult Cardiac Surgery

Miss. Kathryn Hewitt

Mrs. Lisa Carson

Thoracic Surgery

Mrs. Xiaohui Liu

Congenital Cardiac Surgery

TBC

Heart & Lung Transplantation

Miss. Emma Matthews

Miss. Amy Chadwick

Audit

Miss. Hemangi Chavan

Mrs. Nisha Bhudia

Education

*Dr. B Krishnamoorthy

*All committee members

Research

TBC

Innovation

Mrs. Una Ahearn

ACTSCP president

Patient Liaison

Miss. Amy Chadwick

Mrs. Zoe Barrett-Brown

Membership Lead

Mrs. Jane Dickson

*All committee members

Communication, Video Editing and Website

Miss. Jeni Palima

*All committee members

Professional Standards

Dr. B Krishnamoorthy

Mr. Noel Kelleher

Annual Meeting Lead

Mrs. Daisy Sandeman

*All committee members

Pharmacist Lead

Mrs. Nisha Bhudia

Operating Department Practitioner Lead

Mrs. Nisha Bhudia

Critical Care Lead

Miss. Anna Gesicka

Perfusionist Lead

Mr. Noel Kelleher

Physiotherapist Lead

Mrs. Zoe Barret-Brown

Occupational Therapist Lead

Miss. Amy Chadwick

Physician Associate Lead

TBC

Regional Tutors

Mrs. Libby Nolan Mr. Michael Martin Miss. Namita Thomas Miss. Sophia Wang

Mrs. Lisa Carson

21 core sub-committee teams within the NAHP sub-committee. All bold indicates the current SCTS sub-committees. All italic indicates the newly formed professional lead NAHP team. All the new listed NAHP committee members have been allocated to the current SCTS sub-committee according to their professional background. *Please note that all NAHP sub-committee leads will work with the education NAHP lead to set out a webinar and a full day course annual basis for their professional group. Additional educational regional tutors have been appointed in the educational team to work with the educational NAHP lead to develop regional teaching activities.

the 16 bulletin

SAC Report Marjan Jahangiri, FRCS (CTh), SAC Chair, Professor of Cardiac Surgery, St. George’s Hospital

The other side of the table is not far It has been a turbulent year for the consultants and their trainee registrars. With our 100% dependency in cardiac surgery on ICU provisions and the need for high dependency care after thoracic surgery, we have been affected more than most surgical specialties. A myriad of problems, ranging from a significantly reduced number of operations to the fear of post-operative Covidrelated complications, as well as patients facing greater hurdles to come in for surgery, have contributed to a feeling of profound disruption throughout the training of our registrars. There has also been a genuine lack of clarity regarding training time-scale and what the future holds. In the midst of these, several important changes have been introduced. At the SAC, with the help of other consultant colleagues and the Training Programme Directors, we are ever more determined to deliver a high-quality training programme and ensure satisfactory completion of training of our registrars.

Curriculum

The new 7-year curriculum, which is approved by the GMC, will be implemented from August 2021. It has three phases with important transition points: There is a lot to fit in. In order for our trainees to qualify after seven years as an independent consultant in their first year, we need to ensure a minimum two days of operating per week and aim for three days. In my view, we have concentrated on generic non-technical skills for surgery in recent years to the detriment of technical aspects.

Ultimately, what distinguishes us from others in medicine and surgery is our technical ability in the context of generic skills. The motto of ‘Cut Well, Sew Well, Do Well and Do It Often’ should prevail. In order to achieve the increased operative exposure, we encourage that the registrar works for more than one consultant at any one time. In addition to operative skills, the curriculum stipulates four papers in seven years and one presentation plus one audit per year. This should be easily achievable by all our trainees. In addition, the implementation of recognised transplantation and paediatric training as part of the curriculum is in progress. This should equip our trainees with wider skill sets.

Pandemic and outcome 10

I hope that the introduction of outcome 10 by the Surgical Royal Colleges and the Joint Committee of Surgical Training has eased the pressure for the consultants and their registrars. It is non-punitive and extends the training time.

Assessment and the revised logbook

We have been revising the logbook and its recording on the ISCP website, and I hope you find it more helpful. Regarding the trainee progress, if it is not documented on the ISCP, it has not happened. This is the only evidence for the training progress. Multiple Consultant Reporting is live, and thorough documentation of progress of our trainees is recommended.

National Selection

Due to workforce planning and the pandemic, the number of doctors appointed in February 2021 was less than previous years (6 ST1 + 2 ST3). From 2022, there will be fewer appointees in the ST3 category and this route of training will be phased out by 2023. The reasons for this are multifactorial

and relate to the overall number of applicants for each category, the new curriculum, and reduction in core surgery/general surgery numbers. As to what the numbers for 2022 will be, the SAC will be in a position to inform you in the Autumn.

SAC Membership

The Joint Committee of Surgical Training and I would like to thank Andrew Goodwin, David Jenkins and Mike Lewis for their invaluable work at the SAC. Their terms have come to an end and new colleagues joining the SAC are: Mahmoud Loubani, Dheeraj Mehta, Kasra Shaikhrezai, Hunaid Vohra and Steven Woolley. We really look forward to working with them. My plea to our trainees is that your consultants are willing to devote time to you, but please be around, take ownership of the surgical service that you work for and your patients. Develop a sense of total responsibility and devotion both to your patients and to your training. Look after your patients on ICU and learn the necessary skills. Please do not look for the angiogram or the CT scan in the morning of the operation; instead, be more knowledgeable than your consultants about the case. Take pride in a scholarly attitude by being up to date with the literature. Ann Thorac Surg and J Thorac Cardiovasc Surg should be mandatory monthly readings – read the Letter and Commentary sections to develop your critical skills, keep up to date with the ESC and AHA guidelines often published in Circulation, and read the cardiovascular trials of NEJM and The Lancet. I can confidently say that many of your consultants believe that it is our duty to train you. The other side of the table need not be far. After a 1970s television programme on cardiac surgery called ‘Your Life in Their Hands’ was released, a clever journalist commented that a more appropriate title was ‘Their Hands in Your Life’. This position is one of immense privilege, and one that we should relish with every opportunity afforded to us. n

August 2021

Audit Update:

Developing a Modern Unit Quality Assurance Programme in Adult Cardiac Surgery Doug West, Audit Subcommittee Chair

his article goes to press amid significant changes in cardiothoracic audit across our subspecialties. The Society’s programme to develop a new quality assurance programme has progressed well, led by the team of Simon Kendall, Uday Trivedi and Umberto Benedetto. The principle behind this to provide reassurance that the whole clinical team is safe, rather than to focus on individual surgeons alone. We believe that this approach better reflects the complex teamwork between surgeons, anaesthetists, intensivists and other team members which is implicit in modern cardiac surgery. The programme will report multiple datapoints for each unit, to provide a wider view of the quality of the service experienced by patients. This includes some of the outcomes data provided by NICOR, but also organisational data derived from unit questionnaires. Regular unit meetings to review outcomes and address negative variation is central to the concept. The Society has run a series of online workshops to explain the changes; hopefully you have had a chance to attend one. Umberto Benedetto the SCTS deputy adult cardiac audit lead has recently left for a new clinical post back home in Italy. We wish Umberto well in his new role, and are pleased that he will be continuing in his role

within the Society, helping to develop the cardiac quality assurance programme. Public Health Scotland had recently announced their intention to take over the responsibility for adult cardiac surgery audit in Scotland, currently held by NICOR. The Society recently held a meeting of its devolved nations audit group to hear the views of members in Scotland on these changes. We have also contacted representatives of the programme and await further details on the structure that is planned. The Society has long experience of national audit in cardiac surgery, and we hope to engage actively with PHS to ensure an audit that effectively safeguards patients while supporting further improvements in heart surgery. In congenital cardiac surgery, SCTS deputy congenital audit lead Serban Stoica has now been appointed as Deputy Chair of the Congenital Domain at NICOR. Serban will be a strong voice within NICOR for congenital cardiac surgeons. NICOR published the latest congenital audit in December 2020. Overall mortality remains historically low at 1.4%, with no negative outlier units identified. Three units were performing better than predicted. A more mixed picture emerges from the recent efforts to publish other non-mortality outcomes, for example reintervention. Reporting of new metrics which affect quality of life is

“NICOR published the latest congenital audit in December 2020. Overall mortality remains historically low at 1.4%, with no negative outlier units identified. Three units were performing better than predicted.”

welcome, but members have raised concerns that the variation found between units is high, and may reflect incomplete definitions of complications, or variable reporting. Work is underway to better define these nonmortality outcomes. In thoracic surgery, the NHS England LCCOP data sheets for the 2018 audit year have now been published. The delay this year has been in part due to the pandemic, and in part due to a delay in the HQIP commissioning process. The eventual HQIP commission this year was to produce last year’s analysis only, and to disseminate only in data table format. Despite this narrow remit, the data and analytics teams have been able to add new metrics on minimal access surgery, and the SCTS has secured funding from Medtronic to produce an online and a paper narrative report this year. 2018 was the busiest year yet for lung cancer surgery, with a 20% increase intersections since 2014. All units were performing within expected survival rates, with no positive or negative outliers. Reassuringly, 2018 also saw the highest survival rates reported so far in LCCOP at both 30 days and a year after surgery, a great testament to thoracic units around the country. There is uncertainty about who will provide the National Lung Cancer Audit and LCCOP in future years. The Royal College of Physicians, who have hosted the NLCA since its inception, have announced that they will not be part of a bid to HQIP to continue this role. The Society is in close contact with the NLCA team and other key stakeholders as we seek to continue the national reporting of outcomes in thoracic surgery. Members should expect the process and outputs of LCCOP or its successor to change from 2021. We will keep members updated as the situation becomes clearer. We can look forward to an eventful but productive year ahead, as we move to a more inclusive and team-based reporting structure for cardiac surgical outcomes across the country. n

the 18 bulletin

Academic and Research Sub-Committee Update Eric Lim, Consultant Thoracic Surgeon Mahmoud Loubani, Consultant Cardiothoracic Surgeon

his year we are very humbled to have been appointed joint leads for the SCTS academic and research sub-committee, taking over the reigns from Professor Gavin Murphy who developed and steered the committee supporting research across cardiothoracic surgery. Amongst his many accolades in this role, Gavin established the James Lind Alliance Partnership Priority Setting Partnership for Cardiac Surgery, leading to the accelerated growth of multiple research streams within cardiac surgery, supported Royal College of Surgeons appointed roles for academic trainees as associate surgical speciality leads to help develop clinical networks for multi-centre surgical studies in both Cardiac and Thoracic Surgery and established the national research meeting. The focus of the academic and research sub-committee for the coming years will be to continue the work that Gavin has established with strong multi-disciplinary representation

across cardiothoracic surgery as a speciality. There is much work to be done in continuing to deliver on the James Lind Priority Partnership in cardiac surgery and to establish similar priority setting partnerships in other specialities such as congenital surgery currently led by Nigel Drury. We aim to integrate cardiothoracic surgery within the national research infrastructure supporting the development of new cardiothoracic surgery trials units recognised by the Royal College of Surgeons and permanent representation on key advisory groups such as the NIHR Clinical Research Network National Speciality Groups. We have also developed academic targets for trainees in general and academic trainees in particular which we submitted to the SAC for consideration. The focus on the committee has always been on the promotion and support of research for consultant, trainees and nursing and AHPs across all the cardiothoracic

sub-specialities. We have also added medical students and are supporting a research mentorship scheme for medical students across the country to increase their involvement in cardiothoracic research. We will be working to generate fellowships for longer term research training and direct drop in-clinics (National Thoracic Research Improvement Initiative – NTRII) for shorter term, more immediate support. This year, we have asked the trainees to take direction in shaping the national research meeting which will take place on Friday 5 November, with a survey of the interests of the trainees. The meeting will be held virtually and include all the key elements highlighted to us in the survey. Judging from the success and expansion, there has never been a better time for research in cardiothoracic surgery, and we will do our utmost to serve the needs and ensure continuing growth in accessibility and impact of cardiothoracic surgical research during our tenure. n

National Thoracic Research Improvement Initiative Academic Division of Thoracic Surgery, Royal Brompton Hospital, London UK

xposure to medical research is essential in the training of surgeons and allied healthcare professionals. Whilst peer-reviewed publications from research is often expected of junior surgeons and allied healthcare professionals in surgery, there is often very little guidance on how to formulate a clinical question, design, conduct and delivery on how to answer the question posed. The National Thoracic Research Improvement Initiative is forum designed to provide high quality research support through the guidance and personal support for thoracic surgeons and allied healthcare

professionals in thoracic surgery who are leading on a research project. The aim is to mentor and educate, ultimately improving the quality of research in thoracic surgery in the UK. Support for individual researchers and projects will be provided through a series of workshops coChaired by Professor Eric Lim (Royal Brompton Hospital, London) and Mr Paulo De Sousa (Royal Brompton Hospital, London). The weekly meetings will be planned by the organising secretary Dr Aina Pons (Royal Brompton Hospital, London) and open to thoracic surgeons (of all grades) and allied healthcare professional in thoracic surgery based in the UK.

Researchers will attend a weekly workshop (currently Mondays 09:00 via Microsoft Teams) and receive personal guidance on their research project through the lifecycle of the research from conception, delivery, write up to submission for publication. Interested researchers, simply write to ntrii@rbht.nhs.uk to register for the programme (at no cost) and we look forward to seeing you on Mondays! n

Professor Eric Lim, Co-Chair of NRTII Mr Paulo De Sousa, Co-Chair of NTRII Dr Aina Pons, Organising Secretary of NTRII

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the 20 bulletin

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

t has been a challenging and exciting year for the Education sub-committee. The last few months have brought in a bit of refreshing positivity with courses getting back on course with Covid restrictions. We welcome new faces to the team and bid farewell to some. We have an ambitious Consultant Leadership Academy which was launched in the AGM. The SCTS National simulation rollout has commenced. It is only the first half of the year and we have awarded two rounds of Ionescu fellowships and the annual Ethicon fellowships. Letty Mitchell who has served as the Education and Fellowship administrator has gone to pastures new. Letty has been an integral part of the team and we wish her well in her new ventures.

Committee Members

We welcome new members to the sub-committee Vivek Srivastava as Communications lead, Kandadai Rammohan as Trust Appointed Doctors Thoracic lead and Espeed Khoshbin as Transplant lead to the Education committee. The committee has strived hard to continue to provide quality education amidst the challenges of the pandemic. This has resulted in hybrid events with a few virtual events as well as face-to-face events.

Ionescu Collaborations

We were fortunate to award two rounds of fellowships and published the book on 50 years of Pericardial Valve edited by Mr Kirmani, which celebrates one of the greatest inventions of British cardiac surgical history. A pericardial valve medal has been created and the first recipient is Prof Sunil Ohri. There will be a final round of fellowships this year from Mr Ionescu. The meetings team produced a great Ionescu Virtual University, which was hosted from a hub in the Royal College of Surgeons of Edinburgh.

We thank Mr Ionescu for his phenomenal generosity over the last decade supporting the Ionescu University, the great number of fellowships, the perspective in cardiothoracic surgery book series and educational courses. Words simply cannot express our gratitude to his immense generosity and the impact of this will reverberate in the years to come as the skills gained will improve British cardiothoracic surgery and patient outcomes.

Masterclass on mental training for surgeons We had another virtual masterclass focusing on mindfulness and mental training for surgeons. Given the spread of expertise of the speakers and the fact that it is generic, we chose to run this with the Royal College of Surgeons of Edinburgh and opened it up to the wider audience. We had excellent national and international speakers offering insight into the value of human factors, the role of decisionmaking challenges, and mental training for surgeons, team working and building a team. A recording of the masterclass is available via the SCTS website (SCTS.org).

SCTS Education Courses in 2021 Date

Course

Venue

6th – 8th September

ST4B Core Thoracic Surgery course

Ashorne Hill, Leamington Spa

17th September

Trainee Appointed Doctors Professional Development

Virtual course

13th – 17th September

ST7A Revision & Viva course for FRCS CTh

Virtual course

22nd September

SCTS NAHP Research Webinar

Virtual course

23rd – 24th September

ST6A & ST6B Cardiothoracic Subspecialty course ̶ live operating

J&J Institute, Hamburg

27th – 28th September

ST2 Essential Skills in Cardiothoracic Surgery

Nottingham City Hospital

5th – 8th October

ST3B Operative Cardiothoracic Surgery course

J&J Institute, Hamburg

22nd – 24th November

ST4A Core Cardiac Surgery course

Ashorne Hill, Leamington Spa

1st – 2nd December

Trainee Appointed Doctors Wet Lab

Ashorne Hill, Leamington Spa

6th – 7th December

ST8B Professional Development course

Virtual course

14th – 17th December

ST8A Cardiothoracic Pre-consultant course

J&J Institute, Hamburg

August 2021

Thomas Tsitsias – ST8 St. George’s Hospital, London has been accepted at Toronto General Hospital in the Department of General Thoracic Surgery and started his fellowship in January 2021 for 12 months. Thomas will be working and regularly operating next to the attending surgeon who routinely performs major pulmonary resections (incl. bronchoplastic sleeve), resection of mediastinal tumours, chest wall reconstruction and tracheal resection.

TAD Education

SCTS Ismailia Masterclass

SCTS Education helped to run the 25th Anniversary meeting of the Egyptian Society for Cardiac and Thoracic Surgery along with the 1st Ismailia Masterclass. The plan then was to run a regular SCTS Masterclass in Ismailia annually. Unfortunately, with the pandemic this was not possible last year. We held a very successful virtual masterclass covering all aspects of cardiac and thoracic surgery with a large number of attendees, not only Egypt but as well as North Africa and United Kingdom. We plan to have a hybrid event post pandemic to keep the collaboration going.

upcoming offering from the consultant leads is The Virtuous Surgeon, which again will be a virtual event focusing on the ethics, morality and virtues of being a good surgeon.

NTN Education

The Tutors, Debbie Harrington and George Asimakopoulos, have worked relentlessly to get the programme running as detailed in their report. We are delighted and grateful that new industry partners are joining us in this journey to ensure sustainability.

Ethicon Fellowships

We were fortunate to run another annual round of Ethicon fellowships at the beginning of the year and we are pleased to announce the Ethicon 2021 Fellowship winners and their placements:

Consultant Education

SCTS Consultant Leadership Academy is a new venture of the SCTS, which will be offered free to members. This will focus on generic aspects of management and leadership. Professor Punjabi and Mr Shahzad Raja, the consultant education leads, have created this exciting programme together which will consist of four separate sessions, delivered virtually over the next year. Another

Stuart Grant – ST8/Academic Clinical Lecturer, Wythenshawe Hospital has been accepted at Toronto General Hospital and will start his fellowship in January 2022 for 12 months. The focus of Stuart’s fellowship will be advanced aortic surgery, structural cardiac surgery and transcatheter techniques. James Barr – ST8, Guy’s Hospital, London has been accepted at Toronto General Hospital specialising in Lung transplantation and thoracic surgery and will start his fellowship in October 2021 for 12 months. James will spend six months working in the department of thoracic surgery and the remaining six months of his fellowship in lung transplantation.

The trust doctors have benefited from the opportunity to join the NTNs in the professional development course and examination viva courses. The main courses aimed at Trust Doctors will be rolled out soon for this year after the easing of restrictions. We are aiming to have a virtual Professional development course on the 17th September and the residential Cardiothoracic update course on the 1-2nd December. In addition, senior Trust appointed doctors will be invited to apply and partake in the ST7A Exam viva course and ST8B Professionalism and Leadership Course. The new offerings will also include a cadaveric course and a virtual course on CESR in the New Year.

AHP Education

The webinars offered by the AHP team have been excellent with great feedback. The thoracic virtual study day was hosted by the Glenfield Thoracic Unit. The cardiac study day was scheduled for June.

Medical Student Education

The medical student leads have formed a medical student committee and are planning to host this year’s medical student engagement as a virtual event.

Simulation Rollout

The national simulation rollout in partnership with Ethicon has commenced with the first event in East Midlands. The trainees were able to focus on coronary anastomosis, mitral repair, aortic valve replacement and root repair in cardiac surgery as well as basic and anatomical lung resections in thoracic surgery. SCTS Education continues on its journey from strength to strength. We thank all our leads, course directors, faculty members, industry partners and the executive committee for all their support in making this happen. We hope to catch up soon in person in a day not so far away. Stay safe. n

the 22 bulletin

SCTS Education Tutors’ Report Debbie Harrington, SCTS Thoracic Tutor George Asimakopoulos, SCTS Cardiac Tutor

e are pleased to report that since the last Bulletin we have continued with the restart to the Education Portfolio, although it was a somewhat chequered start in the New Year. We had already taken the decision to conduct as many aspects of our courses as possible, via a virtual platform, in order to minimise potential disruption due to the pandemic and to enable inclusion of as many delegates and faculty as possible. The ST4A Core Cardiac course was the first course to go virtual in November 2020, and a huge thank you to the Course Directors and Faculty for facilitating this at short notice. The Wet lab aspects were initially postponed but thankfully have now been completed as the first face-to-face course to be conducted when Ashorne Hill reopened in April 2021. Thanks in particular to Gianluca Lucchese and Attilio Lotto for their commitment and perseverance to enable the course to be delivered. The ST8B Professional Development course on 7th - 8th December was run via an entirely virtual format for the first time. This enabled us to open up the course to a number of eligible Trust Appointed Doctors in addition to the NTN cohort, a decision which was very well received. Unfortunately, due to the emergence of the second wave of the COVID pandemic, the ST5A Intermediate viva course was postponed but took place virtually on 14th -15th June. The ST6A & B course ran two virtual days for the theory aspects of both cardiac and thoracic components in February. This was followed by the ST7A Revision

& Viva course at the beginning of March which we were also able to open up to some Trust Appointed Doctors due to sit the intercollegiate FRCS CTh exam in the spring. Due to the popularity of this course we have scheduled a further ST7A course in September for those candidates sitting the autumn diet of the exam. The ST8A Pre-Consultant course was also run virtually for the theory aspects of the cardiac component in March. As we go to press, we are still hoping to be able to run the live operating aspects of

operating courses in Hamburg, when they do resume, will only be offered to those trainees who have already participated in the virtual theory elements of the relevant course. Once again, we would like to thank all Faculty and Course Directors who have taken time out of their already busy schedules, to continue to provide high quality teaching to our trainees. On behalf of SCTS Education it is much appreciated. Many thanks also to those who have volunteered to become new Faculty members, we will be in touch with you soon. We would like to express our enormous thanks to Emma Ferris and Letty Mitchell in the SCTS administration team who have continued to work tirelessly throughout the pandemic and we wish Letty very best wishes as she moves on to pastures new. We are indebted to Emma who has played a pivotal role in setting up & administering the virtual courses, enabling them to continue despite the many and varied technical issues. Going forward, Emma will continue to administer the majority of the SCTS Education courses via the new booking system on the SCTS website. Please can we remind all trainees to ensure your membership and contact details are up to date on the SCTS website in order to book onto the relevant course for your training level. Although you will be reminded to book through the new system, you will not need to wait to be invited as we have done previously. Please do contact Emma on emma@scts.org if you need to confirm your eligibility on our NTN courses. Finally, we wish everyone a safe and happy summer and look forward to seeing many of you again soon. n

“As we go to press, we are still hoping to be able to run the live operating aspects of the postponed ST3B, ST6A & B, and ST8A courses at the Johnson & Johnson Institute in Hamburg in the autumn.” the postponed ST3B, ST6A & B, and ST8A courses at the Johnson & Johnson Institute in Hamburg in the autumn although clearly these will be subject to both UK and German government restrictions nearer the time. We will be in touch with all those involved in due course. We have updated the provisional course schedule for the remainder of this year, and plan to continue using a combination of virtual platforms and face to face courses for the time being. We would like to continue to ask both trainees and faculty to please send us your feedback as we continue to evolve the portfolio going forward. We would like to remind trainees that they are expected to take study leave for the entire duration of virtual courses and that attendance and participation in all sessions is expected. Participation at live

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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,§.

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 The LigaSure™ Maryland Jaw Thoracic Device

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

medtronic.com/covidien/uk

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.

the 24 bulletin

Ionescu Annual Fellowships 2021 Sri Rathinam, SCTS Education Secretary Carol Tan, SCTS Education Secretary

he Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) invited applications for the Annual Fellowships for 2021 sponsored by Mr Marian Ionescu. The broad range of the fellowships was aimed to benefit all members of the SCTS: Consultants, Surgeons in training, Nurses, Allied Health Professionals and Medical Students. Mr Ionescu has supported the SCTS with his donations to the society for educational activities for many years. His contributions

Mr Ionescu has supported the SCTS with his donations to the society for educational activities for many years

over the years have enabled the Ionescu University, Ionescu Fellowships and the Perspectives in Cardiothoracic Surgery and recently the Ionescu legacy courses. The applications were advertised on the SCTS website as well as by flyers to all our members. The deadline was the 15th January 2021. 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 recommendations were finalised by unanimous decision by the scoring teams for various streams and were submitted to the President and Mr Ionescu and were approved. We can confirm that all applications were duly considered and recommended after section leads and relevant teams due to the spread of experience and variation in the specialty. SCTS Education thanks Mr Ionescu for his generosity with these two rounds of fellowships in 2021, which has enabled us to offer all these awards to our membership for the wider benefit of our patients.

Awardees SCTS–Ionescu Fellowships 2021 The Marian and Christina Ionescu Travelling Fellowship for a Team Mr Bilal H Kirmani, Consultant Cardiac

Surgeon, Liverpool Heart and Chest Hospital to visit the Ottawa Heart Institute to learn techniques in minimally invasive cardiac surgery under Dr Marc Ruel. Ionescu Consultant Team Fellowships: 4 awards, £15,000 each Mr Attilio Lotto, Consultant Congenital

Cardiac Surgeon Alder Children’s–NHS Foundation Hospital for sick children, Toronto, Canada for an immersion in Congenital cardiac surgical techniques and education and simulation based on 3D printing under Prof David Barron. Mr Manoj Purohit, Consultant CT Surgeon

Blackpool Victoria Hospital to visit the Shanghai Chest Hospital to gain experience in Advanced VATS mediastinal surgery under Dr Vincent Fang. Mr Dincer Aktuerk, Consultant Cardiac

Surgeon, St Bartholomew’s Hospital, London to visit Robert Bosch Hospital, Stuttgart, Germany. The fellowship team aims to learn and enhance understanding of minimally invasive cardiac surgery under Prof. Ulrich Franke. Mr Ioannis Dimarakis, Consultant

Cardiothoracic Transplant Wythenshawe Hospital Manchester for a fellowship visit to Hospital Herzzentrum Leipzig to gain more insight into mechanical cardiovascular support and total artificial heart programme under Prof. Diyar Saeed.

August 2021

Ionescu NTN Trainee Travelling Fellowship: 2 awards, £10,000 each

Ionescu Trust Appointed Doctors Surgical Fellowships: 2 awards, £10,000 each

Mr Yama Haqzad, Specialty Trainee

Mr Syed Faisal Hashmi, Senior Thoracic

in the Yorkshire and The Humber Deanery to visit the Michael E Debakey Department of Cardiac Surgery, Baylor College of Medicine, Texas Dr Joseph S.Coselli to focus on aorto-vascular surgery and aortic surgery.

Fellow, Wythenshawe Hospital, Manchester for a fellowship in robotic thoracic surgery and advanced VATS in the St Bartholomew Hospital under Mr Stamenkovic and Mr Lau.

Mr Tom Combellack, Specialty Trainee

in the Welsh Deanery to visit Barts Thorax Centre, London to train under Mr Sasha Stamenkovic in Robotic thoracic surgery and a fellowship in Shanghai Pulmonary Hospital under Dr Diego Gonzales Rivas focusing on Uni-portal VATS. Ionescu NTN early years (ST1-4) travel award: 1 award, £5,000 Mr Amer Harky, Specialty trainee,

Liverpool Heart and Chest Hospital to visit the Hospital Cardiac Surgery Department, Instituto Cardiocentro Ticino, Lugano–Switzerland. The fellowship will focus on minimally invasive cardiac surgery under the Supervision of Prof. D S. Demertzis.

Clinic Arizona for a fellowship in thoracic surgery under Dr Dawn E. Jaroszewski. Ionescu Nursing & Allied Health Professional Fellowships: 4 awards, £5,000 each

None awarded as no suitable applicants.

Mr Mohamed Ahmed Osman, Senior clinical

Ionescu Medical Student Fellowships: 4 awards, £500 each

fellow in cardiothoracic transplant at Royal Papworth Hospital for a fellowship in advance cardiothoracic transplantation in Toronto General Hospital under Prof Shaf Keshavjee.

Anoop Singh Sumal, Cambridge University

to visit the James Cook Hospital, for a clinical immersion in cardiac surgery with Mr. Simon Kendall.

Ionescu SAS UK small travel grants: 4 awards, £2,500 each

Caleb Johnson, University of Warwick,

None awarded as no suitable applicants. Ionescu small travel awards for FYs and CTs: 2 awards, £5,000 each

Coventry, on a fellowship for exposure in paediatric cardiac surgery in the Hospital for sick children, Toronto, Canada under the supervision of Prof David Barron.

Jordan Green, Academic Foundation

Jeevan Francis, University of Edinburgh to

Programme, Hull University Teaching Hospitals to visit the Royal Papworth Hospital, Cambridge for clinical immersion in Thoracic surgery under Mr Aman Coonar.

Rishab Makam, Hull and York Medical school

Omar Zibdeh, Foundation trainee, Charing

Cross/Hammersmith Hospital, to visit Mayo

visit Golden Jubilee National Hospital, for an immersion in Thoracic surgery under Mr Alan Kirk.

to visit Leeds Teaching Hospital under Ms Carin Van Doorn for an immersion in paediatric cardiac surgery. n

Ionescu Fellowships 2021: Celebrating the 50 years of the Pericardial valve The Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) invited applications for the Special Fellowships to Celebrate 50 years of the Pericardial Valve 2021, solely sponsored by Mr Marian Ionescu. The broad range of the Fellowships were aimed to benefit all members of the SCTS: Consultants, Surgeons in training, Nurses, Allied Health Professionals and Medical Students. The applications were advertised on the SCTS website as well as by flyers to all our members. The deadline was 15th April 2021. 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 recommendations were finalised by unanimous decision by the scoring teams for various streams and were submitted and approved by the President and Mr Ionescu. Ionescu Travelling Fellowship for a consultant: 1 award, £10,000 Mr Vipin Mehta, Consultant Cardiac and

Transplant Surgeon, in the Wythenshawe Hospital, Manchester University NHS Foundation Trust, to visit Toronto General Hospital to focus on Cardiothoracic Transplantation under Prof Shaf Keshavjee. The fellowship will focus on EVLP (Ex Vivo Lung Perfusion) technique in Lung transplantation. >>

the 26 bulletin

Ionescu small travel awards for FYs and CTs: 2 awards, £5,000 each Dr Jason Trevis, Academic Foundation

Trainee in James Cook University Hospital, Middlesbrough to visit Royal Papworth Hospital for an all-round clinical immersion in cardiothoracic surgery under the supervision of Mr Aman Coonar. Ms Rachel Chubsey, CT2 in Vascular

Surgery, University Hospitals of Leicester to visit Prof Donna Eaton, in the Mater Misericordiae University Hospital, Dublin to learn advance thoracic surgery including Robotic Thoracic Surgery.

Ionescu Consultant Team Fellowships: 2 awards, £15,000 each Ms Carin Van Doorn, Consultant Congenital

Cardiac Surgeon Leeds teaching hospital, to visit the Toronto Hospital for sick children, Toronto, Canada for an immersion in congenital cardiac surgical techniques and education and simulation based on 3D printing under Prof David Barron. Mr Hazem Fallouh, Consultant Thoracic

Surgeon University Hospitals in Birmingham to visit Toronto General Hospital to focus on Cardiothoracic Transplantation under Prof Shaf Keshavjee. The fellowship will focus on Lung transplantation with a supplementary trip to Vienna to visit Prof Walter Klepetko’s unit. Ionescu NTN Trainee Travelling Fellowship: 4 awards, £10,000 each Mr Damian Balmforth, London NTN

Hospital Nantes, France to train under Dr Thomas Sénage to gain further exposure into cardiac surgery as well as focusing on aortic surgery and TAVI. Mr Umar Hamid, Northern Irish NTN,

Royal Victoria Hospital, Belfast to visit the Maastricht University Hospital, Netherlands to gain exposure to minimally invasive mitral programme under Prof Peyman Sardaria Nia. Ionescu NTN early years (ST1-4) travel award: 1 award, £5,000 Mr Mayooran Nithiyandan, East Midlands

NTN, Specialist Registrar in Cardiac Surgery in Nottingham University Hospitals to visit Dr Marc Gillinov at Cleveland Clinic to gain exposure to advanced cardiac surgery with a focus on minimally invasive and robotic cardiac surgery.

Cardiothoracic Registrar in St Bartholomew Hospitals, London to visit Dr Malakh Shrestha, Hannover Medical School and Professor Michael Borger at the Leipzig Heart Centre to develop a specialist interest in aortovascular surgery. The fellowship will also include a visit to the Professor Anthony Estreraat Memorial Hermann Hospital in Houston Texas.

Ionescu Hospital Appointed Doctors Fellowships: 2 awards, £10,000 each

Mr Oliver Harrison, Wessex NTN, Registrar

Research fellow in Academic department of Cardiac Surgery, University Hospitals of Leicester to visit the Aortic Institute, Yale New Haven, Connecticut, USA to observe Aortic Surgery under Prof John Elefteriades.

in Thoracic Surgery, University Hospital Southampton to undergo a fellowship in the Guy’s Hospital to train under Mr Tom Routledge in Robotic Thoracic Surgery. Mr Nikhil Patil, West Midlands NTN Trainee

in Cardiothoracic Surgery, Royal Stoke University Hospital to visit University

Mr Adnan Raza, Senior Clinical Fellow,

Department of Thoracic Surgery, Nottingham University Hospital to visit the Lenox Hill Hospital, New York, United States to learn Robotic surgery under Richard Lazzaro. Dr Riccardo Giuseppe Abbasciano, Clinical

Ionescu Hospital Appointed Doctors small travel grants: 2 awards, £5000 each

None awarded as no applicants.

Ionescu Nursing & Allied Health Professional Fellowships: 6 awards, £5,000 each Mr Janesh Nair, Senior Cardiothoracic SCP

in the Wythenshawe Hospital, Manchester University NHS Foundation Trust to Seoul National University Hospital, to learn non touch vein harvesting technique under Prof Ki-Bong Kim. Ms Sophie Wang, Senior Scrub Nurse in

Harefield Hospital London to visit the Shanghai Chest Hospital Shanghai under the supervision of Professor Wentao Fang. The fellowship will focus on advanced thoracic nurses as well as to create mutual nursing education. Ionescu Medical Student Fellowships: 4 awards, £500 each Josh Brown, Queen’s University Belfast to

visit the Cardiac surgical department in Royal Sussex Hospital in Brighton to gain exposure to cardiac surgery under Mr Mike Lewis. Bertram Harrington, Newcastle University

to visit the James Cook University Hospital Middlesbrough to gain experience in cardiac surgery under Mr Simon Kendall. Clarissa Ng, Kings College London to visit

the Harefield Hospital and Brompton Hospitals to gain further exposure to cardiothoracic surgery under Mr S Raja, Dr Nandor Marczin and Mr Habib Khan, and to attend the EACTS annual conference. Momna Raja, Brighton and Sussex Medical

school to visit Faisalabad Institute of Cardiology under Dr Shahbaz Ahmed Khilji to gain insight into cardiology and cardiothoracic surgery. n

Quantra delivers ‘sniper attack’ to deal with critical bleeding “Without viscoelastic testing, I would have treated this patient with shotgun therapy…now I use the Quantra for sniper attacks on hypocoagulability”, cardiac surgeon Dr Pierre R. Tibi on open heart surgery protocols at Yavapai Regional Medical Centre, Arizona, US

Acute perioperative situations demand fast action on whether to transfuse critically bleeding patients. Patient blood management must therefore be a multidisciplinary effort aimed at improving patient outcomes.

With a fully enclosed cartridge, Quantra needs no manual pipetting In less than 15 minutes, the Quantra® haemostasis analyser and QPlus ®cartridge provide critical information about clotting time and the quality of any formed clot. You can read the results the moment they appear on the screen, without needing to decipher complex curves. Data can also be shared remotely with the blood bank, clinical colleagues or laboratory. Quantra is the ﬁrst viscoelastic testing device to provide direct quantiﬁcation of the Platelet Contribution to Clot Stiffness (PCS), measuring clot elasticity, rather than amplitude. This accounts for both platelet count and platelets’ ability to aggregate, contract, and contribute to clot strengthening. The Quantra can measure the evolving clot stiffness without any manipulation or disruption to the clot.

Comprehensive diagnostic panel

Pioneering use of ultrasound

There are six parameters on Quantra’s comprehensive diagnostic panel - clot times with and without heparinase (CT and CTH), clot stiffness (CS) and ﬁbrinogen contribution to clot stiffness (FCS). Two unique parameters are then automatically calculated: clot time ratio (CTR), and platelet contribution to clot stiffness (PCS). Unlike some other systems, clot stiffness parameters can be used while patients are on bypass.

For the ﬁrst time in viscoelastic testing, Quantra uses ultrasound technology to measure the dynamic changes as a clot forms. Unlike classic systems, the cartridge is fully enclosed, with no need for pipetting. This minimises the risk of blood exposure.

Clinical studies indicate high precision, generally strong correlation with standard laboratory assays, good concordance with the clinical presentation and high negative predictive value for thrombocytopenia. A recent study identiﬁed potential cut-off values for the FCS and PCS parameters for use in place of, or alongside, lab-based ﬁbrinogen and platelet thresholds to guide transfusion decisions.

Also, there are no moving parts to come into contact with the blood and potentially disrupt clot formation, increasing sensitivity to early clot formation and to the soft clots often linked to bleeding. Data from Quantra can be integrated into a treatment protocol for the management of perioperative bleeding, as recommended by the International Society on Thrombosis and Haemostasis (ISTH) among others.

Diagnostica Stago is a global leader in haemostasis and thrombosis, with Stago UK now providing around 20% of NHS haemostasis instruments or specialist haemostasis kits. The company expanded into point-of-care when it acquired Quantra as part of US company, HemoSonics.

Easy-to-interpret, intuitive dials display

For more information, visit www.quantrapocsolution.com or email pocsolutions@uk.stago.com for a video demonstration or to request an on-site visit.

Diagnostica Stago UK Ltd, 2 Theale Lakes Business Park, Moulden Way Sulhamstead, Reading RG7 4GB. Phone: 0845 054 0614

References on request

the 28 bulletin

SCTS Forum Nursing and Allied Professional Research Update Professor Julie Sanders, Director Clinical Research, St Bartholomew’s Hospital, SCTS Nursing and Allied Professional Academic and Research Lead

The Inaugural SCTS Forum Research University Day We were delighted to host our first nursing and allied professional research university day at the 2021 annual meeting. Sessions were delivered on the Cardiothoracic Interdisciplinary Research Network, NIHR Associate PI scheme, implementing guidelines in practice, writing conference abstracts and for publication, and several attendees took advantage of the speed mentoring sessions. We welcomed an international faculty with presentations from Prof Ben O’Brien (Universitatsmedizin Berlin), Prof Suzanne Fredericks (Ryerson University, Canada) and Prof Tiny Jaarsma (Linkoping University, Sweden) as well as from our esteemed colleagues in the UK (Mr Ricky Vaja, Ms Helen Munday, Mr Sean Griffith, Dr Martina Buerge and Dr Dylan Wills). Overall, the day was a huge success, with excellent feedback. I would like to thank the SCTS Forum Research Sub-committee, particularly Rosalie Magboo who led the organisation, for such a fantastic event.

New Webpage for Nursing and Allied Professional Research Part of our vision is to provide members with an expanding online research resource. As part of the new SCTS website, Zoe Barrett-Brown (lead for SCTS Forum communication and membership/ nursing and allied professional research sub-committee member) has given the research page a fantastic overhaul! There is still work to do, and the pages will be updated monthly, but please do visit the

pages at: https://scts.org/professionals/ surgical_sub_specialities/ct_forum/ research_audit.aspx. As a member if there is any additional information or useful resources you would like to see on the webpages please get in contact.

British Journal of Nursing Cardiovascular Nurse of the Year: Rosalie Magboo In March, SCTS Forum Research Subcommittee member Rosalie Magboo, Senior Sister in Critical Care at St Bartholomew’s Hospital, was awarded the prestigious British Journal of Nursing Cardiovascular Nurse of the Year accolade for her clinical and research work in cardiac surgery. We are very proud of Rosalie’s achievements and wish her every success for her PhD. For information can be found at: https://www.bartshealth. nhs.uk/news/rosalie-magboo-crownedcardiovascular-nurse-of-the-year-10239

Upcoming events • SCTS Nursing and Allied Professional Clinical Academic Career Webinar: September 22nd 2021, 19:00-20.30. Details will be available soon and emailed to SCTS Forum and NARG members. • The SCTS National Cardiothoracic Research Meeting: The abstract deadline is September 6th and the meeting will be held virtually on Friday November 5th. • SCTS Nursing and Allied Professional Evidence in Practice Webinar: This is planned for February 2022.

Research round-up As mentioned in the last Bulletin, Tracey Bowden and Ashley Thomas are leading the initiative to highlight and provide a brief bite-size summary of useful research findings that have implications for nursing and allied professional cardiothoracic practice. These will be delivered through a variety of formats

August 2021

(Bulletin, website, podcasts etc) and will also aim to highlight the role of the nurse or allied professional in the research, where possible. Research round-up: Delivering healthcare remotely to cardiovascular patients during COVID-19 (Paper can be accessed at: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC7717235/) In a world drastically changed by the COVID-19 pandemic, nurses and allied professionals have had to learn to adapt to an everchanging situation, whilst providing the same standard of care we value. The impact on patients, the community, and health care services, has been strained due to prolonged isolation. Prolonged isolation can adversely affect mental health, physical health, and quality of life. Professor Neubeck and colleagues performed a rapid review to collate the evidence for remote health care during a quarantine situation, to support people living with cardiovascular disease during COVID-19 isolation. Rapid reviews have emerged as an efficient method to

synthesise knowledge in a shorter timeframe, enabling policy makers and stake holders to utilise available evidence and make informed decisions. In this rapid review, nine articles, all of which were considered expert opinion papers were identified. Three overarching themes were highlighted: • Preparing the workforce and ensuring reimbursement for remote health care. Not only do staff require sufficient skills and knowledge to deliver remote healthcare, they also require appropriate equipment and technology. Furthermore, these remote services should be considered essential practice and therefore receive appropriate funding. • Supporting physical and mental health. Mental health has been a prominent theme in the news throughout the pandemic. Supporting mental and physical health has always been an essential element of cardiac rehabilitation. Redeployment of NHS staff, patients isolating, and social distancing, has had an impact on cardiac

rehabilitation services. The authors advocate transitioning existing services to online programmes to ensure patients continue to benefit from this activity. • Supporting usual care. Inevitably, COVID-19 has led to a rapid increase in the use of digital technologies. This has been instrumental in ensuring that cardiovascular patients have access to their usual care such as, medications, health care services, healthy food, and other essential supplies. This review highlighted how remote health care and telehealth can be implemented to mitigate the impact of COVID-19. During the pandemic urgent and emergency surgery continued and there was an increase in remote consultations, follow-up and cardiac rehabilitation. Nurses and allied professionals have therefore had to overcome a number of barriers and adopt new strategies, techniques and skills that continue to deliver a high standard of care to this particularly vulnerable patient group. About the author Professor Neubeck is a cardiac nurse with over 25 years of experience in a range of cardiac in-patient and out-patient settings. She lived in Australia for 11 years undertaking her PhD and then subsequently a Post-Doctoral Fellowship. She is currently a Professor of Cardiovascular Health in the School of Health and Social Care at Edinburgh Napier University and President of the Association of Cardiovascular Nursing and Allied Professionals of the European Society of Cardiology. Professor Neubeck has also recently taken up the role of National Health Service Research Scotland Cardiovascular Clinical Network Lead. Her own research focuses on innovative solutions to secondary prevention of cardiovascular disease, identification and management of atrial fibrillation, and use of digital health to improve access to health care.

The SCTS Forum research website: https://scts.org/professionals/surgical_ sub_specialities/ct_forum/research_ audit.aspx For any further information on above, or to join the SCTS CIRN, please contact Julie Sanders, SCTS Forum Academic and Research Lead at j.sanders@qmul.ac.uk n

the 30 bulletin

Trainer Awards in Cardiothoracic Surgery 2021 Duncan Steele, ST6 Cardiothoracic Surgeon & Senior Cardiothoracic Trainee Representative Abdul Badran, SCTS trainee representative, Specialist Registrar Cardiothoracic Surgery

rainers are teachers and many even considered mentors. The success in conveying knowledge or skill largely depends on a great working relationship between trainer and trainee. With the combined effort producing exceptional examples of training with some excellent and competent trainees making it out at the end of the UK cardiothoracic training programme. As people we are the sum of our experiences and this mantra still holds for us as surgeons. Our experiences as trainees are moulded by the trainers and supervisors we work with as well as the role models set by our senior colleagues, which directly shapes our clinical and surgical approach. The misplaced nostalgia that ‘everything used to be better’ completely ignores the improved patient outcomes we’ve seen in the last 20 years. Rather than letting trainees sink or swim, we’ve correctly moved to far closer supervision with trainees being given a graded surgical experience as they grow into fully competent surgeons. Great patient care remains the number one priority for all doctors and with the stakes being high in cardiac and thoracic procedures it is even more pertinent to be mindful of patient factors, environment as well as insight into competence. The result of this transition has

however meant a more directed approach with increased pressure and administration. The best trainers go above and beyond to help mentor, develop and shape trainees into better surgeons and people. Although many cite the successes of those they teach and train as reward in itself, they rarely get the recognition they deserve. The role models our trainers set us, were themselves influenced by their own training and this positive cycle needs to be reinforced at every possible opportunity. This in addition to identifying what the best training even looks like was the drive in creating these awards. Nominations come from trainees across the country. The nominees are then invited to put forward colleagues for interview. These colleagues are asked about leadership, resourcefulness, development, professionalism and communication in a paired structured interview. The different perspectives are used to build a comprehensive picture of what makes each trainers approach so highly valued. Although it’s clear that each and every nominee deserves the award in their own way, we then vote on the summary of each nominees interviews. To avoid bias we anonymise the summaries and vote as a trainee council, joined this year with our President of the SCTS, Simon Kendall. The three awards are Golden Heart awards for exceptional training in cardiac

“The best trainers go above and beyond to help mentor, develop and shape trainees into better surgeons and people. Although many cite the successes of those they teach and train as reward in itself, they rarely get the recognition they deserve.”

surgery by a consultant surgeon, Golden Lungs award for exceptional training in thoracic surgery by a consultant surgeon and Silver Sternum award for exceptional training of peers by a cardiothoracic surgeon in training. Through this process we’ve heard about some truly fantastic examples of training in our specialty despite the Covid-19 elephant. We’ve heard about great mentors helping support trainees who’ve found this time especially difficult. We’ve heard how the exceptional team working skills and leadership skills in some departments meant the wider team never questions if a list occasionally runs over to facilitate training. Finally, we’ve learned how the ethos of continued development of the wider team is infectious, building not only a more resilient workforce but one whose professional standards are elevated like nothing else can. We hope these awards help make these examples of positive training even more contagious. The Inaugural 2021 Winners are:

Golden Heart Trainer Award 2021 Winner – Kamran Baig from Guys and St Thomas’ (Runner Up – Mahmoud Loubani from Castle Hill)

Golden Lungs Trainer Award 2021 Winner – Aiman Alzetani from University Hospital Southampton (Runner Up – Apostolos Nakas from Glenfield General Hospital)

Silver Sternum Trainer Award 2021 Winner – Ahmed Al Adhami from Glasgow Jubilee (Runner Up – Yassir Iqbal from Birmingham Childrens Hospital) Again we congratulate all 28 nominations from the 16 different centres who participated and also demonstrated outstanding examples of training and support, we hope to hear further about this great work in the coming years award process. n

the 32 bulletin

SCTS Annual Meeting 2021:

Student Engagement Day Report Javeria Tariq, Leeds Medical Student Ms Karen Booth, Consultant Cardiac Transplant Surgeon Professor Farah Bhatti OBE, Consultant Cardiac Surgeon

he year 2021 saw SCTS host its first virtual AGM and on Sunday 9th May the student engagement day took place. Although the transition to a virtual setting was unfamiliar, it enabled growth in the number of attendees with representation from countries across the world from Italy all the way to India. The day featured pioneering and exciting new sessions that will hopefully become annual staples of this event. Highlights included the inaugural SCTS University Challenge and the introduction of the new Student Education Committee. Overall, the day was well received with over 100 attendees, with excellent feedback on the delivery and content of the sessions. The morning commenced with congenital cardiac surgeon Mr Joseph George delivering a fantastic session exploring cardiothoracic anatomy through the description of key anatomical landmarks. Following this session, Miss Charlotte Holmes returned with her

popular talk informing students of what is required to gain ST1 entry in cardiothoracic surgery, as well as describing her personal journey. The morning concluded with the inaugural SCTS University Challenge where the Universities of Manchester and Leeds were quizzed by SCTS President Mr Simon Kendall. Thirty questions and some very tense exchanges later one team was victorious. The scores were close, but the University of Leeds came top and won the £300 cash prize. In the afternoon, an expert panel of inspiring surgeons – Ms Betsy Evans, Miss Deborah Harrington, Miss Gillian Hardman, and Ms Melanie Jenkins – fielded questions on a career in cardiothoracic surgery during a live Q & A session. Next, SCTS President Mr Simon Kendall returned to deliver a talk about the future of cardiothoracic surgery, where he candidly discussed the highs of the job contrasted with the challenges we can anticipate in the future. After this, patient

Michelle McCaffrey explained how cardiac surgery changed her life, demonstrating a heartfelt example of the countless lives touched by the specialty. Following a short break, oral presentations began for the prestigious Pat Magee medal, allowing chosen students to exhibit their quality research projects. The 2021 student engagement day succeeded in educating and inspiring the next generation of cardiothoracic surgeons by providing a flavour of what the specialty has to offer. Students benefitted from an engaging day filled with informative sessions led by inspiring surgeons and we hope attendees left motivated to pursue a career in cardiothoracic surgery. We are grateful to all speakers who contributed to the day and would like to extend a special thanks to Professor Bhatti OBE and Ms Booth, SCTS Student Education Co-chairs who must be credited for the day, along with the help they received from the SCTS Student Education Committee. n

New SCTS Student Education Committee Announcement

rof F Bhatti and Ms K Booth, Student Education Co–Leads were delighted recently to announce to the membership, the new working group for Student Education. The committee have already delivered a very successful Pat Magee University Day at our recent SCTS meeting. The committee is made up of: SCTS Student Education Lead – Amerikos Aryriou, Manchester University

SCTS Student Committee Treasurer – Rishab Makam, Hull York Medical School SCTS Student Committee Widening Access Officer – Javeria Tariq, Leeds School of Medicine SCTS Student Committee Regional Events Officer – Amelia Websdale, University of Leeds

SCTS Student National Events Officer – Bertie Harrington, Newcastle University

SCTS Student Committee Mentorship Officer – Kirstie Kirkley, University of Bristol Medical School

SCTS Student Research Collaborative Officer – Maria Solange de Paiva Moura, Universidade Potiguar, Brazil

SCTS Student Committee Communications Officer – Josh Brown, Queen’s University Belfast

SCTS Student Committee Equality and Diversity Officer – Alexander Reynolds, Swansea University Medical School SCTS Student Committee Medical School Liaison Officer – Chaninda (Holly) Dejsupa, University of Bristol In the coming months we hope to announce plans for widening access to Cardiothoracic Surgery through sixth form school iniatives and student mentorship. FB SCTS Students @SCTSINSINC n

August 2021

Women in Cardiothoracic Surgery The SCTS is delighted to announce membership of its inaugural Women in Cardiothoracic Surgery Working Group. Its main aim will be to encourage diversity within the speciality of cardiothoracic surgery in Great Britain and Ireland, by focussing on the development of female cardiothoracic surgeons, thereby fulfilling a leadership role and to advise the SCTS Executive and its members regarding existing gender disparities.

Co-chair:

Karen Booth

Consultant Cardiac and Transplant Surgeon, Freeman Hospital, Newcastle Co-chair, SCTS Women In Cardiothoracic Surgery Working Group SCTS Student Education Co-Lead

Narain Moorjani

Consultant Cardiac Surgeon, Royal Papworth Hospital, Cambridge Co-chair, SCTS Women In Cardiothoracic Surgery Working Group SCTS Honorary Secretary

Academic Cardiothoracic Representative

Prof Julie Sanders RGN BSc (Hon) MSc PhD FESC

Director Clinical Research, St Bartholomew’s Hospital, Clinical Professor Cardiovascular Nursing, WHRI, QMUL

Cardiac Surgery Representatives

Rashmi Yadav

Consultant Cardiac Surgeon Royal Brompton Hospital, London

Debbie Harrington

Consultant Cardiac Surgeon Liverpool Heart and Chest Hospital

Cecilia Pompili

Academic Thoracic Surgeon St James’ Hospital, Leeds

Melanie Jenkins

Consultant Thoracic Surgeon St George’s Hospital, London

Elizabeth Belcher

Consultant Thoracic Surgeon John Radcliffe Hospital, Oxford

Congenital Surgeon Representative

Carin Van Doorn

Consultant Congenital Cardiac Surgeon Leeds General Infirmary

Cardiothoracic Transplantation Representative

Gillian Hardman

Clinical Research Fellow Cardiothoracic Surgery Freeman Hospital, Newcastle

SCTS Executive invited member

Betsy Evans

Consultant Cardiac Surgeon Leeds General Infirmary

Specialty Doctor Representative

Laura Viola

Clinical Fellow James Cook University Hospital

Trainee Cardiothoracic Surgery Representatives

Michelle Lee

Locum Thoracic Registrar & Honorary Research Fellow in Cardiothoracic Surgery St Barthomlomews Hospital, London

Georgia Layton

ST2 (East Midlands NTN) Glenfield Hospital, Leicester

Theatre Surgical Care Practitioner Representative

Esme Shone

Trainee Surgical Care Practitioner Freeman Hospital, Newcastle

Advanced Clinical Nurse Practitioner Representative

Lorna Whitford

Clinical Educator (Nursing) Royal Victoria Hospital, Belfast

Clinical Perfusionist Representative

Rosie Smith

Lead Perfusionist Royal Brompton Hospital, London

Medical Student Representative

Asmita Singhania

Third Year Medical Student University of Manchester (Wythenshawe Hospital)

Thoracic Surgery Representative

the 34 bulletin

This article (Rules of (Virtual) Engagement – SCTS Bulletin - Issue 9) has been reprinted with some corrections

the 36 bulletin

I Confess That I Have Lived Nights and I Have Lived Days Luis Sergio de Moura Fragomeni, Professor of Cardiothoracic Surgery, University of Passo Fundo, Brazil No pain, no palm; no thorns, no throne; no gall, no glory; no cross, no crown. – William Penn, 1669

Night I had to take that fragile little girl in a hurry to the operating theatre (O.T.). She was not four years of age, and was having repeated crisis of cyanosis. It was a cold afternoon of March 1984, “Thriller”, the frenetic song by Michael Jackson, was constantly heard on the radios around the world.

On the days leading to this urgent event, she was admitted to hospital for surgical assessment of Tetralogy of Fallot syndrome. While we were deciding the best approach in her situation, during an intense crying episode she became extremely cyanotic, which was followed by loss of consciousness. We then decided that she had to be operated immediately. The parents understood the gravity of the situation and with confidence, encouraged all of us. She was taken to O.T. and all preparations for surgery were taken. Oxygen saturation and vital signs were in critical levels. The incision was not yet performed when she went into ventricular fibrillation, with no response to electrical defibrillation. In a crucial moment like this, a troublesome thinking always arises: Shall we accept this fate and interrupt any previous planning or, despite all odds, decide to carry on? It is common knowledge that usually surgeons decide to proceed. Until we managed to put the

child into Cardiopulmonary bypass (CPB), alternating cardiac massage and opening the chest, this period was probably not less than eternal twenty minutes. Once on bypass, cardiovascular system stabilized and we proceeded with total correction. From there on, the procedure was uneventful and the patient was taken to Intensive Care in a stable condition. Within the next 24 hours, she was off ventilatory support and by the third day, back to the ward. We were all amazed with her progress. The family was extremely pleased and thankful to all the medical staff. Due to an academic appointment, I had to be away for three days. Update from colleagues was that she was stable. As soon as I returned, I went to see her. In the moment I entered her room, the girl, sitting on her bed, cried out loudly. Her physical aspect was normal, her lips well saturated, nothing wrong to be noticed. The parents were quiet, apprehensive, sort of angry. I soon realized that something was out of order. Her father shouted loudly: She is blind, doctor! She cannot see a thing! Since last night she cries and screams asking us to turn on the lights! For a moment, I was astonished. But soon I understood that the situation was probably related to the long period between cardiac arrest and the establishment of CPB.

“She ran to me and hugged me tightly! Right there, all the misery we all went through had vanished. I asked about her sight and the father said ... ‘Marvellous!’”

August 2021

Neurological investigation suggested cortical amaurosis. Few days went by. From the cardiac point of view, she was very well, but no change in her blindness. In that regard, the prognosis was said to be poor and only time could tell if it would be any improvement. And that was how the family left the hospital. They went home with the world on their shoulders. On farewell, many resentments towards me and everybody else. That night was a dark night, oh, for sure it was.

Day About six months went by with no news of her. However, shortly after that, I was informed that a clinical consultation was scheduled. When that day arrived, I was very anxious to see what I would encounter. The moment they entered through the door, when I saw the parents, the smiling girl in a radiant light green dress, I immediately realized that the moment was of joy. She ran to me and hugged me tightly!

Right there, all the misery we all went through had vanished. I asked about her sight and the father said ... ‘Marvellous!’ About three months after she left hospital, one morning, the father asked the people in the room, if anybody had seen his wallet. To everybody’s surprise, was the girl who answered: “it is there, daddy, over the sofa!” Well recovered and amazed with the wonderful news, peace and happiness was back home! After my clinical examination, I was pleased to tell the parents that everything was fine, that she had recovered fully. Relieved, I started to explain the physiological reasons for her improvement. Then, I immediately noticed that they changed their expression and became very sceptical. Doctor, it was not the doctors or the medical science that cured our daughter. No …? No. It was this famous clairvoyant in the State of Parana that we took her to see on many occasions! After all these years, I have knowledge that my little patient continued to develop

well, got married, became a kindergarten teacher, had children and continued to celebrate her life. As I revisit these memories, recalling moments of apprehension and even panic, it is difficult not to recall Ambrose Bierce in the “Devil’s Dictionary”, “The physician is one upon whom we set our hopes when ill and our dogs when well”. But, “when we have shuffled off this mortal coil”, we must understand that despite all praise or critics that anyone can express to us, there is always the mission, that strength beyond the goal of healing, that is also the one of relieving the suffering and the effort to comfort always. I do not need to close my eyes to see that open and happy smile when she ran into my arms. In a few seconds, we shared all the complicity and built bond between an almost strange surgeon and such a brave little patient. In that moment, it was just us, and more than anything, we had an interaction, an understanding. No other theory mattered. It was a moment of happiness and redemption. Priceless. That day was a bright day. Yes, it was! n

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the 38 bulletin

All Change for Monitoring of Results in Cardiothoracic Surgery Keith Buchan, Cardiothoracic Surgeon

hen I started my Consultant career in Cardiothoracic Surgery more than 20 years ago there was no surgeon specific monitoring of surgical outcomes in adult cardiac surgery. The only recourse the dissatisfied patient (or their relatives) had was to litigate or complain. A certain amount of professional failure was considered inevitable and surgeons paid their medical indemnity fees each year in recognition of this so that patients injured through professional neglect would at least be entitled to financial compensation. When the oversight was considered very serious the process could shift up a gear to a coroner’s inquest or fatal accident enquiry which could have GMC or, in theory, even custodial implications. Data has been collected on cardiac surgical outcomes since 1978 under the remit of the UK Cardiac Surgical Returns (UKCSR) office of the SCTS. It tended to rely on an SpR having to trawl through physical operation log books and the corresponding mortuary log books to get a tally of the number of operations and deaths which had occurred each year. The results were presented for each unit and not broken down by individual surgeon. There were no guidelines as to how data was to be collected and how it was done undoubtedly varied from unit to unit. There would be nothing to stop a unit from taking a random sample of their activity over a certain time period and then multiplying it up to get an idea as to what the years

figures would look like. The unreliability of the UKCSR was attested to by a number of witnesses at the BRI Inquiry, but nevertheless was still used as a bench mark (personal communication Mr J Wisheart). Collecting data about cardiac surgical outcomes became a sensational matter after the poor results from the arterial switch operation and complete AVSD repair at Bristol Royal Infirmary in the early 1990s were publicised. A docusoap TV film was

struck a chord with me – that he had carefully documented the surgical outcomes in Bristol and conveyed them honestly for scrutiny. He was not altogether sure that the other surgical units had done likewise and wished that this matter had been formally investigated and reported on before submitting to the censure he experienced. This remains a weak link in all our data collection although it has been mitigated to a large extent by taking the process out of the hands of surgeons and handing it over to dedicated data clerks. They are an essential part of our data collection effort and must have power to resist any interference with their work from surgeons trying to manipulate the data in their favour. There are still grey areas in the way we record outcomes. Some surgeons boast that when they use a pre-op intra-aortic balloon pump they tick the box for pre-op circulatory assist device (the same box that would be ticked if the patient had a pre-op LVAD). Our data clerks would not permit this. Having just attended the SCTS webinar led by Simon Kendall this evening on the new approach to unit-specific monitoring of results I welcome the change. We like to congratulate ourselves that our results are getting better and better year on year. Maybe they are. Or are we just rejecting more high risk patients for surgery, albeit often in favour of stenting or TAVI? I am glad I trained in the era of non-reporting of surgeon specific surgical outcomes.

“Dedicated data clerks are an essential part of our data collection effort and must have power to report any interference with their work from surgeons trying to manipulate the data in their favour.” made re-enacting the events and helping to vilify the cardiac surgeons at the centre of the debacle. I visited James Wisheart at his home in the year 2000 to ask him about the impact the experience had had on him. It had been quite devastating but he had received a lot of support from many hundreds of patients who had undergone successful surgery under his care. He wished in retrospect that he had taken advice from other Paediatric Cardiac Surgeons about the situation at an earlier stage instead of trying to work his own way up the learning curve of the operations. One of the points he made

August 2021

The current environment is not nearly as favourable for surgical training as the one I was brought up in as a trainee and in my first 10 years of Consultant practice. Oscar Wilde said that “Experience is the name we give to our mistakes”. There is no doubt that this is a most powerful way to learn but for the next generation of cardiac surgeons in training it will be necessary not only to teach them the correct way of doing an operation but to also thoroughly familiarise them with what can go wrong with each procedure. There would be merit in having a periodic SCTS publication detailing these scenarios in a generic way without implicating any particular surgeon. Management culture in our hospitals has moved on from the 1990s. Nowadays there is a recognition that openness and,

where necessary, questioning of decisions by senior team members are to be welcomed. Harmony between members of the clinical team is an essential prerequisite for obtaining optimal surgical results. It could even be said that if we concentrate on the former the latter will happen automatically. I hope our new “team approach” to monitoring surgical outcomes will be fairer to surgeons whose patients have died as a result of events that had nothing to do with the surgical procedure. As part of the Bristol Inquiry a detailed clinical case note review was conducted by Leslie Hamilton and Eric Silove which reviewed in great detail all aspects of the care of 80 selected patients and found that all parts of the team contributed

nearly equally to unsatisfactory outcomes – cardiologists, anaesthetists, surgeons, nurses – and that structural and resource limitations also contributed. Although this was mentioned in the final report (ref) it deserved greater emphasis (Personal communication Mr J Wisheart). With a bit of thought and effort the whole data collecting enterprise could be made much less threatening to the individual cardiac surgeon or surgical unit if deaths could be nominated as surgeon related or non-surgeon related. It might even lead to restoration of a more favourable training environment. n Reference 1 Bristol Enquiry BMJ. 2001 Jul 28; 323(7306): 181. doi: 10.1136/bmj.323.7306.181

Dual Consultant Operating Uday Trivedi – Adult Cardiac Surgery Audit Lead, SCTS Andrew Goodwin – Clinical Lead Adult Cardiac Surgery, NICOR

ual consultant operating (DCO) of the total UK adult cardiac procedures. why more than half the units in the UK have was introduced as a field to the The predicted Logistic EuroSCORE for not used DCO on any cases since it has been national adult cardiac surgery these 110 cases was 27.3% and the observed available. There may be infrastructural issues audit in April 2019. This is a preliminary mortality was 32.7%. and units should ensure that their databases look at the data and a more detailed report Of the 35 NHS units 19 units did not are up to date to capture the DCO fields. from NICOR will follow later in the year. record any DCO cases. No cases of DCO There may also be professional reasons DCO was introduced to mitigate against were performed in the private sector. Of the why individuals do not wish to take up this perceived risk averse behaviour for high16 units that did, the number of cases per operating method which should be respected. risk cases requiring cardiac surgery and to unit varied from 1 to 16 cases in the year. However, units should be reassuring facilitate best practice for patient care within The mortality for each unit for their DCO themselves that there isn’t any risk averse hospitals. Allocation of a case as DCO cases ranged from nil to 100%. However, behaviour and that patients are not being within the national audit requires agreement given that many units only recorded one denied high risk surgery where they would be of the MDT and means that the unit where case, this mortality analysis has little to likely to benefit from it. the operation is performed takes overall inform us at the current time. A more detailed report will be published responsibility for the outcome of the case This early review suggests that the by NICOR with individual unit DCO (as usual), but that the individual surgeon DCO structure is not being abused as the activity. In the interim we would welcome does not have the case counted within number of recorded cases is less than 0.5% any feedback from members about their their annually reported figures by NICOR. of the overall cardiac activity. It is not clear experience or difficulties in using DCO. n The guidance is available on the Predicted mortality calculated by EuroSCORE logistic % SCTS website (https://scts.org/ professionals/surgical_sub_ Nations DCO cases % total cases Deaths (n) Mortality (%) Predicted mortality (%) specialities/cardiac/unit_and_ UK 110 0.34 36 32.7 27.3 outcome_data.aspx). For this first year (2019/2020) 110 cases were performed in the UK under the DCO qualification and of those 109 were in England. This workload represents 0.34%

England

109

Northern Ireland

Scotland

Wales

0.40

32.1

26.6

0.04

100.0

98.2

the 40 bulletin

Anglia Ruskin University Cardiology and Cardiothoracics Society International Virtual Reality Conference 2020 Sophie Mason & George Liu, School of Medicine, Anglia Ruskin University

n 3rd and 4th October 2020, Anglia Ruskin University Cardiology and Cardiothoracics Society (ARU CCTS) hosted the ARU CCTS International Virtual Reality Conference 2020, the first student-led conference of its kind. The aims of the conference were to: • Promote Cardiology and Cardiothoracic specialties to an international audience. • Raise money for the Children’s Heart Federation (Registered Charity No: 1120557). • Provide networking opportunities for our delegates through AltspaceVR – a virtual reality (VR) software. The conference attracted over 150 attendees (from aspiring medical students to consultants) from over 10 countries, including the United States of America, India, China and Egypt. Over the weekend, 18 international speakers addressed a variety of topics (See Figures 1 and 2). Each lecture was very well received. From feedback, using a Likert Scale, speakers scored 4.80/5 over the 12 ‘Speaker Feedback’ forms. Using the same scale, the conference itself averaged 4.98/5 in our ‘General Feedback’ form. Written feedback was also provided: “Great conference, I learnt a lot and the speakers were all so personable. It was

lovely to see their approaches and passion for their professions and has inspired me to pursue a career in this field. Thanks so much for organising it!” – A Level Student “An amazing conference, a great opportunity to obtain contacts and search for future opportunities!” – Medical Student

We raised £1000 from ticket sales, which has been donated to the Children’s Heart Federation – a charity which helps children who are born with heart defects, by improving their quality of life and providing support to their families. This will help at least one family purchase the medical equipment needed to reduce the number of visits their child needs to make to hospital – an unnecessary risk during the pandemic. Throughout the COVID-19 era, we have noticed a sharp decline in the networking opportunities available at virtual conferences. The majority (if not all) have adopted a webinar format, out of convenience, where speakers deliver their talks and then disappear before the next talk begins. For students and trainees, networking is a major factor when attending conferences. Networking

“Networking opportunities allow budding doctors to find experienced mentors who will help guide them through the hurdles of their training life.”

August 2021

opportunities allow budding doctors to find experienced mentors who will help guide them through the hurdles of their training life and beyond. Therefore, we decided to include VR networking sessions, which would provide our delegates the opportunity to foster relationships with potential mentors. Both mentors and delegates highly enjoyed the platform, and the following comment (amongst others) was given as feedback: “I was very impressed with the idea of using VR software to add a networking aspect to the conference. This certainly helped me to address some questions on a one-to-one basis much more effectively than I would have been able using traditional video conferencing.” – Speaker Overall, the conference was a great success. ARU CCTS look forward to hosting future international conferences to help inspire the future generation of cardiothoracic surgeons. We also hope that our experience highlights the importance of education and networking, thus encouraging other healthcare professionals to adopt this virtual reality conference format. n

Invitation to a Wedding: A Thoracic ANP Journey During COVID

Justin Pahelga, Advanced Nurse Practitioner in Thoracic Surgery, University Hospital Southampton

eddings and funerals, these are the only two things when you can get all the family together. In these gatherings, you have a mixture of people with different views and attitudes. You have the people who you always speak to, these are the people you like. There are people who you rarely see but still enjoy their company; and there are people who you do not hear much from. They are the ones whose presence does not seem to make a difference in any party.

In the world of medicine this can be compared to the relationship of cardiac and thoracic surgery. In a field dominated by cardiac, little is made known about thoracic. As Aristotle once said, the whole is greater than the sum of its parts. This can be related to the human body as each system plays a vital role in physiology. However, working in thoracic surgery has made me question Aristotle as it did not feel that way. It felt that cardiac was always given more importance in terms of staffing, equipment, and resources. This has all changed since COVID-19.

March 2020 was when the United Kingdom entered the first national lockdown. This was also the year that the NHS had to modify and develop practices in disaster management. There were new ways of thinking and new ethical dilemmas to face. During this time, thoracic services had undergone many changes too. It started with the suspension and prioritisation of surgical services. As part of the national response, the NHS sought help and utilised private health sectors for cancer surgery. In our local >>

the 42 bulletin

setting, University Hospital Southampton (UHS) is conveniently across Spire Southampton Hospital. Our team of thoracic Advanced Nurse Practitioners (ANP) is composed of five members, two of which have been redeployed to critical care. The remaining three have provided elective thoracic surgery at the Spire Hospital whilst maintaining emergency thoracic services at UHS. The bulk of our patients were at Spire Hospital, but we have few patients who were referred to UHS for surgical management of pneumothorax, pleural effusion, and empyema. We would also get admissions via Emergency Department with chest trauma. The challenge was covering both areas by yourself as the junior doctors (except Specialist Registrar grades) have been redeployed. We are quite lucky that our consultants are very engaging and supportive. This, however, does not change the fact that I was doing at least 20,000 steps a day between the two sites. As the cases went down and it seemed that everything was under control, we bid goodbye to our new friends from the private sector and resumed our services in the NHS and resulted to the birth of ultra-clean wards. Triaging patients based on their COVID status became the new norm. Ultra-clean patients were the ones who isolated for 14 days and had a negative swab 72 hours prior to admission. This also meant that the staff working in these areas were required to perform twice weekly nasal and throat swabs. Although very unpleasant, it was a measure in place to ensure containing possible outbreaks. For our service, this meant that patients were spread across the hospital for infection control purposes. This also meant that good hand hygiene and strict PPE compliance was expected of us as we did not have enough staff to create an ultra-clean team and another team for patients who have pending COVID results and did not isolate prior to admission. We were fortunate that we only had few COVID positive cases during the whole period.

of medical staff. This meant that an ANP will be looking after patients in their designated ward regardless of specialty. It was unnerving as I have always just provided care for thoracic patients in my ANP career. Throughout this time, I have to learn cardiac surgery and cardiology in a matter of days. In normal circumstances, a supernumerary period of a few months will be allotted. This was a luxury that we could not afford. To add icing on top of the cake, one of our footprint wards became an overflow medical ward that we had to cover. From years specialising in thoracic surgery, I was now faced to master other CV&T specialties and medicine. All those years of studying nursing have sufficed and allowed myself to survive this new age of service delivery. Through all the hardships that our service has experienced, the good thing that came out of this was that thoracic was recognised. Our team has been acknowledged by the others for providing continued services through COVID times. It no longer felt that thoracic was the second cousin that may be invited to the wedding. All those moving around the hospital had made people a little bit more aware of what we do. This time we were now the relatives you rarely see but still enjoy their company. It is a long way for thoracic to be in the limelight, but I am happy as we are taking small steps towards it. n

“In a field dominated by cardiac, little is made known about thoracic. Working in thoracic surgery, it felt that cardiac was always given more importance in terms of staffing, equipment, and resources. This has all changed since COVID-19.” As time passed, surgical services have gradually resumed. All of the specialities wanted a taste of the ultra-clean pathway. This meant that thoracic service had to be relocated to accommodate cardiac, neurosurgery, and vascular admissions. Surgical HDU staff have been redeployed to ITU and this left an empty space that we could fill. Like new tenants, we redecorated and redesigned the place to suit our needs. Few more months down the line, SHDU required their space back. We then had to relocate to another ward. Eventually, thoracic went back to its home ward. Most services have resumed almost normal activity and carried on as COVID secure as they can. Erratic and unexpected are words one would use to describe the virus. This also had unexpected results to the public. In January 2021, COVID struck harder and put the nation into its third national lockdown. This was the genesis of the Cardiovascular and Thoracic (CV&T) ANP response team because of the lack

August 2021

The 2021 National Recruitment for Cardiothoracic Surgery Jeremy Chan, ST1 Cardiothoracic Surgery

he 2021 Cardiothoracic Surgery national selection was conducted remotely to ensure it was COVID-safe. All the applications were first assessed for eligibility against the person specification (longlisting). Long-listed applicants were then asked to upload the evidence to an online verification portal ahead of shortlisting. The applications were scored by three assessors independently and candidates who scored above the cut-off threshold were invited to interview, similar to the previous recruitment process. Two major changes were made in this year’s recruitment: 1. The finalisation of the shortlisting score was done before the interview stage using the online verification portal. This is normally carried out during the interview at the assessment centre. 2. The interview was conducted remotely using the Microsoft Teams.

acceptable to justify the application. The Health Education England has therefore uploaded several documents to guide applicants to prepare their portfolio with a list of acceptable forms of evidence. I personally think the online verification portal was very user friendly and allowed applicants to personalise their portfolio digitally. Most of the portfolios including the Intercollegiate Surgical Curriculum Programme (ISCP) are now assessed electronically during the Annual Review of Competence Progression (ARCP). In addition, it is environmentally

setting up for video interview was crucial. Body language and eye contact is a big factor during a faceto-face interview, and it is easy to lose this on Microsoft Teams. To be as natural as possible, I personally tried not to stare at the computer screen and instead tried speaking directly to the camera instead. I had also prepared an extra set of headphone, webcam, and mobile broadband device as sometimes technology does fail. Fortunately, the interview was conducted smoothly, and I had not experienced any major connection issue. Having been through the national selection this and last year, I think the recruitment process remains fair and was conducted to a very high standard. All the evidence was assessed before the finalisation of the shortlisting score to ensure the top-scoring applicants were invited for an interview. A wide range of questions was asked to assess candidates’ clinical knowledge, communication skills, insight, and motivation. This ensures the top candidates were selected for the programme. Once again, I would like to say thank you to all the consultants for giving up their free time during the pandemic to ensure the national recruitment was conducted smoothly. n

“A wide range of questions was asked to assess candidates’ clinical knowledge, communication skills, insight, and motivation. This ensures the top candidates were selected for the programme.”

Instructions for the self-assessment verification portal was given to all applicants in advance. Applicants were asked to name and uploaded the evidence in one of the fourteen domain tag(s), matching the application form. Evidence used to confirm the shortlisting score should be uploaded to the portal. In fact, it could be difficult to determine exactly what evidence will be

friendly as applicants can avoid printing hundreds of certificates, letters, and forms. Candidates can also avoid bringing a heavy portfolio to the assessment centre. Besides, assessors can focus on other parts of the selection progress rather than going through thousands of pages worth of documents. The use of the electronic verification portal could potentially be considered in future recruitment. The interview was conducted remotely using Microsoft Teams and

the 44 bulletin

Welcome ST1 Cohort 2021 Devan Limbachia, ST1 West Midlands

s August is fast approaching, we would like to introduce our new cohort of incoming ST1 cardiothoracic trainees. With each new generation we see fresh ideas, new perspectives, and innovation. We hope our trainees develop through their experiences, making a positive impact on their individual journeys. As a community, we aspire for our trainees to stand amongst role models and contribute to promoting excellence in the practice of cardiothoracic surgery.

What are you hoping to gain with your NTN? I hope to gain general cardiothoracic surgery competences and exposure to transplant surgery. In the future, I aim to pursue a PhD and contribute to research advances in the speciality, alongside furthering my interest in teaching and surgical simulation.

Finally, I would like to say thank you to Mr Parmar, Dandekar, Codispoti, Barker, Bruno and everyone who has helped me massively during my early career. I would not be in this position without the guidance and support from you all.

Any interests in CTS? My subspecialty interests include Adult Cardiac and General Thoracic, alongside Transplant surgery and mechanical circulatory support. Extracurricular interests Triathlete, competing in Ironman 70.3 and full-distance races. Motorbike touring.

Ann Cheng

ST1 ACF Yorkshire & Humber

Jeremy Chan

ST1 Wales

ST1 Thames Valley

Hello everyone, my name is Jeremy Chan. I am excited to start as a ST1 in Wales in this upcoming August.

My name is Ali Ansaripour and I am a current foundation trainee in the East of England, having rotations in Cardiothoracic Surgery and Transplantation at Royal Papworth Hospital. I will be starting ST1 in Thames Valley.

What are you hoping to gain with your NTN? Any interests in CTS? I am more towards adult cardiac surgery at present, but it is still early to make the final call. I also have a strong interest in academic cardiothoracic surgery.

Ali Ansaripour

I’m Ann, a Taiwanese-Canadian who moved to the UK years ago to study medicine in Edinburgh. I’m currently an FY2 at Royal Papworth Hospital in Cambridge. I’ll be joining the Yorkshire and Humber Deanery as an academic clinical fellow in cardiothoracic surgery, starting with my first three years in Sheffield. What are you hoping to gain with your NTN? Looking forward to being a part of the cardiothoracic surgical community. Any interests in CTS? I’m interested in academia and also aortovascular surgery. Extracurricular interests I enjoy traveling, reading, baking, cycling and high intensity interval training.

August 2021

Hello all. My name is Devan Limbachia, and I am the incoming ST1 for West Midlands.

David Hawes

ST1 North West – Manchester Hello my name is David Hawes, I’m one of the new ST1 trainees starting in Manchester this August. I am looking forward to joining you all in the cardiothoracic community. What are you hoping to gain with your NTN? Any interests in CTS? I’m greatly looking forward to moving to the North and continuing my training! I hope to pursue a career in adult cardiac surgery and throughout my training gain experience of other areas within the cardiothoracic specialty. Extracurricular interests Outside of work I play a number of sports, primarily squash. Additionally, I am a keen guitarist although this is becoming an expensive hobby with my growing guitar selection.

What are you hoping to gain with your NTN? I am extremely honoured to join a talented community that strives for excellence, having some of the most dramatic favourable outcomes in surgery. I look forward to developing my surgical acumen and research skills within the field. I hope to improve and innovate, putting my patient’s at the centre of my work. Any interests in CTS? I am particularly interested in minimally invasive surgery, robotics, and VR technology. Additionally, I am passionate about widening the access to surgery and hope to highlight the diversity within our community. Extracurricular interests Outside of hospital, I enjoy painting, poetry and travelling!

What are you hoping to gain with your NTN? I am delighted and extremely honoured to join a speciality which has not only talented surgeons but passionate and hardworking individuals. As I start my career in cardiothoracic surgery, I hope to stand on the shoulders of giants and thrive for procedural excellence, patient satisfaction and technological improvement. Any interests in CTS? With the speciality evolving into 4 subspecialties, I am excited to have opportunity to explore them all individually. Broadly speaking, I am interested in technological advancement and how we can make processes more efficient, whether that be procedures or pathways. Extracurricular interests I am keen cricketer (opening batsmen & can bowl leg-break if required!) – Perhaps a consultant vs trainee cricket match could be on the cards!

Reflecting on my journey to-date, I sincerely thank my mentors, most notably Mr Hawari who has guided me and shown me the true meaning of being a cardiothoracic surgeon. I respect the contribution that each patient and colleague has made to my personal and professional development, and I look forward to the continual learning and growth that is associated with training.

Anuj Wali

ST1 South West My name is Anuj Wali and I will starting ST1 in South West Deanery. What are you hoping to gain with your NTN? Any interests in CTS? I am particularly interested in Thoracic surgery, having had a great experience working in a fantastic team which convinced me to apply for Cardiothoracic Surgery.

Devan Limbachia

ST1 West Midlands

Nikhil Sahdev ST1 London

My name is Nikhil Sahdev and I will be the ST1 starting in London 2021.

Extracurricular interests Playing lots of sports (Tennis/Football/ Hockey). Looking forward to picking up some water sports when starting on the South Coast. n

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Unsuccessful in ST1 Cardiothoracic Surgery National Selection, What is Next? Jeremy Chan, ST1 Cardiothoracic Surgery Amer Harky, ST4 Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool

ardiothoracic Surgery remains one of the most competitive specialities in the United Kingdom. The number of applications to the Speciality Training (ST) Year 1 programme has nearly doubled from 2015 to 2020. It is anticipated to have a higher number of applications due to the uplifting of immigration restrictions allowing overseas applicants and discontinuation of ST3 recruitment. A reduction in recruitment number due to workforce planning will further increases the competition. While it would be an achievement to obtain a national training number (NTN) immediately after completion of the foundation programme, one should not be discouraged because of one or more unsuccessful attempt(s). In fact, both authors did not enter speciality training straight from Foundation Year 2 (FY2) and neither during the first round of application. The key for re-application to the ST1 programme is to understand your weak areas in the well-designed short-listing matrix and optimising each section to maximise the awarded points. Several options can be considered after completion of FY2 to facilitate this. The Core Surgical training (CST) is a 2-year programme aiming to equip junior surgical trainees with basic surgical knowledge and operative skills. Some deaneries offer a small number of Cardiothoracic Surgical theme CST jobs, during which you will be allocated to 1-2 cardiothoracic unit(s) for 12 to 18 months. The CST programme allows trainees to have protected training time and regular access to theatre. One should aim to perform great saphenous vein harvesting, sternotomy opening and closing as well as VATS procedures. It is also beneficial to shadow

“The key for re-application to the ST1 programme is to understand your weak areas in the well-designed short-listing matrix and optimising each section to maximise the awarded points.” the speciality registrar to gain experience in dealing with referrals and managing acutely unwell patients. CST trainees should attend the cardiothoracic surgical teaching, courses and conduct audits/quality improvement projects to strengthen their portfolio. On the other hand, CST trainees may need to spend extra time on achieving other core/general surgical competency and attending additional general surgical courses. Rotation to cardiothoracic surgery may not be possible, especially prior to the application deadline in November. Junior Clinical fellow ( JCF) may address some of the issues above. JCF lets one to stay in the same cardiothoracic surgical unit and avoid rotations between specialities every 4-6 months. JCF should use this as an advantage and familiarise themselves with the team to achieve the academic, clinical, and operative experience listed above. However, JCFs maybe required to spend extra time for service provision as there is no protected theatre time. Pursuing a higher degree such as MRes/MSc, MD or PhD is also a feasible option. A higher degree strength one’s academic profile for the ST1 and academic clinical fellow (ACF) application. Pursuing

a higher degree allows applicants to place an application for a maximum 3 extra recruitment years post FY2. This is due to the ST1 application mandates applicants to have 18 months or less experience in surgery post FY2. Teaching fellow (TF) is another alternative and TF normally is encouraged as well as funded to work on extra qualifications such as postgraduate certificate/diploma in clinical education. It may be beneficial for junior trainees who are interested in medical education as TF often gets to work with local tutor, designs and delivers the teaching programme. Publications related to medical education is also feasible. However, one should be aware that both options may have limited access to clinical training which also plays an important factor in the shortlisting and interview process. No applicant would ever like to receive an email saying, “Unfortunately, your application to Cardiothoracic Surgery speciality training is unsuccessful”. Please do not be discouraged and continue to improve on your applications. Your interest and passion to the speciality will drive you forward and hopefully achieving a national training number in the next recruitment. n

August 2021

The Montgomery Case and the Notion of Consent Sarah Murray, Chair, National PPI Group, National Cardiac Surgery Clinical Trials Initiative

bituaries are fascinating sources of information. Some people read every obituary (my grandmother used to read them in her local newspaper every night to check if she knew anyone in the list) others, like me, glance at the national ones from time to time. Many people live extraordinary lives and some even change the lives of others. One such person died in December and he changed your working life for ever and improved the lot of the patient with a stroke of his pen. Brian Francis Kerr, Baron Kerr of Tonaghmore, PC was a British barrister and senior judge who served as Lord Chief Justice of Northern Ireland and then as a Justice of the Supreme Court of the United Kingdom. He was the longest serving member of the Supreme Court and one of the most progressive judges of his generation. He gave the deciding judgement, with Lord Reid, in the Montgomery case1 - the case changed the way you obtain consent from a patient. Up until this case, consent was controlled by the medic – “doctor knows best” what should or not have been shared with the patient about their condition and the outcomes of an operation. Medical patriarchy ruled. This was all changed by Nadine Montgomery and her son Sam. Nadine, a petite, articulate woman with type 1 diabetes became pregnant and it was soon noticeable at her check-up that her son’s head was growing larger and faster than normal. She was concerned and mentioned to her obstetrician and midwife that her mother had had difficulty delivering her babies and that perhaps she was going

to have the same problem. She was told not to worry everything was fine. But she did worry and kept on mentioning that she was concerned and that her family history showed problematic births. There was no change in the plan; Nadine was induced at the due time and went into labour. After nearly two days of labouring the consultant took her into the operating theatre. The baby’s head had got stuck in the birthing canal. What happened next makes for shocking reading. The medical staff tried to break the baby’s clavicles to ease the birth; no luck, so they pushed the baby back up the canal: they then tried severing Nadine’s pelvis; that didn’t work. As a last-ditch desperate attempt the obstetrician grabbed the baby’s left arm and pulled him as hard as she could. His arm muscles and sinews and nerves tore but he was through. Both mother and baby were very unwell following the birth, they were battered and badly bruised. They recovered

years she coped with a damaged little boy. Then, one day her sister said she had read about shoulder dystocia and its prevalence in babies born to type 1 diabetic women. Nadine went to the hospital trust ̶ no help. She then got a lawyer. She went through two levels of court hearing in Scotland and lost. She kept appealing and finally got to the Supreme Court of the UK. At this point things began to change for her. She was joined in her case by the GMC. She said for the first time she was listened to. To her it was such an amazing, overwhelming experience that it was almost sufficient in itself. That is a such powerful statement. She won her case in the Supreme court and she and her son Sam were awarded £5.25 million. Sam was 15. Lords Kerr and Reid changed the notion of consent. The patient must now be involved in the decision making and is no longer subject to the “medic knows best” thinking. And why is that? Because often the patient is the expert in the room, and they know themselves better than anyone. The phrase I often hear from clinicians is “I consented the patient for surgery”. To me that says that the doctor went through the process and did the consenting. It suggests it is something the doctor does for the patient, and it is completely the wrong way round. The patient gives their consent to you – they are giving you permission to commit a legal assault on their most precious, only real, possession (which they came into the world with and the last thing they leave with).

“The patient gives their consent to you – they are giving you permission to commit a legal assault on their most precious, only real, possession. It is not for you to even think that you are “doing” the consent.” enough for them to be discharged, eventually. Nadine said she felt entirely alone after that. Her mother gave up work as a GP to help her and her baby. For seven

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It is not for you to even think that you are “doing” the consent. Under Montgomery you have to consider when, where and how you obtain this consent. When do you ask for consent? Much of it is now done in a timely fashion in outpatient clinics and gives the patient time to reflect, read leaflets and ask questions. But what happens when you’re running late in your surgery? Does it ever get rushed? Where do you ask for permission? In an outpatient room – NHS style, strip lights, ghastly paint work, uncomfortable chairs, over or round a desk? Strangely, virtual meetings may prove to be a better option

thanks to Covid. The patient is in the comfort of their own home with family. How much time do you give your patients? Do you know how they take in information? Aurally, visually, kinaesthetically, with diagrams, several times over, are they internet experts and seen the op. on YouTube? How good are you at listening? Remember Nadine Montgomery’s comment as she reached the Supreme Court – the law lords listened – for the first time she was truly listened to. Put your patient at the centre of everything you do – don’t just say it – do it and start by listening.

“It takes a great person to be a good listener.” “Most people do not listen with the intent to understand, they listen with the intent to reply.” Lord Kerr listened, understood and changed the law for the better for us all. n Reference 1 Montgomery v Lanarkshire Health Board [2015] UKSC 11 is a Scottish delict, medical negligence and English tort law case on doctors and pharmacists that outlines the rule on the disclosure of risks to satisfy the criteria of an informed consent.

Women in Cardiothoracic Surgery India Premjithlal Bhaskaran, SCTS School Student Ambassador

omen’s role in the community as either a daughter, sister, wife, daughter-in-law, mother or grandmother is an important essential fundamental aspect of the society in which she has enormous duties. A woman works hard to establish a balance between her house and her career in order to build her house and preserve good relationships with her family, community and workplace. However, a worldwide concern is whether the female representation among cardiothoracic surgeons is comparable to the gender distribution in the United Kingdom. Women in cardiothoracic surgery have had various chances for career progress through professional networking, mutual support, and committed advocacy from major cardiothoracic professional organisations. Those that selected a unique field, full of pressures and uphill battles, regardless of gender, have undoubtedly picked a distinctive field. Individuals may confront a range of challenges while pursuing a long and gruelling career path, including financial difficulties, social support, racial and religious disparities and restrictions linked to gender-based preferences.

Despite this, women currently outnumber men in medical schools, yet several specialties still have an unbalanced gender mix. Female representation among cardiothoracic surgery is increasing, with women already accounting for 14% of all cardiothoracic trainees, specialist doctors, and consultants. The presence of women in this speciality is stronger than ever, despite a dropoff in female representation at successively higher levels of training into this area. Emotional intelligence is important in any discipline, but especially in cardiac surgery. Every minute of surgical procedure is planned since this level of preparation and effort is required for the greatest possible results for the patients. Not forgetting that great results are the product of the efforts of the entire team, not just an individual. Although the proportion of female consultants and trainees is progressively increasing at a similar rate, there is still a significant discrepancy between the number of women who enter training and those who turn out to be consultants. It has been emphasised about the challenges that women in this profession

confront, while also acknowledging that some of these difficulties may be relevant to all cardiothoracic surgeons, regardless of gender. It is hoped that many suggestions for achieving work-life balance will be valuable to male colleagues as well. Furthermore, despite much of the discussion being centred on challenges that surfaced during training, it is believed the skills acquired will serve well throughout many careers. What has been found out about accomplishing balance between fun and serious activities are keeping up acceptable associations with loved ones, investigating the world outside of the hospital, making it work regardless of the challenges in life, showing appreciation for accomplices and structuring an organization of comrades, while avoiding reluctance to request help. We are massively thankful to the SCTS Women in Cardiothoracic Surgery working group for their encouragement and support, and we stay obligated to our guides, families, and the female pioneers in our field that have managed to have the benefit of being cardiothoracic surgeons. n

August 2021

National Cardiac Surgery Clinical Trials Initiative National PPI Group

Sarah Murray, Chair, National PPI Group, National Cardiac Surgery Clinical Trials Initiative (With thanks to Jeremy Dearling for his input)

ith every piece of research these days, it gains kudos if there has been a meaningful contribution from patients, carers, and the public. For many funders, the NIHR, Cancer Research UK, the Stroke Association for example, unless the contribution is meaningful there is no likelihood of funding. Those experienced in research already know the value PPI opinion brings, but also know the burden that must go into making it work. Imagine then, the challenge facing Professor Gavin Murphy when handed the task of turning a JLA PSP on cardiac surgery into not just 10 research questions, but 10 research outcomes. By means too involved to describe here, a component of this herculean task meant gathering a group of patients, carers, charities and members of the public to support each of these study themes. Through a variety of routes, assembled virtually and by email we have a core group of people from a wide variety of backgrounds and with diverse experience of reviewing research, contributing to the research conversation, and generally being enthusiastic about these projects. The National Public and Patient Involvement Group was formed at the outset of the National Cardiac Surgery Clinical Trials Initiative and is made up of two patient leads from each of the nine Clinical Study groups (the 10th is in abeyance at present) with myself as Chair. We have varying experience and expertise but we are all well connected to the wider cardiac community and support groups. The first meeting was held on 13th October 2020. Since then, we have held six, monthly, National PPI Group meetings. Despite the pandemic, being a new team, and the need to operate virtually, the

group has worked to develop a team approach to support each other in their respective CSGs (Clinical Study Groups) and promote PPI both in the working groups and the wider PPI network which supports each CSG. We have held the first of our PPI training sessions for both PPI members and clinicians to help them understand our role and we have strongly promoted the use of plain language (and multiple languages) diagrams and visual aids, where necessary, so that we can start to communicate with the ‘hard to reach’ groups. By the end of June 2021 five CSGs will have held large PPI events and programmes to test the questions linked to their research proposals. These events have all had to be virtual and have included live PPI webinars with Q&A sessions (audience numbers consistently in double figures), online surveys, both during the webinars and afterwards, individual email submissions and follow ups from PPI members and focus group discussions. These CSGs will swiftly submit their applications for financing over the summer. For those CSGs which have not progressed so far, we provide support to work through the challenging issues and the respective patient leads are also supported through the main PPI Group. We do this not because we have to, but because we want to. We are not academics or clinicians. We don’t do this because it is a requirement of our employment contract, because anyone expects us to do this, or because we get anything from doing it. It is not our purpose in life, we don’t have patients’ lives in our hands, nor does knowledge depend on us doing what we do. We are valued, but by the same token we have no value. Overall, we do this for free. There are some who really don’t like us doing what we do. We are an obstacle

to overcome, ignore, set aside, or diminish. Professional pride is such that some are offended that they must listen to us. That really isn’t our problem. Our role is to give advice. Our role doesn’t include being upset if our advice isn’t taken. We are a critical friend, the voice on the shoulder whispering, ‘are you really sure you really want to do that?’ Being the whispering voice on the shoulder for one research study is one thing, bringing together a minimum of twenty people to whisper on the shoulders of 10 clinical leads, plus up to ten other associated clinical and academic professionals is quite another ̶ yet we are there. We have had some bumps along the way, but there would be something worrying if we didn’t. In eight months, we have gone from a selection of PPI members of varying ability and experience, who have had to work remotely and engender some team spirit at the end of MS Teams, to a group who are now beginning to work as a team and support one another whilst progressing the Priorities identified in the PSP partnership. Our networks are now being used to spread the word and encourage others to get involved and we are gradually linking everyone together to make as large a PPI group for cardiac research as possible across the four nations. As chair of the National PPI Group, I am very proud with what we have achieved so far. Being part of something so big is immensely rewarding and steering it is immensely challenging. I have a good team behind me, and I am excited at the prospect of the next stage and moving us forward at pace. If you have an idea for a research trial which you think would for into one of the CSGs we want to hear from you. Please contact Professor Gavin Murphy via email: gjm19@le.ac.uk. n

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Congenital Heart Disease Priority Setting Partnership Nigel Drury, Academic Consultant, Birmingham Children’s Hospital and CHD PSP National Lead

ongenital heart disease is the most common type of birth defect, affecting 12 children born every day in UK, with many requiring one or more operations to repair or palliate the defect, often before their first birthday. In recent years, survival has continued to improve, with an overall early mortality of approximately 2% in the UK, and the focus has shifted to the impact of associated morbidities, late survival, and the need for further surgery or catheter interventions. Nowadays around 97% of children born with congenital heart disease are expected to survive into adulthood but many develop late complications related to their condition or previous surgery/interventions and almost all require life-long follow-up; even the simplest defects, apparently fixed in childhood, are associated with reduced life expectancy. Yet there is a lack of evidence to inform clinical decision-making in our speciality; the Cochrane Library contains only 15 reviews on congenital heart disease, none of which are on surgical topics. There is a need for high-quality, multi-centre clinical trials to provide an evidence base for contemporary paediatric cardiac surgery and cardiology practice, and to drive improved outcomes for our patients and their families. The James Lind Alliance is a national non-profit making initiative established in 2004

to bring together patients, carers and clinicians as a priority setting partnership (PSP), to identify and prioritise evidence uncertainties. The list of the Top 10 unanswered questions provides a platform for funders to prioritise the research that matters most to stakeholders. We have recently launched the Congenital Heart Disease PSP, bringing together parents, adult patients, charities, and clinicians from across both the spectrum of congenital heart disease and the UK. This project is a collaboration between the SCTS, the British Congenital Cardiac Association, the Children’s Heart Federation, and The Somerville Foundation, and is being hosted by the University of Birmingham. It is funded by George Davies, the high street fashion entrepreneur behind brands such as Next, Per Una, and George at Asda, through a generous donation to the Birmingham Children’s Hospital Charity; his granddaughter has previously undergone complex cardiac surgery in Birmingham. We hope to build on the success of the recent Adult Cardiac Surgery PSP, led by Prof Gavin Murphy, which identified a Top 10 list of priorities in cardiac surgery but specifically excluded children, adult congenital heart disease, and transplantation. However, the scope of this PSP is broader than just surgery, reflecting the lifelong impact of congenital heart disease, and

“The outputs of this process will be key in developing a national strategy for congenital heart disease research, to address the issues which matter most through multi-centre clinical trials.”

is focused on the management of congenital heart disease throughout life, including prior to birth, in three areas of the patient and families experience: • Diagnosis • Treatment: medical therapy, catheter intervention, surgery including mechanical support and transplantation, and psychosocial intervention • Outcomes of the conditions and/or treatments and the impact on patients and their families, including the physical, psychological, social, and societal effects of living with congenital heart disease. We are not looking at areas which fall outside of these, such as the causes of congenital heart defects, acquired heart disease in those without a congenital heart defect, or aspects of congenital disorders that do not affect the heart. The process is being overseen by a steering committee comprised of congenital cardiac surgeons, paediatric and adult cardiologists, and a paediatric cardiac intensivist, along with parents, adult patients, national charities, and two information specialists, supported by an administrator. It is chaired by Katherine Cowan, the JLA Senior Advisor who also oversaw the Adult Cardiac Surgery PSP. We recognised that South Asian communities are disproportionately affected by congenital heart disease and experience worse outcomes from interventions, whilst being underrepresented in consultations. To address this need we explicitly included a parent of South Asian ethnic origin on the committee and are working with the Centre for BME Health in Leicester to translate the survey into the most commonly spoken Asian languages in the UK (Bengali, Urdu, Gujarati, and Hindi) with cultural adaptation to increase participation from within these communities.

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The initial survey launched in late June, and we encourage all congenital members to contribute their unanswered questions: https://redcap.link/congenitalPSP. It will stay open until September, when we will refine the questions and uncertainties, remove out-of-scope questions and those already answered in the literature, before splitting into paediatric and adult tracks for the second stage, the prioritisation surveys which will open in early 2022. The PSP will conclude with two workshops, one paediatric

and one adult, to be held in June-July next year, bringing together multi-disciplinary colleagues from across the UK to generate two Top 10 lists of priorities. The outputs of this process will be key in developing a national strategy for congenital heart disease research, to address the issues which matter most through multi-centre clinical trials. The adult cardiac surgeons are showing us the way, through the establishment of a national PPI group and formation of Clinical Study Groups to develop competitive

grant applications to address the priorities they identified. We anticipate that this process will similarly shape the future of UK research in congenital heart surgery and guide the scope and design of trials aimed at improving the clinical care and day-to-day lives of children and adults born with congenital heart disease. We look forward to sharing the findings with you in due course. For more information, visit our website: www.birmingham.ac.uk/ congenital-psp or follow us on twitter: @ congenitalPSP n

Heart Research UK Aortic Dissection Masterclass, Keele Anatomy & Surgical Training Centre Deborah Harrington MD FRCS CTh, Course Director

n Friday 28th May 2021 we were finally able to resume the Heart Research UK Aortic Dissection Masterclass series, after being unable to hold any courses in 2020 due to the COVID 19 pandemic. The venue was once again the Keele University Anatomy & Surgical Training centre who were fabulous hosts as always and went to extra lengths to ensure the course remained COVID secure. We were delighted to be able to meet indoors for a pre course dinner, in tables of six, in the new on-site hotel. This was much appreciated by delegates and Faculty alike and helped to fuel informal clinical

discussions face-to-face that have been so lacking during the pandemic. The course was aimed at independent surgeons either consultants or senior trainees wanting to perform aortic dissection surgery including complex total arch replacement. It provided a unique opportunity to gain hands-on experience of aortic dissection scenarios, supervised by an expert faculty. All operating delegates were able to perform a cadaveric total arch replacement using a Thoraflex ™ Hybrid prosthesis, and we are immensely grateful to Terumo Aortic for their ongoing support of the Masterclass.

We were joined by a fantastic Faculty, Professor Aung Oo from Barts, Mr Jorge Mascaro from Birmingham, Mr Graham Cooper from Sheffield and Mr Ahmed Othman from Liverpool. This enabled a lively and comprehensive discussion about operative strategies in dissection repair followed by close operative support for each pair of delegates in the operating room. We are indebted to Heart Research UK for their ongoing support in being able to provide hands on education in this complex and much needed area of aortic surgery. As always, the Masterclass was heavily oversubscribed and we will be providing further courses going forward as soon as we are able to. We would like to thank Keele Anatomy & Surgical Training Centre for their support in prioritising this course as their first one to resume post pandemic, and we appreciate this particularly as the supply of cadavers has dramatically reduced due to new regulations as a result of COVID 19. Thanks also to Kevin Austin from Wetlab, for lending instruments to us free of charge. Finally, a huge thankyou to all delegates and Faculty for your energy and enthusiasm, it is great to be back!! n

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Hybrid workshops:

“The best of both worlds” Ishtiaq Ahmed – Consultant Cardiac Surgeon, Royal Sussex County Hospital Momna Sajjad Raja, Sahil Modi, Yasmin Dhuga – all 4th-year medical students, Brighton and Sussex Medical School

Introduction Since 11th March 2020, the quality of surgical teaching medical students has plummeted with the suspension of elective theatres, practical skills workshops, and less opportunities to attend placements. During these unprecedented times, the inevitable increased use of technology and web-based resources has revolutionised the landscape of medical education. There has been a shift from traditional classroom-based education to e-learning, including virtual lectures, simulations, and remote practical skills workshops. Although this pivot has made learning more accessible, surgical education has historically required practical hands-on teaching with immediate feedback. Previous critiques have been made that lack of interaction and difficulty obtained adequate camera angles make remote workshops The wetlab in the main lecture room where the attendees used animal tissue

unappealing. On the other hand, remote workshops are more accessible as participants from across the United Kingdom can attend. Some feel that this format is “virtually” the same and may be more sustainable in the long-term.

Hybrid set-up: “Remote but not distant” A hybrid work is a synchronous workshop where face-to-face and remote attendees are taught simultaneously. They are a novel alternative which promotes flexible and accessible learning trailed to individual’s needs. As a part of the International Cardiothoracic Conference hosted by Brighton and Sussex Medical School’s cardiothoracic surgical society, we offered students the opportunity to attend hybrid aortic valve replacement workshops. The attendees were given the chance to state their preference (virtual or in-person) based on their comfort level and ability to travel. Because of the virtual nature of the conference set-up, we were able to connect to expert speakers which may otherwise may not have been possible. This included Dr Karen McCarthy (Co-lead of Cardiac Morphology at the Royal Brompton)

who gave the attendees valuable insight in aortic valve morphology, including the normal aortic valve and aortic valve disease, conduction pathways and implications during surgery. This equipped attendees with knowledge that they required for the workshops. The hybrid workshop had a total of 12 stations; eight in-person stations (Wetlab) and four virtual stations (Drylabs). The wetlabs were set-up in the main lecture theatre with sixteen attendees participating. As this was our first hybrid event, four virtual stations (drylabs) were set-up in four separate side rooms. All required equipment for the drylabs was delivered in a ‘grab-and-go’ box which could easily have been set-up in any of the attendee’s room. This included a laptop, camera, and a prepared station. All 10 drylab attendees received instruments regarding The virtual set-up (DryLab). The ‘graband-go’ box was delivered with all the required kit; Laptop (including software camera and light) instruments

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Mr Ahmed with both the wetlab teaching station (in front) and the virtual drylab teaching station (behind)

the set-up, software, and the session programme a week before the workshop. This venture was only possible due to the collaborate efforts of Edward Lifesciences, Connexon365 and Wetlab Ltd.

Feedback We had a diverse training grade of attendees, ranging from year 1 of medical school to foundation year 2 doctor. All candidates were sent out post-workshop questionnaires. Out of 24 attendees, 15 attendees (10 wetlab attendees and 5 drylab

attendees) replied. The feedback received was extremely positive with attendees rating it a 9.7 out of a total of 10. 100% of attendees said they would attend a similar event in the future and recommend it to a friend. 100% of the attendees in the dry lab found the virtual set-up “easy” to use and were “extremely satisfied”. When asked to rate it out of 10, they gave a score of 9.6, 9.6 and 9.4 for the overall platform, audio, and video.

Conclusion Despite the challenges and limitations, the future of surgical education encompasses of such hybrid events. They are an excellent alternative with the optimal blend of in-person and

remote opportunities, which can be catered to the attendee’s preference. With the time for surgical training reduced and requirement for practical skills to be reinforced, surgical education needs to respond to trainee needs. Simulations and virtual wetlabs enable trainees to develop this purposeful practice from the comfort of their own homes. Due to the positive feedback received, we hope to deliver more hybrid/virtual events in the future without warranting concerns regarding the quality of teaching. n

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50th Anniversary of Ionescu’s Pericardial Heart Valve Concept Sunil Ohri, Suvitesh Luthra I will not lose; either I win or I learn. – Marian Ionescu, circa 1971 Marian Ionescu – pursuing his passion for mountaineering

he pericardial heart valve concept is the remarkable legacy of a man and his genius. His single most defining contribution has changed the course of cardiac surgery over the last half a century and benefitted millions of patients worldwide. Since the initial design by Hufnagel of the ball-cage valve implanted in the descending thoracic aorta (1953) to correct a regurgitant aortic valve, nearly 150 valves have been designed and tested. None has stood the test of time as well as the pericardial valve. Since the first successful human implant of the pericardial valve in the mitral position in 1971, 10 million of these have been implanted worldwide. Pericardial valves now constitute 80% of all implanted valves. The invention has driven a multibillion-dollar

industry that today forms the backbone of the healthcare technology sector. It was a stroke of Ionescu’s genius, industry and tenacity that among all the materials available at the time such as polyurethane, ivalon, fascia lata and dacron, he finally chose glutaraldehyde treated bovine pericardium to construct his valves. To arrive at this point Marian Ionescu had already been on a 14 year journey of invention which started in 1957 and included the threepronged coronet design of the aortic valve used to this day. Over the last five decades, we have now realized that pericardium has four unique defining characteristics – pliability, durability, resistance to infection and thromboembolic resilience that make it unique among materials for valve design. It can also be crimped that makes its use possible for catheter-based valves – all of which are pericardial. Ionescu’s original concept of a pericardial valve was reimagined using percutaneous catheter delivery by Alain Cribier in Rouen, France in 2002. FDA granted its approval in 2012 for commercial use which spawned a second revolution of the pericardial valve concept. These pericardial catheter-based valves have already outpaced surgical valve replacements and 280,000 are set to be implanted each year by 2025. What Ionescu recognised 50 years ago about the unique properties of pericardium, has been borne out by five decades of scientific data, evidence and validation from millions of implanted pericardial valves around the world. This successful journey started on 4th April 1971, at Leeds, UK where Marian Ionescu implanted the first pericardial valve in the mitral position. This was designed and perfected by him and handsewn by his wife

and cardiologist Christina Ionescu. The StarrEdwards ball cage valve and the Bjork-Shiley tilting disk valves in the previous decade had both been mechanical valves with problems of noise, thromboembolism, structural fatigue and carried the bane of lifelong anticoagulation. Despite multiple design modifications, BjorkShiley valve was discontinued by Pfizer in 1987 and the Starr-Edwards valve by Edward Lifesciences in 2007. The pericardial valve from its very inception circumvented all these problems and unlike the mechanical valves which were designed by engineers, the pericardial valve was designed by a surgeon. Between 1971 and 1976, 212 patients received these hospital made valves. None of the patients was anticoagulated beyond the initial six weeks. Clinical and laboratory tests, haemodynamic investigations, at rest and during exercise, were performed on 110 patients (51 aortic; 44 mitral; 12 multiple and Sunil Ohri with his Ionescu medal

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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 postimplantation. These studies demonstrated excellent function, better than with porcine valves and equal to the best mechanical valves1. Later, issues of tissue abrasion and cusp tears due to stresses on the pericardium at the struts were managed by unique design modifications including double layer reinforcements and internally mounted commissures. The ‘father of the pericardial valve’ – Ionescu himself made another astounding discovery in 1985. After statistical analysis of the two largest series of patients with the Ionescu-Shiley pericardial valves implanted between 1971 and 1987 in patients of all age groups (Denton Cooley’s series of 2720 patients and Marian Ionescu’s series of 1171 patients) he found that calcification of the pericardial valves occurred more rapidly in The Ionescu-Shiley Pericardial Xenografts

younger patients than in those older than 70 years. Calcification by this time had been identified as the main cause of long-term structural valve degeneration (SVD) and failure. The use of various anti-calcification treatments during manufacture to slow the degeneration of the pericardial valves however remained without much evidence. The second-generation pericardial valves implanted after 1987 were thereafter restricted to patients above 70 years resulting in much slower valve degeneration and superior long-term performance. A contemporary series (Bourguignon et al) with the later iterations of the pericardial valve has reported actuarial valve related survival of 62.4% ± 9.0% at 20 years in a cohort with mean age of 68 years at implantation2. Remarkably, after a follow up of 24.8yrs, the age and gender adjusted life expectancy of patients following pericardial mitral valve replacement was the same as the general population. Most contemporary pericardial valves have a 100% freedom from structural valve deterioration at 5-7 years (Doenst et al)3. Patients over the age of 70 years seldom, if ever, require reoperation for structural deterioration. Expected valve durability for pericardial mitral valves has been estimated at 16.6 years, ranging from 11.4 years in those less than 60 years to 19.4 years for those over 70 years. The varying definitions of SVD make comparisons difficult between studies, particularly older studies when pericardial valves were implanted in younger patients. The overall, all cause re-operation rate including for SVD and endocarditis is 2.5%/valve-year without stratification for age. Bourguignon et al reported 37.1% ± 7.4% actuarial 20-year freedom from reoperation. The reported incidence of pericardial valve endocarditis is 0.5- 1% per patient per year. The incidence in more recent series has been no different from other valves although prognosis is improved as infection is better treated

“I was blessed by the Goddess Fortuna with the creation of the pericardial valve, and I am grateful, but I shall be greatly satisfied if a better or perfect heart valve is created mainly for the benefit of patients.” Marian Ionescu, December 2020

Detailing on the front (l) and reverse (r) of the Ionescu medal

with antibiotic therapy. Freedom from endocarditis is 94.8% ± 1.4% at 20 years. The pericardial valves are particularly resilient to thromboembolism (<0.5% per valve-year). Valve thrombosis is rare for pericardial surgical valves. Bleeding and embolism is usually related to other patient co-morbidities like age, anticoagulation for other causes, atrial fibrillation and impaired cardiac function. Marian Ionescu’s passion, imagination, inventiveness and perseverance to develop the pericardial valve was ignited in 1957 while working as a research assistant to Effler and Kolff at the Cleveland Clinic. He learnt from those who attempted, failed and partially succeeded before him. He experimented, reinvented, persevered and succeeded where others failed. The quest for the perfect heart valve however still continues with research in artificial materials that are equal in strength, inertness, flexibility and thromboembolic resilience to bovine pericardium. Ionescu’s vision of a valve that would last the life of the patient and be completely resilient to thromboembolism remains an unachieved goal which drives worldwide research and development for a perfect heart valve even today. n References: 1) Ionescu MI, Smith DR, Hasan SS, Chidambaram M, Tandon AP. Clinical Durability of the Pericardial Xenograft Valve: Ten Years’ Experience with Mitral Replacement. The Annals of Thoracic Surgery. 1982 Sep 1;34(3):265–77. 2) Bourguignon T, El Khoury R, Candolfi P, Loardi C, Mirza A, Boulanger-Lothion J, et al. Very Long-Term Outcomes of the Carpentier-Edwards Perimount Aortic Valve in Patients Aged 60 or Younger. Ann Thorac Surg. 2015 Sep;100(3):853–9. 3) Doenst T, Borger MA, David TE. Long-term results of bioprosthetic mitral valve replacement the pericardial perspective. Journal of Cardiovascular Surgery; Turin. 2004 Oct;45(5):449–54.

Reprinted with kind permission of the British Journal of Cardiology (BJC). First published online 2nd June 2021. https://bjcardio.co.uk/2021/06/50th-anniversary-ofionescus-pericardial-heart-valve-concept/

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Non-NTN Ionescu Fellowship in Advanced Cardiopulmonary Failure Strategies Sharp Memorial Hospital, California, USA David Quinn - Trust Consultant in Advanced Cardiopulmonary Failure Strategies and Aortovascular Surgery, Queen Elizabeth Hospital, Birmingham

n March 2019 I was awarded the non-NTN Ionsecu fellowship to spend six weeks from September – October 2019 at the Sharp Memorial Hospital, San Diego, California, USA as an observer to their heart failure surgical practice. The chief of cardiac surgery and contact to organise and mentor me was Dr Walter Dembitsky with Drs Rob Adamson, Karl Limmer and Craig Larson as colleague cardiothoracic and vascular surgeons, Dr Joe Bellezzo as the lead Emergency room surgeon and Kristine Ortiz (and her team) as transplant/left ventricular assist device co-ordinator. This private hospital’s cardiothoracic surgical unit is practiced and proficient in treating acute and chronic heart failure, either with heart transplantation and/or short and long term mechanical circulatory support (MCS) devices. They were involved from the very inception of modern implantable left ventricular assist device (LVADs) into US medical practice, participating in many of the clinical trials of either bridges to transplantation or destination therapy and in doing so gaining considerable experience with the evolving models and designs and with patient selection. Dr Dembitsky is a regular

invited speaker to the US and European medical services, lecturing on the clinical and service delivery issues surrounding LVADS. Their experience in using LVADS as destination therapy is particularly relevant as I am a co- investigator on a National Institute for Health Research systematic review grant to investigate the clinical and health-economical impact of destination therapy in the UK. The specifics aims of the fellowship were to examine areas of practice that differ from the UK:

Transplantation • Organ retrieval service provision in the US • Transplantation from LVADS

Short-term mechanical circulatory support: • Delivery of extracorporeal membrane oxygenation (ECMO) services • Management of lower limb reperfusion • Left ventricular venting techniques • Extended cardiopulmonary resuscitation (CPR) patient selection and delivery

“Overall, there was a lot to learn about how to focus on the key issues that make a difference, how to change services to maximise the impact and how to work in concert with other services.”

Left ventricular assist devices: • Destination therapy (DT) patient selection • Anticoagulation strategies for short and long term MCS • Prevention/management of drive line infections • Managing RV dysfunction in long term LVADs • Nursing management of short term MCS patients (rolling, psychological outreach LVAD clinics • Pre-habilitation and rehabilitation of long term LVAD patients There were four main areas I wanted to highlight: 1) Retrieval services in the USA better provided for and can achieve a much higher recovery rate of cardiac organs after team dispatch compared to the UK. Donor hospitals are well remunerated for donation and SNODS attached to each hospital monitor for potential donors, so ensure no donation opportunities are missed should they later meet criteria to donate. Donor optimisation and is the responsibility of the donating hospital and commences as soon after brains stem death declaration through serial transthoracic echocardiography and cardiac output studies and routine coronary angiography in patients over 40 years of age with risk factors. Retrieval teams are dispatched from the recipient hospital which can lead to cumbersome staffing in the theatre but all are senior surgeons experienced in implantation. Provision for jet flight and helicopter-based transport was routine over 200 miles transport and I was lucky enough to attend a retrieval during my

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fellowship. Use of organ care systems was in its early stages but gathering pace. 2) Emergency short term MCS was patientcentric, working backwards to reorganise the service around best outcomes. This took an organisational cultural change identifying emergency medicine clinicians best placed to achieve ECMO in a timely fashion. They had constructed teams and protocols for patient management from the emergency room to the intensive care or general wards. Locally accredited intensive care unit (ICU) nurses provided the rapidly mobile pre-primed ECMO circuits and mobile equipment cupboards to the patient within minutes of arrest. Following institution of ECMO, patients were automatically taken to the cardiac catheter laboratory for echocardiography, consideration of lower limb reperfusion and/ or IMPELLA catheter insertion and coronary angiography before admission to intensive care. Insertion. ECMO circuits were then reprimed by the ICU nurses for the next event. An internationally recognised course (REVIVE) is

now established by the department biannually to teach teams techniques and protocols while ICU nurses gain/keep their accreditation through monthly hospital-based (refresher) courses in delivery and management of ECMO courses. 3) Destination therapy LVADS are an unfunded area interest in the NHS. I spent considerable time with their highlyexperienced team of LVAD co-ordinators and clinical psychologists learning how they assessed patients suitable for DT and how they ran their multidisciplinary meetings. It was clear that even mild dementia, lack of patient motivation and lack of family support were important considerations if DT were to be deployed. They also ran joint pre- and post-operative outreach clinics with referring clinicians to increase patient satisfaction and create an atmosphere of inclusivity. The importance of post-operative clinical psychological support for these patients was reinforced and something not well addressed in the NHS.

4) This team had also reduced their drive line infections rates to less than 5% with aggressive protocols for prevention through patient contracts to ensure patients attend clinics as soon as possible with any signs of trauma or erythema, intensive dressing change training and aggressive surgical treatment should infection occur with some spectacular successes. There were many other impressive aspects of delivery of care, driven by the minutely billing for surgery which enabled enormous efficiency drives. Overall, there was a lot to learn about how to focus on the key issues that make a difference, how to change services to maximise the impact and how to work in concert with other services. Of course, there was much Southern California hospitality to be enjoyed during this stay, including surfing, kayaking and relaxed atmosphere. I would particularly like to thank Walter, Rob, Karl, Craig, Christine and her team and all the intensive care staff for the attention to me and the valuable advice. n

New Roles and Appointments Congratulations to the following ... Role

Name

SCTS Thoracic Committee Chair

Aman Coonar

SCTS Trustees

Betsy Evans, Andrew Parry

SCTS Representative on CEG Lung Cancer & Mesothelioma

Aman Coonar, Syed Qadri

SCTS Representative BTS/SCTS Cross Society Working Group

Mike Lewis

SCTS Women in Cardiothoracic Surgery Sub-Committee Co-chair

Karen Booth

SCTS Education Communication Lead

Vivek Srivastava

SCTS Education Trust Appointed Doctors Lead

Zahid Mahmood (Cardiac), Kandadai S Rammohan (Thoracic)

SCTS Education Transplantation Lead

Espeed Khoshbin

NAHP Representative

Bhuvana Krishnamoorthy

SCTS Trust Appointed Doctors Thoracic Education Lead

Kandadai Rammohan

SCTS Equality, Diversity & Inclusion Co-chair

Indu Deglurkar

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SCTS-Ionescu NTN Travelling Fellowship 2019 Elaine Teh

irstly, I am very thankful and grateful for the generosity of SCTS and Mr Ionescu for the fellowship. All my consultants who had completed a fellowship in their peri-CCT years outside their training deanery unanimously agreed that it was probably one of their best years in training, recalling it with such fondness that it was almost contagious. It is therefore sacrilegious for me if I were not to consider the same. But, what to do, where to go? So many possibilities! As I sat down to seriously consider the options and what specific skill I really want to acquire in my last chapter of training, a remark once made by a boss I very much respected re-surfaced. He said to me, “Elaine, the operations you would do as a consultant would be very different from what you trained for.” How true it is! The last decade has confirmed that the sky is the limit where technology and innovation is concerned. Who would have imagined we can now talk to our devices using Siri and Alexa technology on a daily basis and that Elon Musk’s almost outrageous dream of commercial space travel might soon be a reality in our lifetime? With this in mind, I wanted to acquire the tools and framework in my independent practice to continually improve outcomes and safety for my patients. The idea suddenly came to me when I was out running one evening – I would find a post-graduate course in surgical innovation and consolidate the learning with a practical example applied to the latest surgical technology in thoracic surgery. The postgraduate certificate in Surgical Innovation offered by Imperial College London is the first programme of its kind in the UK. It is a multi-disciplinary programme with first-hand experience of applying new technologies to surgical management of patients, clinical risk management, educational research, research methods and patient safety. Exactly what I was looking for, except the practical component of the programme which leads to a MSc does not include thoracic surgery as a discipline. However, with the flexibility offered by the SCTS-Ionescu Travelling Fellowship, I could

basically make up my own practical element. I would consolidate and apply the principles of the course to robotic lung resection by spending some time under the tutelage of Mr S Stamenkovic in Barts Thorax Centre. The Centre provides cancer services to more than 1.5 million people and is the tertiary referral centre for thoracic surgery. The latest report showed that it has the best surgical resection rates for lung cancer in the country. There is a dedicated 25-bed thoracic ward, with access to critical care beds when required. It has state-of-the-art equipment and technology. It is the regional Cyberknife treatment and the only centre with a dedicated Da Vinci Xi for thoracic surgery. The other major advantage is the availability of dualconsole unit incorporating simulator training which is accessible to me 24/7. This allowed me sole access to the simulator without having to share it with other specialties, therefore ensuring a consistent and rapid acquisition of robotic surgical skills. Besides a highvolume robotic centre, Barts Thorax Centre has very active research programmes and is a recognized training centre for navigation bronchoscopy, robotic surgery, image-guided thoracic centre and cyberknife radiosurgery. I started my robotic fellowship in Barts in the midst of Covid pandemic. However, I was very fortunate. There was a brief respite when I started. Restrictions eased as the incidence of Covid fell with the lock-down and thoracic services, especially robotic thoracic service, in Barts resumed to almost pre-pandemic level. As the simulator was readily available to me, I quickly acquired the basic competence. I was able to use the simulator every evening for the first few weeks and completed online learning modules via the Da Vinci Intuitive Community platform. The only disadvantage caused by the pandemic was the absence of in-service training assessment with the Da Vinci rep or visits to recognized European Da Vinci training centres. However, this did not have a negative impact on my learning. The

readily available simulator and the prowess and attitude of Mr Stamenkovic as a trainer, with immediate feedback via recordings of the operations, enabled me to be console/ primary operating surgeon in anatomical lung resection and I performed my first sublobar anatomical RATS lung resection within four weeks of starting my fellowship. There was a rather steep learning curve at the start. I had an optimal first case but since then encountered quite a few difficult cases either with hyperinflated lungs, extensive adhesions or difficult anatomy. But, it only served as an impetus to learn and master various techniques in robotic dissection to the extent that I was able to operate independently without Mr Stamenkovic present in theatre by case no 15. Other than focusing on robotic thoracic surgery, I partake in all the usual activities within the department – teaching and mentoring of junior colleagues and all clinical duties expected of a ST thoracic trainee. There was a tremendous flexibility in my working schedule and between us, we worked out a schedule that suits the department and my learning needs. The robotic team at large in Barts were extremely dedicated and motivated. They were extremely supportive and patient with me, putting up with me as I find my feet, bearing with my endless questions and all done with a smile! As I write this and coming towards the end of the fellowship, once again Covid has wreaked havoc like never before seen. The mutated variant has caused the number of cases and deaths to increase day-by-day and we are back to combat-mode. But I am extremely pleased to be able to achieve 20 robotic anatomical lung resections, including eight atypical segmentectomy and assisting in robotic sleeve lobectomy. All in all, I have thoroughly enjoyed my fellowship and am very grateful to Mr Stamenkovic and the team in Barts for making me part of their team, albeit only for a short period of time. n

EPIC ™ SUPRA AORTIC STENTED TISSUE VALVE WITH LINX ™ AC TECHNOLOGY

Epic. By Design.

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SCTS/Ethicon Fellowship 2021 – Lung Transplantation and ECMO in Toronto Muhammad Izanee Mohamed Mydin, Lung transplant surgery and ECMO Fellow, Toronto General Hospital

Observership in Toronto First of all, I would like to thank SCTS and Ethicon for this amazing opportunity to work in one of the world’s leading transplant centres. I had previously been to Toronto to be an observer under Dr. Keshavjee in 2017. This was part of their selection process for any fellowship applicant, and functioned as an interview for them! I was due to start in October 2019 but unfortunately, due to various reasons, I had to postpone it to January 2021. I am also ever so grateful to my wife who had to take a career break (from ICU nursing) and look after both our kids.

Quarantine Eyal (surgical fellow) and I with our first harvest of a full heart-lung block – for a heart-lung transplantation

I left the UK at the peak of the third wave of COVID19. Travelling during the pandemic is a surreal experience – empty airports and planes; closed shops and constant health checks. I had to quarantine for two weeks in Toronto prior to starting, which was frustrating! I spent time listening to the many teaching sessions organized via Teams. We had a lung transplant surgery fellows’ induction on Teams organized by Dr. Laura Donahoe who became the new fellowship director. I still remember one of her opening lines – ‘all the fellows must be available 24/7 unless they take annual leave!’

MDT approach Preparing the patient trolley for taking a COVID ARDS patient who was remotely cannulated in a neighbouring town

It is a demanding but fruitful fellowship. All surgical fellows who are selected have already completed their training. Therefore we all have been given free rein in managing the lung transplant patients on a day-to-day basis. The staff surgeons were kept apprised

August 2021

tracheostomies for our ECMO and lung transplant patients, as well as the bronchoscopies and BALs.

Lung transplant Despite the pandemic, we have done 45 lung implants in three months. I started to implant lungs as a first operator in the first week of arriving. Two fellows are assigned to each lung implant, and as a rule each fellow will be implanting one side. I have done a total of 15 lung implants (as a first operator) in three months despite the pandemic, including sick patients with pulmonary hypertension (some were on bridging ECMO). Anaesthetic staff (Dr. Foley and Toronto prides itself in Xin) taking a candid shot during our implant of Canada’s first teaching and training – helping post COVID ARDS lungs programs all over the world by sending trained surgeons back. Every step of the operation is taught in to their patients’ progress via daily emails that meticulous detail, and everything is done in we sent. a standardized fashion. Most of the implants Again, this is very much a MDT are done on ECMO (usually central V-A approach and I was impressed at the close ECMO, occasionally V-V ECMO or both); working relationship of the surgical fellows and some off pump. Cardiopulmonary with the respiratory, Transplant ID, and bypass is rarely used in TGH – this is only the ICU team. We are tasked with looking done for concomitant cardiac procedures. after patients in all aspects – surgical, Thanks to Dr. Cypel, I was lucky immunosuppression and medical. Dr. enough to implant the left lung in Canada’s Keshavjee’s vision is to train all-rounded first post-COVID ARDS lung recipient surgeons who will be able to step up and (already on pre-operative bridging ECMO). take a leadership role in their own units – Dr. Waddell took me through my first lobar especially in countries where the transplant transplant. I have seen three redo lung infrastructure is limited. We do one week of transplants in the three months (including lung transplant surgery calls (24/7) where paediatric lungs which we implant in Sick we are the ‘Chief ’; organizing the fellows in Kids’ Hospital). terms of jobs, implants, retrievals and then do Additionally, I came to learn from the another week (24/7) of ECMO calls. world’s largest Ex-Vivo Lung Perfusion Program (EVLP) – this has allowed TGH to seek and use extended donor criteria/ marginal lungs with a good results. They The pandemic added a new dimension to have performed over 747 EVLPs – there is the busy program – ECMO for COVID a dedicated EVLP rota staffed by surgical ARDS. The critically unwell COVID cases started increasing, followed by the new variant patients who were younger and sicker. Our team also provides an ECMO retrieval service to hospitals around GTA and Ontario. Two surgical fellows go with one or two ICU Staff Intensivists and a perfusionist. We now have 27 patients on V-V ECMO for COVID. The surgical fellows independently cannulated these patients. I have done at least 20 cannulations for ECMO – including five (l-r) Myself, Cristina (surgical fellow) and Dr. Granton on another remote remote cannulations in the GTA area. ECMO cannulation and retrieval We also perform all the percutaneous

Third Wave – COVID19

research fellows. I have spent some time with the EVLP fellows to learn how to correctly set up, assess and recondition these lungs. Additionally, I have also learnt the decision making process in proceeding to implant.

Teaching Surgery is not just about operating. Learning about the assessment and selection process of recipients is crucial. There is a lung transplant assessment MDT that occurs every Thursday. It was great to observe these great minds sitting together, discussing often complex patients and making decisions and plans for them. We also have to present at the weekly donor review M&Ms on Fridays, and the monthly lung transplant M&M. Every Wednesday mornings – there is the MOT Grand Rounds – teaching presented by a Staff or a fellow from the MOT service covering all aspects of MOT. I feel that going abroad on a fellowship is worthwhile, not only in collaborative working, learning from and teaching others; making new friends; but also working in a different health care system. I know that I can count on the staff surgeons, respirologists and intensivists here for advice and mentorship when encountering a complex problem in the future. My experiences post CCT have broadened my horizon, and opened my eyes to what is truly possible, in the name of improving patient care and outcomes. I am truly grateful for the opportunity given to me by SCTS and Ethicon, and I will definitely use my skills, knowledge and experience that I gained here to help push UK lung transplantation further for the benefit of our patients. n

Glossary of terms: COVID19 – SARS-Coronavirus 2 ECMO – Extra corporeal membrane oxygenator LAT – Locum appointment for training (now extinct) NTN – National Training Number LVAD – Left ventricular assist device RVAD – Right ventricular assist device MOT – Multi Organ Transplant service BTT – Bridge to transplant ARDS – Acute respiratory distress syndrome CCT – Certificate of completion of training M&M – Morbidity and mortality meeting GTA – Greater Toronto Area TGH – Toronto General Hospital

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Thoracic Surgery Resident Association (TSRA) Collaboration and Current United States Pathways of Training Abdul Badran, Jason Trevis, Clauden Louis, Yihan Lin

hallenges and difficulties in training have come to the forefront, not least due to the recent COVID pandemic which has impacted on every aspect of healthcare but also, perhaps disproportionately, the training grades in surgery. A silver lining to the pandemic has meant a more integrated and global response to challenges and problems. We have reached out to our North American colleagues to understand how the training in our specialty is delivered there and will be working together on training and research initiatives to work out the best way to navigate through the times ahead. It is a pleasure to include a short introduction to the TSRA, as well as the cardiothoracic training pathways currently available.

Thoracic Surgery Residents Association: Pathways for cardiothoracic training in the United States Since its establishment in 1997, the Thoracic Surgery Residents Association (TSRA) has been the official representative organization for thoracic surgery residents across the United States and North America. Trainees become members of the TSRA upon their enrollment in a thoracic surgery residency program that is accredited by the Accreditation Council of Graduate Medical Education (ACGME), and membership is maintained until the completion of residency. The TSRA endeavors to provide for trainees within the pillars of education, community, research, and career advancement. Resources produced by the TSRA are used internationally, and membership is similarly open to residents beyond North America.

The cardiothoracic surgery specialty has successfully faced many paradigm changes and innovations in training. As the field of cardiothoracic surgery aims to train the best and brightest residents, we seek to assess and objectively identify the driving interest of resident trainees regarding cardiothoracic surgery, as well as identify areas of concern regarding attrition of the general surgery applicant. At present, several issues including limited seats in training, work-life balance, attrition following non-cardiothoracic pathways, prolonged training, and advanced average age with retiring experts continue to threaten impending shortages in manpower.

In this discussion, we review the pathways of training cardiothoracic surgery as this is a necessary first step to understand and effect change in the US systems with transferable lessons that can be applied internationally. Currently, there are three training pathways in cardiothoracic surgery, including: Independent Programs known as the “Traditional Pathway”, an “Integrated Pathway” and a Joint Thoracic and General Surgery Track known as the “Fast-track pathway” that are all completed at one institution. The “Traditional Pathway” consists of the completion of a general surgery

August 2021

or vascular surgery residency, followed by additional cardiothoracic training. Medical students apply to general surgery or vascular residency, which consists of five clinical years and often includes two additional years of research. During the 4th year of residency, they apply to cardiothoracic fellowship. Fellowships are two or three years in length. Fellows are trained in both cardiac and thoracic surgery, however some programs may track residents into focus on one pathway. Following successful completion of training, residents can apply for certification by both the American Board of Surgery and the American Board of Thoracic Surgery. Additional experience, if desired, can be obtained in several different fellowship opportunities, including heart failure/ transplantation, thoracic aortic surgery, congenital heart surgery, or thoracic surgery. As of May 2021 there were 74 independent programs for the traditional pathway for trainees who completed either general or integrated vascular surgery training. The “Fast-track Pathway” also known as “Early Specialization Program” consists of four years of general surgery followed

by three years in cardiothoracic surgery, all completed in one institution. Medical students can apply to general surgery residency programs that offer a fast-track pathway. Residents interested in fast-track programs generally apply formally or informally after their 2nd year of general surgery residency. Residents who complete this track are eligible for board certification by both the American Board of Surgery following the General Surgery portion and the American Board of Thoracic Surgery following completion of the cardiothoracic training. As of September 2020 there were 19 fast-track programs. The “Integrated Pathway” consists of six clinical of years of cardiothoracic surgery. Some programs require or recommend an additional one to two years of research. Medical students apply directly to an integrated cardiothoracic surgery residency program, like standard applications for other residency programs. The overarching objective of this training program is to provide a more comprehensive and rational total immersion in the diagnosis and management of all aspects

of cardiovascular and thoracic diseases through multidisciplinary training, including rotations in interventional radiology, interventional cardiology, endovascular surgery, oncology, and pulmonary disease. Upon completion of an integrated residency, residents are eligible to sit for American Board of Thoracic Surgery certification, but not for the American Board of Surgery certification as this pathway provides only partial general surgery exposure. As of May 2021, there were 33 programs listed as thoracic surgery integrated residency programs with majority programs accepting one applicant annually. As we attempt to elucidate the factors motivating the decision to pursue Cardiothoracic Surgery among applicants, it is evident that the various pathways may address needs that are independent to each path among graduating medical students and general surgery trained individuals. The TSRA will continue to assist with early clinical exposure and positive mentorship as these may prove to be critical for cultivating interest in Cardiothoracic Surgery among applicants. n

New Consultant Appointments – February 2021 to August 2021 Name

Hospital

Consultant or Locum Consultant

Starting Date

Mr Umar Rafiq

Royal Papworth Hospital, Cambridge

Consultant Cardiac/Transplantation Surgeon

September 2020

Mr Joyce Thekkudan

Blackpool Victoria Hospital

Locum Consultant Thoracic Surgeon

January 2021

Mr Ali Zamir

Blackpool Victoria Hospital

Locum Consultant Thoracic Surgeon

January 2021

Miss Elaine Teh

Leeds Teaching Hospitals NHS Trust

Locum Consultant Thoracic Surgeon

February 2021

Ms Rashmi Birla

Golden Jubilee National Hospital, Glasgow

Consultant Cardiac Surgeon

March 2021

Miss Louise Kenny

Freeman Hospital, Newcastle

Consultant Congenital Cardiac Surgeon

May 2021

Ms Alessia Rossi

Essex Cardiothoracic Centre, Basildon

Locum Consultant Cardiac Surgeon

May 2021

Mr Hatam Naase

Essex Cardiothoracic Centre, Basildon

Locum Consultant Thoracic Surgeon

June 2021

Mr Eshan Senanayake

University Hospitals, Birmingham

Locum Consultant Cardiac Surgeon

June 2021

Mr Gopal Soppa

Liverpool Heart & Chest Hospital

Consultant Cardiac Surgeon

July 2021

Mr Simon Messer

Golden Jubilee National Hospital, Glasgow

Consultant Cardiac/Transplantation Surgeon

August 2021

Mr Saleem Jahangeer

St James’s Hospital, Dublin

Consultant Cardiac Surgeon

Q4 2021

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Obituary: Raymond Lambert Hurt 1922-2020 Steve Edmondson, Consultant Cardiothoracic Surgeon, Chief of Surgery, Barts Health

aymond Hurt, who has died at the age of 98, was for many years a great supporter of our society, a founding member of one of our earliest travelling clubs and one of the earliest recipients of the Evarts Graham travelling scholarship. However, for many cardiothoracic surgeons who passed through his unit at the North Middlesex hospital, he will be remembered as an extremely kind, polite and patient teacher and trainer who regarded every operation as a training case. Raymond trained at St Bartholomews where he qualified in 1944 at the age of 21. In his first house appointment he was assigned by chance to the thoracic surgery department, under JH Roberts and Os Tubbs, which was to determine his future career choice. After further house and junior surgical appointments, national service and a period as resident surgical officer at the Brompton, in 1952 Raymond returned to Barts as registrar and senior registrar until his consultant appointment in 1959. Whilst RSO at the Brompton working for Sir Clement Price Thomas, in 1952 Raymond founded Pete’s club, one of the earliest of the society’s long tradition of travelling clubs with his colleague Peter Jones.

This was on the understanding that members presentations about their work should follow the simple rule “no case presented shall throw credit on the presenter”. Raymond remained secretary of the club for the whole 37 years from its beginning in London to its last meeting in Vancouver in 1989. As the Evarts Graham travelling scholar in 1955 Raymond spent a year with Frank Gerbode in San Francisco working on “the new heart lung machine”. Following his return to Barts, Raymond designed a “double pump” machine (Barts Hospital J, research Supplement No 4 October 1963) before the Dennis Melrose classic cardiopulmonary bypass machine was adopted and for which before the advent of clinical perfusionists, Raymond acted as lead technician-perfusionist in addition to his normal clinical duties. For his new consultant appointment, in 1959 Raymond joined Michael Bates at the regional thoracic unit at the North Middlesex Hospital where he remained until the unit’s transfer to the Middlesex Hospital in 1985. During those 26 years, through Raymond and Michael’s dedication, the North Middlesex gained a reputation as an outstanding thoracic surgical training centre. A reputation enhanced by the twice yearly highly successful FRCS course in thoracic surgery and the publication in 1986 of their book, Essentials of Thoracic Surgery, based on the teaching course. Raymond was also a regular contributor during this time to reference editions on thoracic surgery and subsequently was editor and chapters author of The Management of Oesophageal Carcinoma published in 1989 after his retirement from clinical practice. Raymond demonstrated endless patience assisting from skin to skin in every operation in his service no matter how complex the case or inexperienced the registrar. Many consultant cardiac and thoracic surgeons, myself included, remain grateful for the hugely supportive training provided by Raymond early in their careers.

Amongst his other achievements whilst at the North Middlesex, Raymond was Hunterian Lecturer at the Royal College of Surgeons in 1981 and for many years surgical examiner at the Royal College for the FFA examination and for the PLAB examination for oversees doctors. After a short period at the Middlesex, Raymond rejoined us at Barts and in his own words “I was honoured to join the consultant staff of the hospital where I had trained as a medical student and junior doctor”. He remained at Barts showing the same undiminished commitment to teaching and training until his retirement in 1987. After retiring from clinical practice, Raymond embarked on a second career as a medical historian and was elected President of the History of Medicine section of the Royal Society of Medicine, the Harverian Society of London and the Osler Club culminating in 1996 with the publication of the highly acclaimed History of Cardiothoracic Surgery which he regarded as his “magnum opus”. In 2008 he published a biography of George Guthrie, the eminent Napoleonic wars surgeon and three times President of the Royal College of Surgeons. Raymond continued publishing articles on the history of medicine until 2014 when he was 92 years old. Despite his many attributes, our abiding memory of Raymond will be of his good humour, modest, generous nature and his unfailing kindness and politeness to all whom he met. In all the many hours he spent assisting and training junior surgeons, there was never a single report of anything other than this same equanimity and generosity of spirit. Raymond was predeceased by his wife in 2001 and leaves two children Susannah and Mark and his partner Carmen Beal. Raymond Lambert Hurt. Consultant cardiothoracic surgeon (b 1922; q St Bartholomew’s Hospital, London, 1944; FRCS (Eng.), DHMSA,) died from old age on 13th November 2020. n

the 66 bulletin

Crossword

Set by Samer Nashef

1 5 9 10 12 13 14 16 19 21 24 25 27 28 29 30

Please email solutions by 30/09/21 to: sctsadmin@scts.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE The winner will be randomly selected from successful solutions and will win either a bottle of ‘fizz’ or fine olive oil. Congratulations to Margaret Huang for winning the January 2021 Bulletin crossword competition (right) who chose a fine bottle of olive oil as her prize.

Across Top sturdiest construction for 19 (8) Employ first judge for 19 (6) The type of drink some tosser pseudo-intellectual knocked back (8) Tails partner on purpose to begin with? That covers it (3, 3) Be suspicious to find me among all-star cast (5, 1, 3) Average temperature is indicated (5) 19 in ecstatic rapture (4) 19 BMWs at first securely parked (7) Polish clergyman rejecting work? That’s nonsense (7) Sounds like he would mind (4) Reminder to get naked: at last nothing is hidden (5) What made Londoners choke quietly as Europe disintegrated (3-6) It’s essential for Oxford to step back (6) This compiler before and after depression finally cleared name (8) 19 kittens? (6) Carte blanche for Spooner’s chorus (4, 4)

Down

1 2 3 4 6 7 8 11 15 17 18 20 21 22 23 26

Stylish medic losing a composition (6) Eliot keeps a sword in many a tent (6) Perfect trade is my job (5) Part of the garden where leader slips free from restriction (7) Finally, police force investing two thousand in high street competition (1-8) Turmoil’s rising. What’s rising? Hot stuff’s rising (8) Named party crossed dotted line, perhaps (8) Bust a gut to include men only (4) Once more, state of Eritrea reformed these extremists (9) Learn tap-dancing while pregnant (8) At one’s beck and call to find a place to sleep in the East right away (8) Bob’s wish (4) One hangs on to stuff, but without love, it’s more difficult (7) Fairy corrupting priest (6) I’m leaving acrimony to ferment in a drawer (6) Lightweight uniform previously packaged (5)

Upcoming Events Date/s

Event

23rd September

28th Birmingham Review Course

Virtual

24th September

SCTS Board of Representatives

Royal College of Surgeons/Hybrid

15th October

SCTS Executive Committee

Virtual

22nd November

SCTS Programme Committee

Royal College of Surgeons

PERCEVAL PLUS ®

THE OPTIMAL MIX Facilitates Minimally Invasive Surgery

Designed for Durability BASED ON A CLINICALLY PROVEN TECHNOLOGY

FREE INNOVATIVE FREE TISSUE TREATMENT

UNIQUELY SUITED FOR ViV* PROCEDURES

VIABLE FOR MULTIPLE VALVE PROCEDURES

SIMPLIFIES COMPLEX PROCEDURES

Available to a Wide Patient Population * Valve-in-Valve

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Manufactured by:

Sorin Group Italia Srl

A wholly-owned subsidiary of LivaNova PLC Via Crescentino - 13040 Saluggia (VC) Italy Теl: +39 0161 487472 - Fax: +39 0161 487316 info.cardiacsurgery@livanova.com

LivaNova Canada Corp.

5005 North Fraser Way Burnaby BC V5J5M1 - Canada Tel: 1-604-412-5650

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INDICATIONS: Europe - The Perceval Plus prosthesis is indicated for the replacement of diseased native or a malfunctioning prosthetic aortic valve via open heart surgery. The prosthesis is indicated for use in adult patients who are diagnosed to have aortic valve stenosis or steno-insufficiency. TOP POTENTIAL SIDE EFFECTS: The risks or potential adverse events associated with cardiac valve replacement with a bioprosthesis include, but may not be limited to: cardiac arrhythmias, death, endocarditis, heart failure, hemorrhage, intravalvular and/or paravalvular leak, stroke or any related neurologic disorders, structural valve deterioration, reoperation and explant. Beyond the previously mentioned adverse events, specific events related to the implant of the Perceval Plus prosthesis may include, but not be limited to dislodgment and/or migration of the prosthesis. The decision to make a transcatheter aortic valve implantation in Perceval Plus compared to other options should be done by the Heart team based on individual assessment of the patient’s conditions. The safety and efficacy of Valve-in-Valve procedures in a Perceval Plus valve have not been established. Valve-in-Valve procedures in a Perceval Plus valve should be performed according to indications provided by the transcatheter valve manufacturer. The decision of using Perceval Plus in patients should be based on a careful individual assessment and limited to cases in which the benefits of using Perceval Plus justify the risks. The available clinical data indicate that using Perceval Plus in patients with other prostheses may result in intraoperative valve misplacement or insufficient leaflet coaptation leading to valve replacement, due to possible interference with the other prostheses. MRI conditional. For professional use. Please contact us through our website to receive instructions for use containing full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Not approved in all geographies. Follow your labeling.

IM-01985 E

Perceval Plus, an ideal solution for minimally invasive surgery, makes sutureless aortic valve replacement available to a wide patient population Designed for valve durability Based on more than 10 years of successful clinical experience with Perceval.

ABBOTT MECHANICAL HEART VALVES Regent, Masters HP and Masters

AORTIC VALVE

MITRAL VALVE

IMPLANT CONFIDENTLY. CAUTION: This product is intended for use by or under the direction of a physician. Prior to use, reference the Instructions for Use, inside the product carton (when available) or at eifu.abbottvascular.com or at medical.abbott/manuals for more detailed information on Indications, Contraindications, Warnings, Precautions and Adverse Events. This material is intended for use with healthcare professionals only. Data on File at Abbott. Information contained herein for DISTRIBUTION in Europe, Middle East and Africa ONLY. Check the regulatory status of the device in areas where CE marking is not the regulation in force. Abbott International BVBA Park Lane, Culliganlaan 2B, 1831 Diegem, Belgium, Tel: 32.2.714.14.11 ™️ Indicates a trademark of the Abbott Group of Companies. www.cardiovascular.abbott ©️2021 Abbott. All rights reserved. 9-EH-1-12392-01 06-202