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Issue 03

January 2018

Society for Cardiothoracic Surgery in Great Britain and Ireland

4th International Cardiothoracic Surgery Careers Day p26 Cardiothoracic Surgery Training: What we think p22

Visit to Marmara University Hospital, Istanbul p42

Of Men And Mountains (Retirement or Resurrection or Reincarnation) p48


st rax ve Posth o

Sternum stability What we have seen with the vest Our mediastinitis frequency decreased from 2.2 % in 2011 to 0.6 % in 2012! They do not have so much pain. Hans Jonsson MD PHD Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital Stockholm

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January 2018

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In this issue...

5

3

Society for Cardiothoracic Surgery in Great Britain and Ireland

From the President

Graham Cooper

7

82nd Annual SCTS and CT Forum Meeting and Ionescu University

8

11

13

15

SCTS - How engaged and inclusive can it be?

Simon Kendall

Nursing and Allied Health Professional update

Helen Munday

Tara Bartley

SAC Report

Rajesh Shah

16

Thoracic Surgery Audit Update

18

Doug West

SCTS Education Report December 2017

Sri Rathinam, Narain Moorjani

20 SCTS Education Tutors’ Report

Carol Tan, Sunil Bhudia

22 Cardiothoracic Surgery Training:

What do we think and how can we improve?

Jacob Chacko, Ahmed Al-Adhami

24 Welcoming to Leicester

The First Edition of the SCTS Research Meeting 2017

Marius Roman

26 4th International Cardiothoracic

Surgery Careers Day Harvey George

28 Cardiothoracic Surgery &

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34

SCTS Nursing and AHP Education Portfolio Update

24

Clinton Lloyd

Student engagement Where are we now? Aman Coonar

The Contract Conundrum - My views Duncan Steele

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36

37

38

39

The British and Irish Society for Minimally Invasive Cardiac Surgery - 2nd annual meeting Bilal H Kirmani

Aortic Dissection Awareness Day 2017 - A huge success Christina Bannister

Book review - Minimally Invasive Mitral Valve Surgery Sean Bello

Patient Portraits: A New You Christina Bannister

Nursing & Allied Health Professional Research Developments Julie Sanders

40 Photo at Discharge (PaD): How

Cardiac Surgery is Improving Information to Patients and Carers and Links to Community Melissa Rochon

42 Visit to Marmara University

Hospital, Istanbul, to learn advanced management of Pectus deformities

45

The Christiaan Barnard I Knew

Mehmood Jadoon Richard Page

50

48 Of Men And Mountains

(Retirement or Resurrection or Reincarnation) Marian Ion Ionescu

52

53

Mitral Valve Repair Training at the Bristol Heart Institute: A Fellow’s Perspective

Hunaid Vohra, Daniel Burns

Yorkshire Trainees Win Top European Cardiothoracic Knowledge Competition M Loubani

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Robotic Mitral Valve Repair The Least Invasive Complete Repair Marc Gillinov

56

57 58

The Heart Club Tom Treasure

Upcoming Courses - 2018 United Kingdom Aortic Surgery Alex Cale

59 New Consultant Appointments 60 Obituary: David Ian Hamilton 62 Crossword


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January 2018

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From the President One of the most enjoyable aspects of my role is visiting or taking part in the various courses that we put on. It always astonishes me just how many people contribute to these courses and all the other activities of SCTS. Simon Kendall’s piece illustrates just how many people actively contribute to SCTS. Graham Cooper

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t this year’s Medical Student Engagement Day, held on Saturday 28th October, I was impressed by the number of colleagues who had given up a Saturday to talk about why they were cardiothoracic surgeons and what it meant to them. Even more impressive was the large number of medical students who had given up a Saturday and travelled from all over the country to Sheffield for the event. And not only medical students, we extend invitations to sixth formers of local schools in socially deprived areas and many come. The success of this initiative is undeniable, Aman Coonar provides a report later in this Bulletin, but the biggest testament to the value of this engagement is in the unsolicited letter received from Dixon’s City Academy. A similar letter from an inner city school earlier this year noted ‘We have also

seen a much larger interest in pupils wanting to become cardiothoracic surgeons...’ Cardiothoracic surgery remains the most competitive surgical specialty to gain a place

Congratulations to Gavin for organising this and also for being appointed as Specialty Research Lead for Cardiothoracic Surgery at the Royal College of Surgeons of England. I know that Gavin has an ambitious strategy to develop a national research network and a list of research priorities that will further strengthen research within cardiothoracic surgery in Great Britain and Ireland. Another recent highlight was the ST3a course. Once again the enthusiasm and ability of the delegates was impressive. On this course, as on all of the courses that we run, the dedication, enthusiasm and commitment of the Faculty and Course Directors are outstanding and crucial to the success of the courses. Notable for me is the increasing number of female surgeons. When 60% of medical student are women, the question ‘why are there not more female surgeons?’ is often asked. We currently have fourteen female consultant members, giving the specialty a lower number of female consultants than the national average of 11% across all surgical specialties. This proportion will inevitably increase as we have three times the number of female trainees as we have consultants. Of our trainees, overall about one third are women. For those in ST7&8 the proportion is 24%, however in ST1&2 the proportion is 53%. The 2018 Annual Meeting in Glasgow is shaping up very nicely and, with best wishes for the New Year, I look forward to seeing you there. n

“Another recent highlight was the ST3a course. The dedication, enthusiasm and commitment of the Faculty and Course Directors are outstanding and crucial to the success of the courses.”

4th International Cardiothoracic Surgery Careers Day (page 26)

for higher surgical training both at ST1 and ST3. There are many reasons for our specialty’s popularity but an important one is the opportunities such as this that we afford sixth formers and, along with this, the wider opportunities that we afford medical students to be part of SCTS. I was not able to attend the wetlab held in the afternoon as I drove to Leicester for the first National Cardiothoracic Research Meeting, organised by Gavin Murphy. Again, there was an impressive turnout for a Saturday, from both medics and allied health professionals. The presentations were very strong. This event will, I am certain, become a fixture in the calendar.


January 2018

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82nd Annual SCTS and CT Forum Meeting and Ionescu University The 82nd Annual SCTS Ionescu University, SCTS and CT Forum meeting and will be held 18th – 20th March 2018 and, for the first time, will be held in Glasgow. The Scottish Exhibition Centre (SEC) promises to provide another excellent venue for the Ionescu University on the Sunday, and the main SCTS meeting and CT Forum (Nursing and Allied Health professionals) on the Monday and Tuesday. Clinton Lloyd (on behalf of the meeting team)

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bstract submission closed at the beginning of November with over 500 abstracts submitted. By now all applicants have been informed of their acceptance for the meeting with over half having been accepted for either oral, posters or movie presentation on the Monday and Tuesday. If you have not received confirmation, please contact Isabelle Ferner at sctsadmin@scts.org.

We have again had tremendous support from Industry and the Exhibition Hall will open at 5.30pm on the Sunday at the end of the University, with drinks and canapes. The main theme of the meeting during the Plenary session on the Monday will encompass team dynamics and the evolution of the modern workforce within the current

Isabelle Ferner, the lead Conference Organiser, and Tilly Mitchell, the Exhibition Organiser, can be contacted by email or directly at the SCTS offices with any questions or concerns. (Contact details on www.scts.org) Finally, please note that we will be advertising for a new meetings team deputy secretary in December this year with the aim of appointing during the Glasgow meeting. If you are keen to be involved in this great event and want the chance to help organise and liaise between the many working groups of the Society, then please apply.

“The CT Forum Ionescu University incorporates both cardiac and thoracic Wetlab training for the day which have proved to be very popular in the past.”

Registration opened on 1st December 2017 and please follow the link https://scts. org/annual-meeting/ to register. For the SCTS Ionescu University, you will be able to select your themes incorporating Thoracic Surgery and Adult Cardiac Surgical streams. The faculty comprises leading invited European and Overseas speakers and specialists in their areas of expertise who will both debate a number of contemporary issues and provide updates on latest techniques and guidelines. We have re-introduced industry led ‘lunchbox sessions’ on the Sunday which will allow for a full day of education for those wishing to attend. The CT Forum Ionescu University incorporates both cardiac and thoracic Wetlab training for the day which have proved to be very popular in the past.

NHS and incorporates the presidential address. The Monday will also include the congenital, transplant and mechanical support sessions with Trainee sessions on both the Monday and Tuesday. Tickets for the Annual Dinner held on the Monday evening at The Grand Central Hotel are available through the registration process and prizes from last year’s meeting will be presented.

We look forward to seeing you in Glasgow.

Kind Regards The Meetings team: Clinton Lloyd – Secretary Maninder Kalkat – Deputy Secretary Enoch Akowuah – Treasurer Helen Munday – CT Forum lead Isabelle Ferner – Lead Conference Organiser Tilly Mitchell – Exhibition Organiser n


the 8 bulletin

SCTS - How engaged and inclusive can it be? How many of us fully understand the role of a professional society? Simon Kendall, Honorary Secretary

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n 2012 we updated our year 2000 constitution and the four ‘Objects’ for SCTS are pretty broad head-lines:

https://scts.org/wp-content/uploads/2016/ 10/Constitution-Amended-July-2012.pdf 1. encouraging and promoting excellence in the

practice of cardiothoracic surgery

2. encouraging innovation in and scientific

understanding of cardiothoracic surgery

3. promoting, undertaking, encouraging and

assisting in research in cardiothoracic surgery 4. advancing the education of the public in

cardiothoracic surgery

Out of these headings we might assess ourselves as ‘Good’ for promoting excellence and education but ‘Could do better’ for science and research. The annual meeting is a reasonable forum to share academic progress and we are now fortunate to have Professor Gavin Murphy leading the SCTS Research Committee as one of his many roles to lead and coordinate cardiothoracic research. SCTS is a membership organisation. Initially formed in 1934 by a group of thoracic surgeons with a shared passion to advance their specialty, it went on to adopt cardiac surgery as those innovative thoracic surgeons embraced the new era. SCTS is independent. Independent of the NHS and independent of the Colleges of Surgeons. It is not a trades union which is the remit of the BMA and the Hospital Consultants and Specialists Association.

So, as a self funded and a membership organisation it is for the members to choose the agenda through the Executive, the Board of Representatives, the Annual Business Meeting.

calls from landlines. But technology aside, SCTS has changed the way it works to help this agenda. In all his roles in SCTS (as Meeting Secretary, Honorary Secretary and President) Graham has placed engagement and communication with the membership as the number one priority and has determinedly led all of us to change our society for that purpose.

And facing outwards the Executive will represent the membership on matters of cardiothoracic surgery when approached by organisations such as EACTS, NICE, Public Health England, RCS, NHS, BCS et al. This makes engagement and communication between all of us in cardiothoracic surgery the cornerstone of SCTS. This has been made so much easier and instantaneous with email, the website and social media - our ability to receive and transmit has been transformed from the days of posted letters and phone

Annual Meeting (6 organisers, 25 scientific programme committee and scorers) Now has over 1000 delegates from a total membership of 817 (264 consultant members, 87% of consultant workforce) (Less than 300 delegates in 2005) Board of Representatives (57 members) A biannual meeting with representation from every unit, started in 2007

The Executive Trustees

President President-elect Honorary Secretary Honorary Treasurer Lay Representative

6 elected trustees 9 co-opted members (non-voting members)

Chair of the SAC Chair of the Cardiothoracic Exam Board Chair of the AHP Committee Chair of the Clinical Audit Committee Meeting Secretary Trainee members x 2 Perfusion Representatives x 2


January 2018

The executive meets 3 times a year as well as the Board of Representatives and ABM Sub Committees It is only six years since SCTS channeled its entire agenda through the executive. Now we have 7 committees that have regular teleconferences and an annual meeting at the AGM: Congenital - (11 members with a representative from each unit) Thoracic - (11 members) Cardiac - (8 members) Audit - (8 members) Education - (20 members) Research - (11 members) Allied Health Professionals - (10 members) Education Where do you start to try and describe the education agenda in our humble specialty? A decade ago we could only have dreamed of SCTS aspiring to deliver its current portfolio, but due to a lot of hard work by all concerned and the support of Marion Ionescu and collaboration with

corporate partners, we are very proud of achievements so far. Number of annual courses: 11 NTN and 4 non-NTN Number of delegates: over 300 Number of faculty: 55 (all SCTS members) Allied Health Professionals (81 members) As touched upon already, the SCTS was originally ‘surgeons only’ but even they could appreciate they weren’t achieving things on their own. This provoked the subtle change to the name of the society* in 2006 and was symbolic of a profound change in the way we work - from ‘I’ to ‘We’, from ‘Mine’ to ‘Our’. The previous year around 30 AHPs joined the surgeons at the AGM in London and, hard to believe now, at the time it was an intimidating experience for many of them. Their confidence and their agenda have flourished with a strong Ionescu University and a rolling educational programme. Number of annual courses: 3 Number of delegates: 210 Number of faculty: 32

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SAS and non-NTN doctors (54 members) These are colleagues who can expect better from SCTS. They are essential to cardiothoracic surgery and yet we have been slow to understand their needs and issues. This is now being addressed with some urgency. Number of annual courses: 2 Number of delegates: 30 Number of faculty: 12 SCTS will continue to evolve, but at its core the members should feel they are getting value for their subscriptions and part of that ‘value’ is that they able to participate and interact in their professional society. This brief article shows some measure of that inclusion and involvement, but we can still do better. Just as those thoracic surgeons formed their club in 1934 to enjoy sharing their passion for their surgery and advance their specialty, we should hopefully have the same feelings for our society, and everyone feels able to be involved. * Name changed from ‘Society of Cardiothoracic Surgeons’ to ‘Society for Cardiothoracic Surgery’ n

To discover more, contact your local Fannin Representative Westminster Ind Est, 2-4, Repton Rd, Measham, Swadlincote, DE12 7DT • Tel: 01530 514566

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SCTS Annual Meeting 2018 scottish events campus, GLASGOW 18-20 march

SCTS Ionescu University Sunday 18th March A day of educational sessions

Main Meeting Programme

Monday 19th March to Tuesday 20th March Main Plenary Session – Team Development Presidential address GIRFT Update Abstract presentations and invited guest lectures

SCTS CT Nurse Forum

Sunday 18th March to Tuesday 20th March Interactive Teaching Wetlab day (Sunday) Launch of the SCTS Nursing and AHP Research Group For nurses and allied health professionals Discounts available to group bookings – Buy 5 get 1 FREE

Annual Dinner

Monday 19th March, Grand Central Hotel Limited Half Price Annual Dinner Tickets for CT Forum

Up to 18 CPD Points Early Bird Registration Rates now available. To Register or view the detailed programme please visit www.scts.org

Society for Cardiothoracic Surgery in Great Britain and Ireland


January 2018

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Nursing and Allied Health Professional update 2018 will mark the 70th anniversary of the National Health Service and it is hard to imagine just how far healthcare has progressed in that time. Helen Munday, SCTS Nursing and AHP Representative

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s a result, healthcare providers are frequently required to consider new ways of working, in ways that will maintain quality and drive productivity for the same financial outlay. For nurses and allied health professionals these challenges have provided immense opportunities, where the quality of service can be measured and maintained and staff experience greater job satisfaction. The blurred boundaries that co-exist between roles have led to an evolution of multi-disciplinary teams in hospitals and the importance and value of team working in the healthcare setting is now the rule rather than the exception. Nurses and allied health professionals are integral to the team with the patient at the centre of everything we do. It is not uncommon in my own organisation to have a nurse practitioner, pharmacist and physiotherapist as regular attendees of the daily ward round contributing to the decision-making with the patient. We are also seeing a growing rise in support workers across the disciplines, without whom, patient care and safety would be significantly compromised. Our aim is to address some of these issues at the cardiothoracic forum at the SCTS annual meeting in Glasgow next year where there will be the opportunity to hear about innovative practice, team engagement and patient experience, (amongst other things), as well as networking opportunities and an exhibition of products and devices for patient benefit.

The Nursing and Allied Health Professional Cardiothoracic Forum at the SCTS Annual Meeting.

focus of the plenary talks will be around multidisciplinary teamwork and team engagement, and the impact this has on patient experience.

Planning is well underway for the 2018 Cardiothoracic Forum (CT) at the SCTS annual meeting to be held in the Scottish Event Campus (SEC), Glasgow in March. Furthermore, for the fourth year, nurses and allied health professionals (AHPs) will have the opportunity to attend the ever-popular CT Forum stream at the SCTS University on the Sunday, ahead of the main meeting. This day emulates the two day advanced cardiothoracic course in a condensed format with two half-day sessions dedicated to cardiac and thoracic procedures. It is an interactive wet-lab day for nurses and AHPs to experience putting in chest drains, replacing heart valves and performing bypass surgery, to name but a few of the procedures on offer. There are also skills stations for cardiac pacing, radiograph interpretation, CT imaging and ECG amongst others.

We will be hearing from the 2017 winners of the SCTS Ionescu Nursing and AHP Fellowships who were:

All stations are led by an extremely enthusiastic and knowledgeable multi-disciplinary faculty and feedback from delegates is consistently highly rated. It’s a very enjoyable, highly practical day which offers excellent educational value. I would like to extend my thanks in advance to the entire faculty and also the company representatives for their on-going support and participation in the university day. The CT Forum programme is coming together to deliver a variety of presentations from nurses and AHPs around patient experience, service development and advanced practice as well as cardiac and thoracic specific sessions. The

Louise Best, Emma McIntosh & Roy Pittendriegh from the Royal Sussex and County Hospital, Brighton – who were planning to visit several UK hospitals as well as the New Orleans Conference in the USA to learn about innovations and best practice in the US whilst combining their trip with a visit to the Mayo Clinic, Minnesota. Rachel Brown from The Mater Misericordiae University Hospital, Dublin who was going to be visiting several hospitals in the UK to look specifically at enhanced recovery programmes after thoracic surgery, particularly in respect of lung volume reduction surgery and pectus programmes, which are areas of development in her organisation. Noirin Kearney from the Royal Victoria Hospital, Belfast – the purpose of Noirin’s placement was to observe advanced nurse practitioner (ANP) practice at Liverpool Heart and Chest Hospital and Blackpool to enable her to further develop the role of the ANP role within her own unit. The winners of the SCTS Education Ionescu Nursing and AHP Fellowships 2018 will be announced at the meeting in Glasgow. The Society is optimistic that this educational >>


the 12 bulletin

opportunity to support visits to cardiothoracic centres will continue, so I would recommend that you consider applying in the future and please do advertise the opportunity within your organisations. The advert generally goes out in the autumn with a December deadline and winners announced at the annual meeting in March. We will also be launching the Nursing and Allied health professional Research Group (NARG) in Glasgow under the guidance of Dr Julie Saunders, Director Clinical Research, Quality and Innovation, Barts Health and SCTS Nursing and AHP Academic and Research Lead. More information about this exciting development can be found in Julie’s article in this issue of the Bulletin. The postgraduate Nurses and Allied Health Practitioner day at EACTS was planned by nurses and allied health professionals from the UK, the Netherlands, and Denmark led by Richard van Valen, an Advanced Nurse Practitioner from Rotterdam. The 2017 postgraduate day was held on Sunday October 8th 2017 in the Convention Centre, Vienna. n

EACTS 2017 Christina Bannister, Nurse Case Manager

The SCTS CT Forum top marking presentation, Natalie Lambie from Golden Jubilee, Glasgow was invited to present at the meeting, and nurses from London, Brighton, Birmingham and Manchester also presented. We listened to plenary talks from Specialist Nurses, Allied Health Practitioners and Surgeons from across Europe and the States. We shared knowledge and experiences with other nurses and health care professionals from across Europe during the day, and gained many insights into differing ways of working. Once again, the presentations were peer reviewed and EACTS provided an award

for the best presentation. The 2017 award was jointly given to Rianne Rijsdijk, a SCP from Utrecht for her presentation on ‘Innovations: 100 procedures in 100 days, training of the SCP’ and Richard van Valen, an ANP from Rotterdam for his presentation on ‘Negative Pressure Wound Therapy on closed wounds, a real option?’ Congratulations go to both Rianne and Richard and our thanks go to EACTS for their continued support. n

SCTS Annual Football Cup Saturday 17TH MArch

SCTS Annual Dinn

5-a-side competition

2018

Monday Venue : POWERLEAGUE Glasgow 19th Septemb 1 Kennedy St, Townhead, Glasgow G4 0EB

Grand Central Hotel 99 Gordon Street, Glasgow City Cen

Kick off 4pm |

Cost : £10 a team

The tournament is open to all cardiothoracic This ticket includes Drink, 3 course me centres, deaneries, andWelcome corporate groups.

Dress Code: Black Tie & Cocktail Dresses. *Quilts welcome ó (TFHMJXYTQJF[J

To register your team please contact Jalal BinSaeid : jalal.binsaeid@nhs.net Registration Deadline 3rd March


January 2018

SCTS Nursing and AHP Education Portfolio Update We are delighted to announce that the SCTS Nursing and Allied Health Professional Education, in conjunction with Cardio Solutions and Abbott, are able to offer their entire portfolio. Tara Bartley, Advanced Nurse Practitioner, Birmingham Hospitals NHS Trust

T

he generous support of Cardio Solutions and the use of the new Abbott Education facility in Solihull has enabled the full provision of the education portfolio at minimal cost to delegates. The portfolio includes:

With the exception of the SCTS Core Principles Cardiothoracic band 5 & 6 course and the Master Classes in Cardiothoracic Surgery all courses will run at the new venue which is ideally located and has excellent

pre and post level of learning, assessed by the delegates themselves over the three day course, as well as the exceptionally positive feedback. The course represents significant value for money at just £20 per delegate.

“The Core Skills course will continue to run at venues around the country to enable delegates to access more easily, rather than having to travel to attend.”

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The SCTS Advanced Cardiothoracic Course

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SCTS Core Principles Cardiothoracic Band 5 and 6 Course

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Developing an Advanced Allied Health Professional Practitioner Service Course

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The Theatre Nurse Course

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Surgery Skills in Cardiothoracic Surgery

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SCP Revision Course

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Non-medical Prescribing in Cardiothoracic Surgery

facilities and amenities close by. The Master Surgery Skills in Cardiothoracic Surgery will run in Manchester on 10th April 2018. The Core Skills course will continue to run at venues around the country to enable delegates to access more easily, rather than having to travel to attend. The most recent course ran in Brighton in October 2017, and was an overwhelming success as measured by the

There are plans to take the new Non-Medical Prescribing in Cardiothoracic Surgery to Middleborough during 2018. The aim of this course is to provide an update on hot-topics in non-medical prescribing, a focus on cardiothoracic pharmacology as well as providing a useful CPD opportunity for established non-medical prescribers.

Details for all the 2018 courses will be added to the SCTS website, Nurses and Allied Health Professionals page and we very much look forward to you joining us. Please encourage your colleagues to consider joining the Society as associate members. The annual rate for nurses and AHPs is £30 per year (with a one-off joining fee of £30). Compared to many professional memberships, this represents extremely good value for money given the reduction for associate members in the annual meeting registration – put simply, it pays for itself. Associate membership allows access to many of the educational opportunities offered through the SCTS and access to areas on the SCTS website that are restricted to members. n

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ANNUAL DINNER2 CTSSCTS Annual Dinner Monday 19th September monday 19TH MArch

2018

Grand Central Hotel 99 Gordon Street, Glasgow City Centre G1 3S Grand Central Hotel

99 Gordon Street, Glasgow, G1 3SF

ket includes Welcome Drink, 3 course meal and ent Tickets £65.00

e & Cocktail Dresses. *Quilts (TFHMJXYTQJF[J8 Limited Halfwelcome Price Ticketsó Available to Nurses and AHP’s *([JSZJFY Tickets available to buy online when registering for the Annual Meeting

Welcome Drink, 3 course meal and entertainment Welcome Drinks from 19:30 Carriages 01:00 Dress Code: Black Tie & Cocktail Dresses (Kilts welcome)

Sponsored by


January 2018

15

SAC Report It will be a year since I took office as SAC chair and I would like to use this section to reflect on the achievements in the first year as SAC team and plans going forward. Rajesh Shah, SAC Chair Cardiothoracic Surgery • Curriculum Change: Significant work has been done to change the curriculum. Submission has already been made to the GMC. A further meeting to discuss a way forward with the GMC is scheduled for 9th January 2018. SAC is optimistic but needs GMC approval. Colleagues who have contributed to this work include Andrew Goodwin, Sion Barnard, Tim Jones, Steve Clarke and the entire SAC team.

• Quality assurance of Transplant fellowships: Including fellowship survey done by Steve Clarke.

• Annual specialty reports 2016 /17 /

Quality of Consultants:

review of GMC / JCST surveys:

Annual specialty reports outlining the strengths / weaknesses of all the training programmes including review of the GMC, JCST survey has been undertaken by David Barron. • SAC Review of ROI: SAC was invited to review ROI programme which was successfully undertaken by Sion, myself and Amir Sepheripour in December 2016. • National selection 2017: A very successful National selection was run in Southampton with a very quality assurance report produced by the lay chair. Jonathan Hyde, Steve Rooney, Peter Hockey, Wessex deanery did an outstanding job of providing leadership and organization with support from SCTS members. • Quality assurance report for

National selection 2017:

Was led by Pat Forsyth, J Hyde, Steve Rooney and Peter Hockey. • Measuring success of Congenital Training Programmes: Report was done by David Barron confirming success in training congenital surgeons in UK.

• Review of ST1 Pilot: The pilot has been approved by the GMC, which now confirms the programme as being substantive. Prof. Jahangiri and Sarah Lay did an excellent job in facilitating GMC approval. • Impact of Training on In order to assess if training produces quality consultants SAC / SCTS is looking at evidence if it exists. This project is led by David Jenkins. • Review of CCT guidelines

including research:

• Development of cardiothoracic

trainee committee:

By Ahmed Al-Adhami and Jacob Chacko. Besides completing on Curriculum change and Impact of Training on Quality of Consultants project, the SAC is discussing the following projects: • Measuring Success of 10 years of National Selection: To be led by Sion Barnard and Jonathan Hyde. • Developing Workforce document:

SAC / SCTS joint project:

Led by Prakash Punjabi from SAC.

The CCT guidelines including research requirements have been reviewed by David Barron and Prof. Jahangiri.

• Assessing Impact of training on outcomes

• Developing CCT check list: To facilitate sign off against CCT guidelines Sri Rathinam has developed the CCT check list.

• SAC Quality reports for Programme

• Review of JCST Survey questions: New specialty specific survey questions with review of current ones has been done by Alan Soo. • Review of Exam pass rate

over the last 4-5 years:

Has been done by Mike Lewis. • Measuring success of SAC / SCTS

Education Curriculum aligned courses: This has been led by our Education secretaries and has been published in JTCVS in 2017. This is an outstanding piece of work by Sri Rathinam and Narain Moorjani.

in Thoracic surgery:

Joint SAC / SCTS project led by Sri Rathinam.

Directors / Deanery:

Led by David Barron. The above has been made possible with the help of excellent support from JCST team including Encarna Manzano, Maria Bussey, Susana Cipriano, Cristel Santos and Sarah Lay. As the chair of SAC, I appreciate, recognise and value the contribution made by Programme directors, STC members and all SCTS members who have made a huge contribution to training. It is a privilege and honour to work as Chair of the SAC and have an outstanding team of members to achieve all of the above in one year!! n


the 16 bulletin

Thoracic Surgery Audit Update The recent Board of Representatives Meeting in London provided an opportunity to review the current status of thoracic audit. Doug West, Thoracic Audit Lead

W

hile the Society thoracic returns now includes more than 35 years of data, the database project has wound down, to be partially replaced in England by the Lung Cancer Consultant Outcomes Publication (LCCOP). Since the BORS meeting we have seen the publication of the fourth LCCOP report, covering English lung cancer surgery in 2015. Activity has again increased, this time by 5% year-on-year, with sustained high survival rates at 30 and 90 days. The whole report, and individual unit PDF “dashboards” including local resection rates can be downloaded from SCTS.org. Please go and have a look. The National Lung Cancer Audit team have applied to continue providing this audit for HQIP for the net two years. As a national audit, LCCOP is exceptional in that it covers almost all activity in the country, and

has clinical validation of all cases. By contrast, the US STS general thoracic database and the ESTS database are “opt in” programs, and do not offer a wholenation perspective on outcomes. There are three areas where the Society is promoting further developments. Firstly, we would like to see more outcomes reported in LCCOP. This year has added unit-level one-year survival, and lobectomy data broken down by surgical approach. As mortality continues to show a very welcome decline, reporting it becomes paradoxically less useful as a means to measure quality- in future it may not happen often enough to be that useful. Reporting process measures like readmission levels, and operative details such as node dissection rates could help teams to continue to improve in this low mortality future landscape. Reducing morbidity and widening access to care may assume more importance.

Survival at 30 days, 90 days and one year after lung cancer resection in the first four years of LCCOP

Concerns about thoracic audit in Ireland and the devolved nations have been raised, at BORS and elsewhere. The Society is keen to work with Departments of Health and others to develop thoracic surgical audit across the British Isles, and we have extensive expertise to offer from within the Society. Colin Selby, a respiratory physician who has been involved in the Scottish Lung Cancer QPI initiative, has accepted our invitation to speak at the thoracic audit and QI session at our Glasgow meeting in March. There may be scope for the SCTS to work more closely with similar projects in future, in the same way that we have worked to support LCCOP south of the border. The third thoracic blue book early next year will report 35 years of the thoracic registry. It will document the significant improvements in quality of care and in hospital survival achieved by surgical teams during this period. Two other clear messages emerge from the data; a significant move to minimal access surgery across procedure groups, and a continuing increase in the volume of lung cancer surgery being performed. The data template for the returns has been changed a little this year to allow reporting of robotic cases, as well as updating of the mesothelioma descriptors to bring them into line with IMIG guidance. Remember that both the NHS data in LCCOP and the Society’s thoracic returns data can be accessed for local audit or for clinical research purposes. Please get in touch if you would like more details. Similarly, if you have ideas or reflections on how we can improve thoracic audit, I’d be keen to hear. n


2% CHG / 70% IPA didn't cut SSIs by 41%

*

ChloraPrep did ®

1

* compared with povidone iodine

ChloraPrep

®

Patient Preoperative Skin Preparation 2% chlorhexidine gluconate (CHG) & 70% isopropyl alcohol (IPA) For customer services and all other enquiries please telephone 0800 917 8776, email uk-customer-service@bd.com or visit chloraprep.co.uk. Prescribing Information: ChloraPrep & ChloraPrep with Tint 2% chlorhexidine gluconate w/v / 70% isopropyl alcohol v/v cutaneous solution. Refer to the Summary of Product Characteristics before prescribing. Presentation: ChloraPrep – each applicator contains 0.67ml, 1.5ml, 3ml, 10.5ml or 26ml of 20 mg/ml chlorhexidine & 0.70 ml/ml isopropyl alcohol; ChloraPrep with Tint – each applicator contains 3ml, 10.5ml or 26ml of 20 mg/ml chlorhexidine & 0.70 ml/ml isopropyl alcohol. Indication: Disinfection of skin prior to invasive medical procedures. Dosage & administration: Applicator volume dependent on invasive procedure being undertaken. May be used for all age groups and patient populations. Use with care in newborn babies and those born prematurely. Applicator squeezed to break ampoule and release antiseptic solution onto sponge. Solution applied by gently pressing sponge against skin and moving back and forth for 30 seconds. The area covered should be allowed to air dry. Contra-indications: Patients with known hypersensitivity to ChloraPrep or ChloraPrep with Tint or any of its components, especially those with a history of possible Chlorhexidine-related allergic reactions. Warnings and precautions: Solution is flammable. Do not use with ignition sources until dry. Do not use in excessive quantities, allow to pool in patient skin folds or drip on materials in contact with patient skin. Remove any soaked materials before proceeding with the intervention. Ensure no excess product is present prior to application of occlusive dressing. For external use only on intact skin, do not use on open skin wounds or broken or damaged skin. Over-vigorous use on fragile or sensitive skin or repeated use may lead to local skin reactions. Avoid prolonged skin contact. Avoid contact with eyes, mucous membranes, middle ear and neural tissue. Chlorhexidine may induce hypersensitivity, including generalised allergic reactions and anaphylactic shock. May cause chemical burns in neonates, with a higher risk in preterm infants and within the first 2 weeks of life. Pregnancy & lactation: Although no studies have been conducted, no effects are anticipated as systemic exposure is negligible. Undesirable effects: Very rare; allergic or irritation skin reactions to ®

Reference: 1. Darouiche R et al. N Engl J Med 2010; 362: 18–26. ©2016 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company.

chlorhexidine, isopropyl alcohol or sunset yellow (E110, present in ChloraPrep with Tint only), including erythema, rash, pruritus and blisters or application site vesicles, other local symptoms have included skin burning sensation, pain and inflammation. Frequency not known; hypersensitivity including anaphylactic shock, dermatitis, eczema, urticaria, chemical burns in neonates. Discontinue use at the first sign of local skin reaction. Per applicator costs (ex VAT) ChloraPrep: 0.67ml (SEPP) - 30p; 1.5ml (FREPP) - 55p; 1.5ml – 78p; 3ml – 85p; 10.5ml - £2.92; 26ml - £6.50. ChloraPrep with Tint: 3ml – 89p; 10.5ml – £3.07; 26ml £6.83 Legal category: GSL Marketing Authorisation Numbers: ChloraPrep, PL31760/0004 & ChloraPrep with Tint, PL31760-0001 Marketing Authorisation Holder: CareFusion UK 244 Ltd, The Crescent, Jays Close, Basingstoke, Hampshire, RG22 4BS. Date of Preparation: February 2016 Reporting suspected adverse reactions is important to monitor the benefit/risk balance of the medicinal product. Reporting forms and information can be found at www.mhra.gov.uk/ yellowcard. Adverse events should also be reported to CareFusion Freephone number: 0800 0437 546 or email: CareFusionGB@professionalinformation.co.uk


the 18 bulletin

SCTS Education Report December 2017

Learning is a four-way process is what they say…You learn, You retain, You become an expert but You are truly learned when you pass the wisdom to the next one! Sri Rathinam, SCTS Education Secretary Narain Moorjani, SCTS Education Secretary

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ducation is all about passing the wisdom, the skills and professionalism to our brethren. It has been a year in our new role as Education Secretaries and we have addressed a few of the challenges we faced.

Ethicon for their continued support and benevolence to allow SCTS to offer the fellowships for the continuous professional development of our members.

As tutors we embarked on uncharted waters, like Bernard Shaw said “you see things; and you say “Why?” But I dream things that never were; and I say “Why not?”. The ‘why not’ was a portfolio of free structured surgical simulation courses which we set up and nurtured; there are always parting pangs but we couldn’t have handed it over to better hands than Sunil Bhudia and Carol Tan.

• SCTS Education Marian and

The new tutors have delivered the portfolio very successfully particularly in the era of new contractual obligations with our industry partner. A great big thank you to Carol and Sunil and all the faculty for delivering yet another year of successful SCTS Courses. The curriculum change spearheaded by the SAC with SCTS support has been successful with specialty focus training to deliver future thoracic and cardiac surgeons.

SCTS Fellowships We are delighted to offer another round of various fellowships to all members of the SCTS starting from consultants, NTNs, non careers grade doctors, AHPs and Medical students. We are grateful for the generosity of Mr Marion Ionescu and

The categories are as follows and details are found in www.sctsed.org Christina Ionescu Travelling Scholarship for Consultants

• SCTS Education Ethicon Fellowship

• SCTS Education Ionescu Non-NTN Fellowship

• SCTS Education Ionescu Medical Student Fellowship

• SCTS Education Ionescu Nursing & AHP Fellowship

SCTS Courses NTN Portfolio The courses are progressing well with the 2017 regulations of Ethicon in place under the able oversight of the tutors Sunil Bhudia and Carol Tan. Carol and Sunil have detailed that in their report. We are pleased to report the JCST is impressed with our portfolio and they are now listed as mandatory courses. The attendance of these courses will now be reviewed at the annual ARCPS by the Training Programme Directors. The next stage is to assess the impact of the training at work place level. This includes objective MCQ assessment before and after sessions and OSATS

on specific procedures before and after course with local educational supervisors. We are delighted to report we have secured continued funding from Ethicon. However there is a change in the mechanism which allows SCTS freedom in running the courses but with the increased workload of administration of the courses ourselves. The manuscript detailing the programme of structured, curriculum-aligned cardiothoracic surgery training courses has been published with an invited editorial by JTCVS. Non NTN portfolio The non NTN courses continue their current structure under the able leadership of Maninder Kalkat and Uday Dandekar, with the aim to introduce a wet-labs component to complement current two courses in 2018. We have almost completed the workforce data which will enable better engagement of the non NTNs, with only 5 units outstanding. AHP The AHP portfolio is going from strength to strength with various courses mapped already. We have planned courses in 2018 in both previously held centres as well as in industry venues. We have secured robust industry support in supporting and sustaining this portfolio. Royal College of Surgeons of Edinburgh /SCTS Webinars The webinars have progressed successfully webinars on various cardiothoracic topics with accomplished national and international


January 2018

speakers, including Tirone David. Registration is free for anyone but archives are available for RCSEd members only. We urge trainees and consultants to make use of the useful resource for their continued professional development. Consultant Education The consultant fraternity was surveyed to understand their educational needs both on clinical and professional arenas to offer more courses to complement the well-established SCTS Ionescu University. Donald Whitaker’s survey offers insight into what the consultant membership expect from SCTS Education will help direct our future ventures aimed at our consultant members. We are delighted inform consultant colleagues that we have a provisional commitment from

Ethicon to run a faculty update training the trainer course and a consultant thoracic symposium in 2018. Acknowledging faculty We have submitted a proposal seeking the support of the SCTS Executive to acknowledge and facilitate the outstanding contributors to SCTS Education by way of

offering them Honorary Lectureships of SCTS. The proof of the pudding SCTS with the support of Ethicon are planning on holding a ‘real life feedback’ event in the SCTS AGM where newly appointed Consultant’s will be invited for a feedback meeting on how the portfolio helped them in settling into their new position as consultants. We are eagerly awaiting the event will reveal feedback that will underpin the future direction of the education agenda for trainees. We once again thank our industry partners for making this educational project possible for offering logistics and financial support. All of this would not be possible without the continuous hard work of Letty Mitchell our administrator. n

SCTS Education Operative Video Prizes • Cardiothoracic Surgical Trainees (NTN and non-NTN) are invited to produce an operative video, appropriate to their year of training • Prize for the best overall cardiac and thoracic video • The videos should be submitted as a high definition (HD), AVI or MPEG-4 video file, 4-8 minutes in duration, and can be made using any recording device, including smart phones, video cameras or professional equipment • Please include patient consent and consultant approval with the submission • If selected, the videos may be edited and included in an SCTS operative videos app • For further details, please contact Sunil Bhudia (SCTS Cardiac Tutor) or Carol Tan (SCTS Thoracic Tutor) at tutor@SCTS.org • Closing date 18th February 2018

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the 20 bulletin

SCTS Education Tutors’ Report We were appointed in December 2016 and were handed the baton from Narain Moorjani and Sri Rathinam. They had a “record breaking” stretch by anyone’s imagination and we have the task of maintaining the momentum with the busy SCTS education course calendar for cardiothoracic NTNs. Carol Tan, SCTS Thoracic Tutor Sunil Bhudia, SCTS Cardiac Tutor

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e would like to thank both of them for the work they did and the portfolio of courses they have developed for the cardiothoracic trainees. Having an established programme has made our transition easier. This first year has been an eye opener and we have had to get up to speed with our role on the job, quickly realising how much work is expected of us to continue delivering the courses and ensuring that standards are maintained. However, the task has been made very pleasant and fulfilling by the team working behind the scene. There has been support from Letty Mitchell (SCTS Education Administrator), SCTS Executive Committee, Cardiothoracic Surgery Specialty Advisory Committee, Training Programme Directors and our partners in the Industry. The courses will of course not be

deliverable without the dedication and commitment of Course Directors and Faculty, which is made up of at least 59 Cardiac and Thoracic consultants, and several others from allied specialties, many of whom have been teaching for a number of years, and many of whom teach on more than one course per year. We would like to express our gratitude to all involved in this successful programme which remains unique in specialty surgery.

“We have continued to run the courses as set up previously and with financial support of our partners in industry, these remain free of charge to all nationally appointed cardiothoracic trainees as long as they are members of the SCTS.”

We have continued to run the courses as set up previously and with financial support of our partners in industry, these remain free of charge to all nationally appointed cardiothoracic trainees as long as they are members of the SCTS. For the first time this year, the ST7B Clinical examination course for the FRCS (C-Th) was added to the portfolio and makes up the final 12th course as envisioned by our predecessors. The ST7B course was held in Papworth Hospital in September 2017, and received

positive feedback both from trainees and faculty. All trainees who attended this course and subsequently presented for Section 2 of the FRCS (C-Th) examination in October have passed. As much as we would like to solely base the success of the ST7B course on the FRCS (C-Th) pass rate, the utility of portfolio of courses needs to be assessed to demonstrate benefit to trainees and to our specialty in the long term, particularly to justify funding, time and effort for all concerned. In regards to practical courses where wetlab sessions and live animal operating sessions are involved (ST3A/B, ST4/B, ST6A/B and ST8A), we are adopting the Objective Structured Assessment of Technical Skills (OSATS) matrices to assess trainee performance for specific procedures taught on the course. These will be sent out to trainees before each of the relevant courses, for completion by a senior assessor, and the process will be repeated following attendance at the course. We expect that the OSATS should not add significant time to the clinical task and completion of the form showed take no more than 5-10 minutes. In addition to trainee feedback and assessment, we have been engaging with Course Directors and faculty as much as we are able to, and have encouraged Course Directors to produce a report after the conclusion of each course. This will ensure we are kept on our toes, and that any hiccups are reviewed and improvements are made for subsequent courses.


January 2018

“In addition to trainee feedback and assessment, we have been engaging with Course Directors and faculty as much as we are able to, and have encouraged Course Directors to produce a report after the conclusion of each course.” As with previous years, we are continuing to run the SCTS Education Operative Video Prize which is open to cardiothoracic surgical trainees, both NTNs and non NTNs. This has been popular over the past few years, and we are accumulating a substantial number of training videos which will soon be made available in an SCTS quality approved library of videos, accessible to trainees. Once again, the best cardiac and thoracic videos will be shortlisted by the SCTS tutors and SCTS education secretaries following this year’s closing

date (18th February 2018), but the winners will be voted by trainees at the SCTS Annual Conference during the Trainee meeting. Last year’s winners were Silviu Buderi for his video on Right VATS upper lobectomy, and Mohamed Elsaegh for his video on Minimally Invasive ASD Closure. For the coming year, we are in the process of developing a multidisciplinary course with the help of Mr Shahzad Raja, Consultant Cardiac Surgeon at Harefield Hospital. The one-day course

will be delivered by trained human factors personnel from The Royal Brompton and Harefield NHS Foundation Trust and aims to highlight the interaction between Behavioural Human Factors, Team Skills and Performance. Teams from each cardiac and thoracic unit in the country will be invited to this exciting course, which we believe will result in more effective team work and communication in the workplace, particularly in the scenarios of multiple complex conditions, emergencies and during care transition. Finally as we wish you a Happy New Year for 2018, there will be administrative changes with the SCTS Education office taking on the responsibility of logistical arrangements for faculty and delegates for the courses, reflecting the changes to financial support from our partners in Industry. We therefore urge all faculty and delegates to confirm attendance at the courses with SCTS Education as early as possible to allow sufficient time for travel and accommodation arrangements. Please do not hesitate to get in touch with us (S.Bhudia@rbht.nhs.uk) and Carol.Tan@stgeorges.nhs.uk) should there be any queries. n

Forthcoming SCTS Education Courses • 22nd-23rd January 2018 Intermediate Viva Course (ST5A)

Venue: Hilton Bracknell Course Directors: Donald Whitaker/Kelvin Lau

• 7th-9th February 2018 Cardiothoracic Surgery Sub-Specialty Course (ST6A and ST6B) Venue: European Surgical Institute, Hamburg Course Directors: Deborah Harrington/Michael Shackcloth

• 5th-8th March 2018 Revision and Viva Course for FRCS (C-Th) (ST7A) Venue: J&J Pinewood Campus, Wokingham Course Directors: Max Baghai/Jagan Rao

• 3rd-4th May 2018 Operative Cardiothoracic Surgery Course (ST3B) Venue: European Surgical Institute, Hamburg Course Directors: Rana Sayeed/Steve Woolley

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• 15th-16th May 2018 Non-Operative Technical Skills for Surgeons (NOTSS) Course (ST5B) Venue: Advanced Patient Simulation Centre, St George’s Hospital, London Course Directors: Tim Jones/Mike Lewis/Ian Hunt/ Gianluca Casali

• 18th-20th June 2018 Core Thoracic Surgery Course (ST4B)

Venue: Minimal Access Therapy Training Unit (MATTU), Guildford, Surrey Course Directors: Nilanjan Chaudhuri/Donna Eaton

• 9th-11th July 2018 Cardiothoracic Surgery Pre-Consultant Course (ST8A)

Venue: European Surgical Institute, Hamburg Course Directors: Deborah Harrington/Sunil Bhudia/Kelvin Lau/Sri Rathinam


the 22 bulletin

Cardiothoracic Surgery Training:

What do we think and how can we improve? On taking over the roles of SCTS Trainee Representatives we were tasked with assessing overall trainee satisfaction. In the current climate of changing contracts and an increasing move towards shift based rota patterns, training in surgery, in particular cardiothoracic surgery remains challenging. With this in mind we constructed a national survey to gauge current trainee opinions and to highlight any areas the SCTS, SAC and us as trainee representatives can target for improvement. Jacob Chacko & Ahmed Al-Adhami, SCTS National Trainee Representatives

A

survey template was created on www.surveymonkey.com and the link was emailed to all current national trainees. On closing the survey we had 83 responses that amounted to a response rate of 53%. Responses were collected between November 2016 – March 2017. Here is a summary of the key findings from the survey.

Question 1: How many hours per week are you contracted to work?

Question 3. Of the hours you work, what percentage do you currently spend performing the following activities?

Question 2: How many hours per week did you work?

Question 4. On a scale of 1-10, how would you rate the following aspects of your placement (within the previous 4 months)? (1-extremely poor, 10-excellent)


January 2018

Question 5. Please use the following space to elaborate on any specific concerns with your placement.

23

Question 9. Of the hours you work, what percentage do you feel should be allocated to undertaking the following activities?

Common Themes:

• Rota gaps affecting training opportunities • Discontent with trainer/quality of operative training • Lack of junior support affecting training • Inadequate organised teaching Question 6. Changes to which of the following aspects of your placement do you feel will most improve the quality of the training? (4-most important, 1-least important)

Question 10. How can the Society further support you in your professional development? Rank in order of importance (1-least important 6-most important)?

Question 7. Please use the following space to elaborate on your ranking choices and highlight any potential solutions you feel are appropriate. Common Themes:

• Importance of

trainer allocation and this being the key factor in ensuring successful training

• Improve regional teaching • Lack of NTN priority/focus on ensure NTNs achieve training needs Question 8. In your opinion, what is the optimum number of hours per week needed to gain the appropriate training exposure whilst delivering the department’s service needs?

Question 11. Please use the following space to elaborate on any specific avenues that you wish the Society to explore in order to improve your training conditions and working experience. Common Themes:

• Support NTNs to be prioritized over non NTNs with regards to training opportunities

• Ensure penalties/rewards for units & regions which are failing or delivering on training

• Facilitate fellowship opportunities both within and outside the UK.

Conclusion Cardiothoracic surgery remains both an extremely challenging and rewarding specialty. This is evidenced by the high competition for national training numbers. Results from this survey have highlighted areas to be targeted for improvement. On analysing this survey we have identified the need for greater coordination with regional representatives to ensure standards in training are regularly reviewed. With this is mind we have created a National Cardiothoracic Surgery Training Committee (NCSTC). The challenges of training in a technically demanding specialty, such as ours, are unique. We intend for the NCSTC to work towards regular review of training, highlighting areas of strength and shortcomings alike. Whilst working to support the efforts of the SCTS and SAC towards ensuring a high standards of training and most importantly producing Cardiothoracic surgeons of the future who are capable of delivering the highest quality of patient care. n


the 24 bulletin

Welcoming to Leicester

The First Edition of the SCTS Research Meeting 2017 On the 28th of October 2017, the first edition of the SCTS Research meeting was held at Glenfield Hospital in Leicester. As a cardiothoracic surgical trainee and meeting organiser, I have enjoyed playing an active role in this important platform for all UK cardiothoracic researchers. Marius Roman, MD (Cantab)

U

nder the guidance of Prof. Murphy, we have organised the facilities including the lecture theatre, catering, registration and IT support for the presenters. The meeting was an excellent opportunity to find out the direction of cardiothoracic research in the UK. One of the plenary sessions presented by Mr. Lim, focused on clinical trial designs and how to conduct high quality clinical research. It highlighted the importance of finding a good research question, which questions are likely to attract funding, how to design randomised trials, the analysis of results and achievement of clinical utility. Additionally, Mr. Lim emphasised both that the cardiothoracic community should lead from the front in the trials involving surgery, and as well the importance of research networking and successful collaborations. The significance of basic science research was discussed by Prof Corno, who is the chair of Congenital Cardiac Surgery at Glenfield Hospital. The review of the patient blood management evidence was presented by Prof. Murphy.

Prize winners for the best presentations at the research meeting

Interestingly, it showed that point of care testing has poor accuracy, while outcomes are not improved by increased red cell masses and liberal transfusion protocols. An excellent talk was given by Prof. Dion Morton from the Royal College of Surgeons on the national surgery research collaborative. The aim of this pan-surgical initiative involved an increase in the trainee involvement in research, development as leaders and research networks. New funding opportunities are being made available for these projects. A lunch break meeting of the SCTS trainee research collaborative discussed the pitfalls, planning and future meeting schedules. All of these were reinforced in the enlightening presentation of the academic clinical training pathway and career choices by Prof. Murphy. The oral presentations were divided into four sessions: Thoracic surgery, Congenital and Transplantation, Cardiac Surgery and Plenary lectures. This has allowed a topicfocused approach, with strong interaction from the experienced moderators and audience alike. The subjects discussed included pertinent topics like the clinical experience and outcomes of the Papworth DCD heart perfusion program, which increased significantly the number of heart transplantations performed in the UK. Additionally, the topics ranged from translational

basic animal research to comparison of aortic valve replacements or experimental pulmonary artery banding devices, or blood transfusion systematic reviews. Each session was moderated by a panel of expert Consultants, which stimulated exciting discussions following each presentation. These sessions culminated with the announcement and award ceremony of the prizes for the best presentations, consisting of a free admission to the SCTS 2018 annual meeting in Glasgow. Prizes for the oral presentations were presented by Prof. Murphy to Dr. Albertario on her study of RVOT tissue engineered patch reconstruction, Ms. Amy Kerr for the Thirsty feasibility study, Dr. O. Zibdeh and Dr. I. Bugg on the 10 year comparison of Mosaic versus Carpentier-Edwards aortic valve replacements and Mr. Ariyaratnam for the poster presentation award. Special considerations are given to Mrs. Sue Page, Mr. Douglas Miller, Dr. Alexandra Monaghan, Ms. Farhaana Surti, for their invaluable contribution in the organisation and smooth running of this meeting. With the aim of the meeting being the funnelling of the latest research in cardiothoracic surgery, it was a great opportunity for trainees to get involved and present their research. Hence why, one of the most important benefits of this meeting was the research networking, which allowed further exchange of ideas and collaborations to advance cardiothoracic surgical research in the UK. I am looking forward to the next edition of this great initiative. n


the 26 bulletin

4th International Cardiothoracic Surgery Careers Day 28th October, Sheffield The Sheffield student team led by Harvey George, Mr Briffa and Mr Gooseman welcomed over 100 medical students and sixth formers to the 4th Cardiothoracic Surgery Careers Day, 28th October at the Northern General Hospital. After months of preparation and anticipation the first enthusiastic students arrived early ahead of a full programme. Harvey George, Sheffield MBChB and BMedSci Student

T

he morning comprised of inspiring talks from various cardiothoracic subspecialties; adult thoracic surgery, paediatric and congenital cardiac surgery to careers application advice and insight in to the life of a cardiothoracic trainee. The morning talks engaged students, there was often healthy discussion after each lecture. Students were then given the opportunity to practice various skills in the afternoon. The sixth form students received a talk from the Undergraduate Admissions Lead at Sheffield University before having the chance to learn some key skills in basic life support and surgical skills. All under guidance from Sheffield medical students and trainees from all over the country. There were stations for the medical students in the afternoon: chest drain insertion; lung stapling; aortic anastomosis; and basic surgical skills. Medical students were able to hone their skills on animal tissue, using state of the art surgical equipment. Realtime feedback unsurprisingly was extremely positive as the challenging hands on experience was enjoyable for all students. To finish the event there was a social attended by students and faculty, another key opportunity to network with like-minded students and surgeons. Overall the event was a great success. It is a unique day for students from all over the country at various points in their training and from different backgrounds. They left having been inspired and welcomed in to the cardiothoracic specialty. n


For more information visit us at SCTS, booth 013 www.atricure.com MKT-2369A-G


the 28 bulletin

Cardiothoracic Surgery & Student engagement Where are we now? Aman Coonar, Consultant Thoracic Surgeon

Medical students October 2017 saw our fourth international cardiothoracic surgery student day in Sheffield. This was a great success with much energy and reflected the great oversight from Norman Briffa and enthusiasm of the student team led by Harvey George. This now recurring event set in the autumn follows on from events in Bristol in 2014, Cambridge 2016 and Barts (joint with Kings) in 2016. The project grew out of the many excellent local efforts, the cardiothoracic section of Royal Society of Medicine as well as SCTS’ own activities. We heard that medical students rarely got much exposure to CT surgery. We recognised a need to expose medical students to our specialty. We recognised that some of the best students were being pulled in the direction of specialties that offered ST1 recruitment and we needed to compete. What started tentatively as an uncertain pilot in which we wondered about viability has grown and become established with excellent teams bidding to host the meeting. Some of our earlier student leaders are applying for CT surgery. Watch out for the applications for 2018. In addition to the student engagement day in the autumn we also run a half-day session at the SCTS annual meeting with a series of focused lectures and also have started oral presentations for the Patrick Magee student prize. Students have the opportunity to present relevant work at the annual meeting as part of the Patrick

We also have an active social media presence via facebook and the internet.

engaged with have subsequently had their first ever applicants to medical school and our ‘alumni’ have now started at medical schools. The first ever student who attended is more than half way through her course in London and has her own resuscitation training website!

Realising how the demographics of the specialty and medicine is changing we have had special sessions relating to ‘Women in Surgery’ and ‘Less than Full time working’ as well as ‘International work and training’.

The schools engagement has become an important part of our public engagement whereby more people are favourably disposed to cardiothoracic surgeons and our specialty.

The activity of the RSM and SCTS student engagement is complemented by many other excellent initiatives. For example The Royal College of Surgeons of Edinburgh, under the supervision of Johnny Ferguson from Middlesbrough, runs a funded student engagement programme whereby students undergo a 1-2 week immersive elective in a UK cardiothoracic unit.

For me personally it has been absolutely inspiring to see these school children and medical students throw themselves into these events and become acquainted with our specialty.

Schools

Some of the Student engagement activities

Magee competition and they also get free entry. On top of this SCTS supported by the Ionescu foundation & Ethicon generously offers student travel awards.

What we realised, almost by accident, was that school children were also interested in our project. Many schools have established links with hospitals and medical schools and for their students it is relatively straightforward to get placements. We have purposefully sought to identify schools where that opportunity was not available or there was not much history of University or Medical school success. Whilst we realise that very few of theose students will become cardiothoracic surgeons, we feel it is of value to those schools and students to make them aware of the opportunities. We were overwhelmed by the response, with many keen young people attending our events. Some of the schools we have

All of this would not be possible without the support of our tirless team in SCTS, various sponsors in particular Ionescu and Ethicon.

• Autumn student engagement day • SCTS Annual meeting • Student engagement half day • Patrick Magee prize – best oral presentation, best poster, most innovative idea by a student

• Travel Awards • 6th form outreach • RCSEd programme of immersions in cardiothoracic units

• RSM cardiothoracic section programme and travel awards

• Many local initiatives n


January 2018

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the 30 bulletin

The Contract Conundrum - My views

Much time has been spent discussing the diminishing proportion of UK trained consultants in our specialty (1). Many influences such as the European Working Time Directive (EWTD) and Surgeon Specific Mortality Data (SSMD) have led to both positive and negative alterations in the day to day activities and relationships of trainees and trainers. Duncan Steele, Trainee Cardiac Surgeon

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he negative impact of these changes has come, at least in part, due to difficulties in our profession’s ability to work proactively with rule changes. This new contract whose terms and conditions have been rolled out for all national trainees this October past, is another significant change that will undoubtedly alter the very fabric of what it means to be a UK trained cardiothoracic surgeon. We are exceptionally privileged to have a career so interesting and challenging with relatively good pay and job security. However conditions are getting worse, much worse, and the current generation of trainees are now even more than previously, tempted by greener fields elsewhere. At around 7%, Cardiothoracic training in the UK also has held the highest rate of attrition of any surgical specialty (2). Attrition and burn out are real risks to both individuals and our specialty, not least through difficulties in work force planning. Since I applied to medical school relative pay has reportedly been cut by around 22% (3), pensions have twice been cut, free housing for recently qualified doctors has been abolished and the hours we are supposed to be in hospital, learning what is the most wonderful profession I could

imagine, have been reduced. Worse still the new contract limits trainees to be in work for a maximum 48 hours average per week and a maximum of 72 in any given 7 days. Many senior colleagues will remember working those hours consecutively and although hard, I’m certain provided a priceless learning experience. The subtle yet significant move to clock watching is a disenchanting thought for all of us who think of surgery as a vocation where our patient comes first, irrespective of anything else.

Pay changes: • Paid for all hours worked is the single

At King’s College Hospital, through proactive discussions with HR and management, we have taken significant steps to ensure the contract change has at least some benefits to the department.

the same if on the same rota

In my view every department up and down the country should proactively engage with this change, so that we can work with, rather than against, the new rules, regulations and more importantly, mind set that the much debated new contract creates. In this article I would like to suggest how that can be achieved. To clarify the changes this contract imposes, I have included the key issues below.

most important introduction and why the BMA supported it after negotiations

• Instead of banding, salaries will be determined by the exact hours scheduled to work

• Each hour over 40 scheduled during an average week will be paid at a set rate with uplift for ‘out of hours’ work (between 9pm and 7am)

• All registrars, ST3 to ST8 will be paid Hours: • Irrespective of the EWTD, rotas

are limited to max average 48 hours OR up to 56 hour average if trainees ‘opt out’

• 72 hour maximum in any consecutive 7 days

Shift pattern: • No more than 8 consecutive days working • No more than 4 nights in a row • 13 hour maximum shift • Never working two consecutive weekends


January 2018

“It is my belief that if dealt with well this contract could lead to a better working environment for trainees, making them feel more valued and supporting them through what is, after all, one of the longest training pathways of any specialty in the world.” Exception reporting: • When hours worked don’t reflect

scheduled/ rota plans exception reports must be placed. As a consequence the doctor working is paid 1.5 x normal hourly rate for this time and the department fined 2.5 x hourly rate which goes directly to the guardian of safe working

More details can be found on NHS employers and the BMA website.

Likely consequences: • A significant pay cut based on an estimated 1/5 rota

• No recognition of progression through training in registrar years

• Possibility to fracture firm structure further

• Reduced incentive for higher study and research

• Reduce time in theatre • Reduced continuity of care for patients • Increase frustration of consultants that trainees are not ‘around’

• Reduced flexability of rotas Opportunities: • Possibility to raise average hourly week to 56

• Recognising trainee’s commitment when they work longer hours by paying them for hours

• Allowing more free time in the week to work on research and other interests

• Help prevent burn out

It is my belief that if dealt with well this contract could lead to a better working environment for trainees, making them feel more valued and supporting them through what is, after all, one of the longest training pathways of any specialty in the world. I would suggest the following would help implement the new contract to its best advantage: 1. Rotas are designed early with close consultation of trainees 2. Rotas must reflect actual working patterns 3. Exception reporting supported (and encouraged) by all consultants in the department

even on call commitments. In return the additional hours, up to an average 8 extra a week, are paid at an agreed locum rate. If these simple steps are rolled out across our specialty, it will not only ensure trainees are not exploited by trusts to cover extra hours for free, but will nurture a supportive and enthusiastic atmosphere for cardiothoracic trainees that will snowball in the right direction. Without it the spiral of destruction of training, burn out and struggling departments is in my opinion, inevitable.

Disclaimer - I didn’t vote for the contract and think a move to an hourly rate undermines what it is to not just be a doctor, but a surgeon.

4. All trainees opt out of the 48 hour max

References:

5. The extra 8 hours a week are used to ensure firms work together to cover their clinical commitments

(1) S. Westaby, K. Baig, R. De Silva, J. Unsworth-White & J. Pepper. Recruitment to UK cardiothoracic surgery in the era of public outcome reporting. 2015. Europeon Journal of Cardio-thoracic Surgery, 47 (4), pp 679-683.

6. Extra hours are claimed back and therefore paid for, negating the pay cut 7. Monthly feedback from juniors to evolve the rota to suit each department

At King’s College Hospital, we’ve worked over several months with our HR and management colleagues to do exactly this. In the past the rota HR believed registrars were working, didn’t reflect real life however now, all registrars are able to follow the new rota design. Moreover, the extra hours are used to allow flexibility week to week to cover theatres, clinic and

(2) T. Hampton, R. Greenhalgh, D. Ryan, P. Das-Purkayastha. Female Surgical trainee attrition. 2016. The Royal College of Surgeons Bulletin. 98 (3), pp134-137. (3) https://www.bma.org.uk/ news/2017/july/sharp-decline-in doctors-pay n

31


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Abbott | One St. Jude Medical Dr. | St. Paul, MN 55117 USA | Tel: 1.651.756.2000 | SJM.com |St. Jude Medical is now Abbott. * Until fully deployed. ™ Indicates a trademark of the Abbott group of companies. 1. Linke, A. (2015). Multicentre Clinical Study Evaluating a Novel Self-expanding and Resheathable Transcatheter Aortic Valve System. PCR London Valves 2015. 2. Linke, A. (2015). Treatment of Aortic Stenosis with a Novel Resheathable Self-expanding Transcatheter Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use. © 2017 Abbott. All Rights Reserved. SJM-PTC-1017-0100 | Item approved for International use only.


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All comparative claims for Mitraclip NT are based on tests performed against the Mitraclip device. Data on file at Abbott Vascular. Abbott Vascular International BVBA Park Lane, Culliganlaan 2B, B-1831 Diegem, Belgium, Tel: +32 2 714 14 11 Product is subject to prior training requirement as per the Instruction for Use. This product is intended for use by or under the direction of a physician. Prior to use, reference the Instructions for Use provided inside the product carton (when available) or at eifu.abbottvascular.com for more detailed information on Indications, Contraindications, Warnings, Precautions and Adverse Events. Information contained herein is for distribution for Europe, Middle East and Africa ONLY. The following needs to be considered by French healthcare professionals only: Clip de réparation mitrale MitraClip et accessoires. Dispositifs médicaux de classe III et I, organisme notifié BSI. Fabriqué par Evalve Inc, mandataire européen Abbott Vascular BVBA. Se référer aux informations de la notice d’instructions qui décrivent les informations de bon usage du dispositif. Veuillez lire attentivement les instructions figurant dans la notice. Non pris en charge par les organismes d’assurance maladie. MitraClip is a trademark of the Abbott Group of Companies. All drawings are artist’s representations only and should not be considered as an engineering drawing or photograph. Photo(s) on file at Abbott Vascular. For more information, visit our web site at abottvascular.com. © 2016 Abbott. All rights reserved. 9-EH-2-6100-01 08-2016


the 34 bulletin

The British and Irish Society for Minimally Invasive Cardiac Surgery (BISMICS) 2nd annual meeting Glaziers Hall, London 2nd – 3rd November The two-day meeting was hosted by a multi-disciplinary faculty including cardiologists, anaesthetists, perfusionists, industry partners and patient representatives. Bilal H Kirmani, Consultant Cardiac Surgeon

Presentation at BISMICS by Mattia Glauber

T

he charity is now in it’s 2nd year (www.bismics.org.uk) and with generous support from across industry, the meeting aims to bring together national expertise in minimally invasive techniques to foster development in centres nationwide. In addition to members from Britain and Ireland, there were invited speakers from prominent European and North American centres, who provided insight as to how their units had achieved such high penetrance in their minimally invasive programmes. An update on the randomised, controlled Mini-Mitral trial sparked lively debate from the chiefs of two international units, who questioned the morality of denying patients minimally invasive surgery if it was available. This answered a question that was later posed by the president of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) during his talk: Why was there a need for BISMICS

when ISMICS already exists? With commissioning restrictions growing ever tighter, the need to scientifically demonstrate the clinical and financial benefits of minimally invasive cardiac surgery could only be conducted and effectively recruited to here in the United Kingdom. As such, therefore, the need exists for a separate support, lobbying and training group with awareness of local political pressures. Those responsibilities, highlighted in the BISMICS charter, were demonstrated amply in the meeting agenda. Debates between cardiologists and minimally invasive surgeons served as reminders of the existing arena and players that centres wishing to start minimally invasive programmes will have to contend, compete and ultimately collaborate with. The opportunity for trainees and junior surgeons to have handson experience in the wetlabs during the first day highlighted the importance of exposure to technologies provided by industry. Training – at junior and consultant levels – featured heavily in the programme and plans to develop fellowship and in-house training for interested surgeons were also discussed. Of particular interest were the speakers from surgery, anaesthetics and perfusion who gave pragmatic technical

talks, including equipment options, strategies and pitfalls to avoid. The meeting was well attended and we look forward to next year’s meeting in November 2018. n


dates NICE up hial nc endobro utine o ro valves t igible el use for s! patient

Precision Therapy for Your Emphysema Patients

The Zephyr® Endobronchial Valve is an endoscopic lung volume reduction therapy that has been proven to significantly improve lung function, exercise capacity and quality of life for emphysema patients across four randomized, controlled clinical trials and across 12,000 patients worldwide. The UK’s National Institute for Health and Care Excellence (NICE) has updated its guidance for endobronchial valves and now considers current evidence sufficient to support routine use. The change in NICE guidance is based on safety and efficacy data from multiple randomized clinical trials evaluating the Zephyr EBV, which has demonstrated clinical and quality of life benefits, and long-term safety for eligible patients. Randomized Controlled Trials (RCTs) advance the Clinical Evidence for clinical efficacy of Zephyr® Endobronchial Valves therapy:

RCT

Size & Follow-up Period

TRANSFORM4

n=97, 6 months

29.3%*

79 m*

- 6.5 pts*

IMPACT 3

n=93, 6 months

16.3%*

28 m*

- 7.5 pts*

STELVIO2 VENT1

n=68, 6 months

17.8%*

74 m*

- 14.7 pts

n=122 (post hoc subset) 6 months

24.8%

28 m

- 8.4 pts

(post hoc subset, US + OUS)

Lung Function (FEV1%) † Exercise Capacity† Quality of Life (SGRQ) †

Complications of endobronchial valve treatment can include but are not limited to pneumothorax, worsening of COPD symptoms, pneumonia, dyspnea and, in rare cases, death.

* Intent-to-Treat population

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StratX™ Lung Analysis Platform

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StratX Lung Report TM

Upload Date 27 July 2016

Patient ID 35-127-AJJ

Report Date 27 July 2016

Scan ID 0026671 CT Scan Date 16 February 2011

Scan Comments

SUMMARY KEY ≥70% Voxel Density Less Than -910 HU 60-70% Voxel Density Less Than -910 HU 50-60% Voxel Density Less Than -910 HU

Zephyr® Endobronchial Valve

<50% Voxel Density Less Than -910 HU >95% Fissure Completeness 80-95% Fissure Completeness

RESULTS

% Fissure Completeness % Voxel Density Less Than -910 HU

% Voxel Density Less Than -950 HU

Inspiratory Volume(ml)

<80% Fissure Completeness RIGHT LUNG

LEF T LUNG

RUL

RUL+RML

RML

RLL

LUL

LLL

64.2

65.0

84.9

65.0

100

100

84

79

63

66

83

67

59

36

40

69

16

1120

1492

372

1901

1717

1520

Disclaimer: Report contains quantitative assessment only and should not be construed as a complete radiological analysis.

43

CE 12345. Powered by Thirona. Version X.X

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90 % Combined Accuracy5 of StratX Lung Analysis and Selective Use of Chartis

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1 Scuirba F.C. et al. N Engl J Med. 2010; 363(13): 1233-44/ Herth F. J. et al. Eur. Respir. J. 2012; 39(6): 1334-42/ Ad hoc analysis on file at Pulmonx. | 2 Klooster K. et al. N Engl J Med. 2015; 373: 2325-2336 + Supplementary Appendix | 3 Press release “New Data from Two Multi-Center Randomized Clinical Trials Demonstrate That Zephyr Endobronchial Valves Deliver Benefit to Both Heterogeneous and Homogenous Emphysema Patients without Collateral Ventilation”- May 23, 2017 | 4 Kemp S et al. Am J Resp Crit Care Med 2017; (196)12: 1535-1543 | 5 Koster TD, et al. Predicting lung volume reduction after endobronchial valve therapy is maximized using a combination of diagnostic tools. Respiration, 2016; 92: 150-157 (DOI:10.1159/000448849)


the 36 bulletin

Aortic Dissection Awareness Day 2017 - A huge success

September 19th saw the second Global Aortic Dissection Awareness Day, with twenty one countries holding hands to create a wave of awareness for a medical emergency that is all too often missed in Emergency Departments. Christina Bannister, Nurse Case Manager, University Hospital Southampton NHS Trust

T

he main event, organised by Aortic Dissection Awareness UK on the theme of THINK AORTA! was hosted by Liverpool Heart and Chest Hospital. Chief Executive of LHCH Jane Tomkinson and Lead Aortic Surgeon Mr Mark Field set the day in motion. Fascinating presentations were given by leading Aortic Surgeons, Professors, Geneticists and Rehabilitation Specialists, alongside Aortic Dissection survivors and patient advocates. During his talk, Mr Graham Cooper, President of SCTS,

gave his full support to Aortic Dissection Awareness UK and congratulated the team on the organisation of the day and their ongoing campaign to raise awareness and improve outcomes for patients with Aortic Dissection. Videos of all the day’s presentations can be viewed by searching for ‘Aortic Dissection Awareness UK September 19th’ on YouTube.

by Barbara Harpham, Chief Executive of Heart Research UK is for a project to promote awareness of Aortic Dissection by placing THINK AORTA! posters within Emergency Departments throughout the UK. The posters will combine clinical expertise from Liverpool Heart & Chest Hospital with design input from Aortic Dissection Awareness UK.

The event was a great success, with future projects and collaboration now in the making. An exciting initiative unveiled

I attended the day on behalf of the SCTS as nursing & patient involvement lead. Within the day there were two presentations


January 2018

given by patients who had experienced Aortic Dissection surgery, which were excellent. From a clinical perspective, the opportunity to hear patients’ stories with all their experiences, good and bad, was something we can all learn from. Both the wait for surgery and inpatient stay, especially within the ICU, had ups and downs and the entire audience took valuable information from the presentations. Aortic surgery, whether performed as an emergency or planned, is an emotional experience for the patient and their families and carers. The opportunity to listen to two different patient stories and then hear comments from an audience of clinicians, Aortic Dissection survivors and their families with further discussion goes a long way to improve not only the physical side of the experience, but also the emotional and psychological aspects. I thank all survivors and their families who attended and participated in the Awareness Day. By sharing each patient

journey we can improve the pathway and support all affected. Making an announcement at the close of the day Gareth Owens, an Aortic Dissection Survivor and Patient Advocate, said: “The 2017 event we held here in Liverpool, hosted by Mr. Mark Field and his team, is going to be a tough act to follow. However, the multidisciplinary aortic surgery team at Barts & The Royal London, who I know from personal experience, have great expertise in this field and lots of valuable knowledge and experience to share. I’m delighted that they will be hosting Aortic Dissection Awareness Day 2018 and I look forward to sharing a speaking platform with some of the surgeons who saved my life.” Representing Barts Health NHS Trust, Mr. Paul Flora, Consultant Vascular Surgeon, thanked ADAD UK for the opportunity to host the event and issued an open invitation to professional colleagues and patients with an interest in Aortic disease to attend Aortic Dissection Awareness Day 2018 in London on Wednesday 19th September. Among the one-hundred plus audience at Aortic Dissection Awareness Day UK

Book Review Sean Bello, Trainee Cardiac Surgeon Title: Minimally Invasive Mitral Valve Surgery Authors: Hunaid A. Vohra and Marco Solinas Publisher: Nova Science, New York, USA

T

he past two decades have seen a rapid rise in the development and implementation of minimally invasive approaches to the surgical management of cardiac diseases. The lead author’s first book entitled “Minimally Invasive Aortic Valve Surgery” provides a broad overview of the key aspects of minimal access aortic valve surgery. In this book, the authors turn their attention towards a technically challenging, yet highly

37

2017 were around 30 members of the Aortic Dissection UK Buddies group. Offering emotional support to survivors of AD once home is a major factor for a stronger and speedier recovery and the UK Buddies pride themselves in giving just that. The group is free to join and exists as a platform for patients and their families to come to terms with their traumatic experience and receive guidance and support about the way forward. Many people joining the group are affected by emotional trauma or even depression after a diagnosis of Aortic Dissection and/or major surgery for the condition. Perhaps you have patients attending your clinic who would benefit from linking-up with other survivors of Aortic Dissection. If so, you can direct them to Aortic Dissection Awareness UK Buddies on Facebook. If you would like to find out more about Aortic Dissection Awareness UK for yourself, or register to be kept informed about future events, please e-mail the Founder of ADAD UK, Dan Burgess, at: aortic_dissection_awareness@ outlook.com n

appealing area of minimally invasive cardiac surgery. Minimally invasive mitral valve surgery is being widely adopted by surgeons and is gaining favour with patients as evidence mounts showing that this technique provides excellent results comparable to those from mitral valve surgery performed through a full sternotomy. Minimally Invasive Mitral Valve Surgery is a very well written book with an abundance of pertinent illustrations. The reader is guided through the practical steps involved in setting up a minimally invasive mitral valve repair programme with particular emphasis on the UK medical system. This is followed by well-structured chapters detailing the steps involved in appropriate patient selection, the relevant investigations, and anaesthetic considerations. The book then focuses on operative techniques with contributions from several experts in the field, coupled with carefully selected references to aid broader review. Details provided range from the optimal patient positioning to facilitate adequate access to the mitral valve, cannulation techniques, the rationale behind choice of aortic occlusion strategies, and in-depth analysis of the various approaches to minimal access mitral valve surgery; from the adoption of mini-sternotomy or mini-thoracotomy, to totally endoscopic and robotic mitral valve surgery. This book is very topical and will undoubtedly be an excellent resource for cardiac surgeons at all levels of training and also clinicians with an interest in minimally invasive surgical approaches to cardiac disease. n


the 38 bulletin

Patient Portraits: A New You On 5 December the team at Heart Valve Voice in association with the Royal Photographic Society will be launching a photography competition aimed at raising awareness of heart valve disease by showing how patient’s quality of life can be significantly improved after treatment. I have been asked to be on the selection panel for the competition and I couldn’t be more excited. Christina Bannister, Nurse Case Manager, University Hospital Southampton NHS Trust

T

he selection panel will be made up of professional photographers, a valve disease patient and myself and our task will be to choose the photographer that best depicts the precious heartfelt moments in patient’s lives after treatment for valve disease. It’s an exciting honour to be a part of something that is so focused on the patient and their experiences.

UK charity dedicated to raising awareness and improving diagnosis and treatment of heart valve disease. We have worked together on some really exciting events, such as testing events at some high profile sporting matches, regional best practice summits and conferences. These events all have the underlying theme of ensuring that valve disease patients have a voice and that their needs and expe-riences are heard.

As someone who works so closely with valve disease patients, I see first hand what they go through before treatment and how much better they often feel after treatment. Heart valve disease affects over 1.5 million people over the age of 65 in the UK, according to a 2016 Heart Valve Dis-ease Survey. However, awareness of this disease is very low with an average of 94% of people over the age of 60 being unaware of what aortic stenosis (the most common form heart valve disease) is. As such it is so important to raise awareness amongst the general public.

It’s work such as this, that focuses on making the lives of our patients better that makes me so passionate about getting involved. Now I’m really excited to be a part of their next venture, the Patient Portraits: A New You photography competition. The contest asks keen photographers to cap-ture heartfelt moments in time and convey what life after heart valve disease means to patients. The images captured will help raise awareness of heart valve disease, its prevalence and symptoms and educate audiences that with appropriate treatment, patients can return to a good quality of life.

Over the past couple of years I’ve worked as an ambassador for Heart Valve Voice, a

Once we have chosen all of the finalists, they will go on to have their photographic

documentaries exhibited at the Houses of Parliament as part of the National Final. In addition, the overall winner and regional finalists, will also have the chance to have their photographic documentaries exhibited at hospital heart clinics across the UK, as part of a road show to celebrate the first European Heart Valve Disease Awareness Day in 2018. At Heart Valve Voice patients are the reason they exist. Their patients not only represent the work that they do but they also form one of the strongest voices of Heart Valve Voice. It is essential to have a clear understanding of what patients with heart valve disease experience so that we can get the best understanding of the disease and how it effects everyday life. This photography competition will provide a wonderful visual representation that shows with timely treatment, patients can go on to live full lives. If you know any amateur photographers or patients that would like to get involved in the competition visit their website here: https://heartvalvevoice.com n


January 2018

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Nursing & Allied Health Professional Research Developments Julie Sanders, Director Clinical Research, Quality and Innovation

Nursing and AHP Cardiothoracic Research in the UK All health care professionals have a duty to ensure patient, their relatives and communities receive high quality evidence-informed care, and it is widely acknowledged that patients in researchactive environments have better outcomes. However, it is also recognised that there is a shortage of nursing and AHP (NAHP) research in the UK and that the NAHP evidence-based needs to increase. While 5% of the medical profession is in a research-focused senior academic position, this is true for only 0.01% of the current NAHP workforce. This is also reflected in UK research income with NAHPs being awarded only 1.9% of total health research income, compared to 63.7% in clinical medicine. Thus, the national strategy is to increase NAHP-led research to deliver high quality evidence-informed care and for 1% of the registered nursing, midwifery and allied health professional workforce to be research-focused senior clinical academics by 2030. The message is no different for NAHP cardiothoracic research. In the UK, there are only seven nursing professors with a cardiovascular background (2.5% of all nursing professors) and none specialise in cardiothoracic research, compared with 24 cardiothoracic surgeon professors (highlighted in the 2015 Cardiothoracic Surgery UK Workforce Report). Following the 2017 SCTS Nursing and AHP Cardiothoracic Forum Research Questionnaire we identified two nurses/ AHPs that have a PhD in the speciality, one now at Reader level, with a further 28.3% of respondents stating they conduct their own research. Funding awards have also been sparse with two NIHR awards, two BHF awards, one RCN award and four

local Trust charity awards over the last five years. Thus, it is of no surprise, that research support, networking opportunities and sign-posting to funding opportunities and relevant research resources were requested. We are, however, delighted that 34% indicated their willingness to support members in research areas they had expertise in.

The SCTS Forum vision for cardiothoracic NAHP Research The vision of the SCTS Forum is to encourage, promote and assist in the development of NAHP clinical academic career and research opportunities in cardiothoracic surgery in the UK. This is particularly important in areas that impact clinical practice, patient and staff wellbeing and have the potential to influence policy. There is clearly a long way to go, but we have started this work through scoping the national landscape, engaging with the BHF to consider clinical research training fellowships (PhDs and post-doctoral opportunities) for NAHPs, showcasing excellence in NAHP research at The National Cardiothoracic Research Meeting in October 2017, and we are launching the SCTS Nursing and Allied health professional Research Group (SCTS NARG) at the 2018 SCTS annual meeting.

The Launch of the SCTS Nursing and Allied health professional Research Group (SCTS NARG) The SCTS Nursing and Allied health professional Research Group (NARG) is the first step in creating a community of NAHP cardiothoracic researchers to encourage and support the development of NAHP-led research, share expertise, and highlight research opportunities (including existing funding sources of MSc and PhD studentships). The SCTS NARG will launch at the 2018 annual meeting, including a dedicated webpage for SCTS members. The SCTS NARG is available to all SCTS members. If you are not already a member of the SCTS, please do consider joining. NAHP membership offers excellent value value for money (£30 annual fee and £30 one-off joining fee) and will pay for itself due to the reduction in fee for members to attend the SCTS annual meeting - plus you get access to a range of educational, and now research, resources! For more information, or to offer your expertise to the SCTS NARG, please contact Julie Sanders, SCTS Forum lead for Audit and Research at julie.sanders@bartshealth.nhs.uk n

“In the UK, there are only seven nursing professors with a cardiovascular background (2.5% of all nursing professors) and none specialise in cardiothoracic research.”


the 40 bulletin

Photo at Discharge (PaD): How Cardiac Surgery is Improving Information to Patients and Carers and Links to Community Melissa Rochon, Lead for Surveillance, Royal Brompton & Harefield NHS Foundation Trust

Background As an estimated 65% of cardiac surgical site infection (SSI) present post-discharge, it isn’t surprising that this complication is a leading cause of readmission to hospital within 30 days. The high proportion may be due to the time it takes bacteria to elicit host response; it can be down to a delay in treatment, or perhaps as Clinton and Obama suggest in their 2006 White Paper, some of the problem may be down the fragmented communication and information shared between acute and community care.

number of readmissions for incisional SSI through early detection, which the team felt was critical to reducing the severity and duration of incisional infection. Although evidence demonstrating the benefit of patient/carer involvement in the process of monitoring and identifying SSI post-discharge is lacking, the improved assessment, documentation and advice given to patients was felt to be better than

A few years ago at the Royal Brompton and Harefield NHS Foundation Trust (RBHT), we found that despite relatively low SSI rates, we were still spending a significant amount managing readmissions for cardiac SSI, using on average 391 non-elective bed days per annum and in turn, £488,000 in capacity was lost a year to non-elective admissions for SSI. Following on from themes identified from root cause analysis, the Photo at Discharge (PaD) project was introduced via an iterative process of small tests of change on the surgical wards. The aim was to reduce the

generic versions of advice previously examined in Australian study ten years ago. The colour photo in the PaD form is of the patient’s own wound on the day of discharge and the assessment and information is specific to the individual (Figure 1). This is a practical tool to help determine whether the wound is improving or deteriorating, helping to persuade patients to action if there is a change in condition. In broader terms, the scheme may also help with clinical decision making. Telemedicine studies suggest that the addition of a photo to clinical review can reduce the risk of overtreatment. PaD provides information on pre-existing skin appearance (dependent rubor, normal discolouration of healing process etc at discharge). Mr Habib Khan, SpR comments “This is a very important tool…especially if there is an issue with the wound, we have something to compare. Helps us to decide how the treatment is working”.

Implementing the PaD scheme Figure 1

Our surveillance team modified their existing electronic system for NICOR submission (Intellect) to


January 2018

41

“It is fantastic to have cardiothoracic centres leading the way on initiatives such as PaD. Many cardiothoracic centres undertake prospective surveillance to monitor and report on SSI rates as well as measures to reduce its incidence but there is a need for more efficient processes.” create the forms and photos, as well as store and analyse trends. In the beginning, specialist nurses in surveillance provided PaD for patients discharged in main hours, capturing approximately 25%. With the introduction of a standard operating procedure and ward staff nurse training, this has increased and been maintained over the last two years with > 90% of our cardiac patients receiving PaD. In contrast to centres relying on TVN specialists or Medical Illustrators, our site has all our cardiac surgical nurses trained in digital photography, information framework and database management for quality control and audit. We feel strongly that complete wound assessment improves patient outcomes and that all cardiac surgical nurses should have these skills. Matron Carol Barlow from Sheffield Teaching Hospitals is interested in implementing PaD and she reflects:

“PaD would be an excellent communication tool between us and primary care in that it provides a baseline assessment of the wound …This in turn will improve the management of the wounds and avoid unnecessary treatments, especially antibiotic therapy. Getting the stakeholders to agree to this was not particularly difficult. Our nurse director… was keen for us to get involved. When the project was passed through our governance system, it was received positively and was perceived as the right thing to do.” Sammra Ibrahim, Surgical Care Practitioner and lead for introducing

PaD at St Bartholomew’s Hospital points out that there is a lot involved with rolling PaD out because all staff need training and Trust policies and procedures need to be updated but agrees that PaD will help accuracy and communication of wounds and believes it will improve processes. Now in its third year, our staff, patient and carer feedback on the scheme has been incredibly positive, as one patient put it: ‘The photo, information and instructions …great! It gave a sense of security and eliminated worry while recovering.’ Our Trust was delighted to receive the Patient Safety Award, Infection Control 2017, and Harefield Hospital is celebrating its OneTogether Award in November this year.

wound types and care) with St Barts, who also have a site-wide licence. Nursing and Allied Healthcare Representatives for SCTS at RBHT and St Barts have collaborated with the infection control lead from the Royal College of Nursing as we recognised the need to create a framework for cardiothoracic nurses to ensure the usability of photographs in patient care and establish a standard approach for quality control.

SSI is considered a significant quality and cost control metric for clinicians, Trusts and policy/strategy makers. SSI prevention strategies need to consider their role in reducing avoidable demand for emergency admissions, as well as demonstrate their impact on quality and productivity within the Getting It Right the First Time (GIRFT) programme. PaD is associated with cost avoided by reducing SSI readmissions of between £110,645 and £196,202 per annum. This releases capacity of 285-336 cardiac bed days, which is the equivalent of an additional 41-48 elective coronary artery bypass graft procedure a year.

It is fantastic to have cardiothoracic centres leading the way on initiatives such as PaD. Many cardiothoracic centres undertake prospective surveillance to monitor and report on SSI rates as well as measures to reduce its incidence but there is a need for more efficient processes. We have used Intellect for our SSI surveillance system. The registry, which clinicians use to submit to NICOR/SCTS uses the same dataset, with a ‘bolt-on’ section for the Public Health England surveillance scheme. Adding fields to the existing data registry significantly improved our process for PHE submission. Unnecessary duplication was removed, saving time and resources – not to mention using an existing system avoided a huge cost because we didn’t have to buy a separate infection surveillance system. PaD is a way to create a remote electronic surveillance system or a way of validating SSI data. We have used the digital images to assist in cases of arbitration and litigation which has highlighted the benefit of PaD in terms of record keeping.

Dendrite has kindly shared the Intellect PaD registry and it’s accompany registry WoundCare1 ([W1], a database for all

We are hoping to share innovation and new ways of working through the SCTS and CT Forum. n

Future


the 42 bulletin

From left to right: Malih (visiting surgeon from Izmir), Prof. Yuksel and Mehmood Jadoon

Visit to Marmara University Hospital, Istanbul, to learn advanced management of Pectus deformities It all started a year ago when Mohammad Hawari, who is a Thoracic consultant in Nottingham advised me to consider a visit to the Thoracic unit of Marmara University Hospital to learn advanced management of different types of Pectus deformities. I contacted Prof. Yuksel, who is world renowned in management of Pectus deformities and arranged a week-long placement.


January 2018

43

Information stall on pectus day

Mehmood Jadoon, Trainee

F

lights are very economical if booked well in advance. There are two airports in Istanbul. Although Sabiha-Goken is very close to Marmara University Hospital on the Asian side of Istanbul, the flight to Ataturk airport gave me an opportunity to visit the old Sultanahmit district of Istanbul. Transport systems in Istanbul has improved in recent years. Metro, tram and water boats are linked and commute between the European and Asian sides have become very comfortable. Access to tourist attractions is easy and one can cross Bosphorus on ferryboats. The Istanbul card, which is a travel card very similar to the Oyster card, is the most economical way to move around in Istanbul and can be used on all forms of public transport in Istanbul including ferryboats. Prof. Yuksel invited me in June during school holidays. He very kindly scheduled a variety of pectus deformity cases for the week. On Monday we operated on five pectus patients. There was a spectrum of Pectus deformities cases. l

Pectus Excavatum with rib flaring.

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Simple Pectus Excavatum

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Grand Canyon type of Pectus Excavatum deformity

Three patients had Pectus excavatum with rib flaring and received cross bars. Prof. Yuksel prefers doing cross bar for these patients with rib flaring because he believes that a simple

Residents and fellows, Prof. Yuksels’ pectus team

bar depresses the mid thorax and causes flaring to become more prominent. I learnt how to plan and place cross bars. Professor Yuksel uses only one stabilizer on the top side of bars as the stabilizer is perpendicular to ribs and sits well on top of the ribs. One patient had a simple Nuss bar for Pectus excavatum deformity. Another patient had two Pectus bars for Grand Canyon type of Pectus excavatum deformity.

“We did five pectus cases on Thursday. I had the opportunity to perform two cases as operating surgeon. These were single Nuss bar for Pectus Excavatum. Procedures went very well.”

We again performed five Pectus cases on Tuesday. The first case was a redo case which had failed the Nuss bar repair before. We started the case from right side but visibility was difficult because of adhesions. A sub xiphoid incision was made and the bar was passed across guided by the finger through sub xiphoid incision. The second case was a mixed Excavatum and Carinatum deformity. Prof. Yuksel use the Abrahamson bar for Pectus Carinatum and the Nuss bar is placed for Excavatum deformity. He calls them Sandwich bars. Laterally two ribs are exposed and a sternal cable is passed around to fix the stabilizers for the Abrahamson bar. He used to use sternal wire but has now replaced wire with cable for more tensile strength and for the fact that it doesn’t cut through the rib. He doesn’t use a separate stabilizer for the Nuss bar and uses the stabilizer for the Abrahamson bar to fix the Nuss bar. >>


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The third case was Pectus Carinatum. An Abrahamson bar was placed with two lateral stabilizers fixed to ribs. He uses clips/screws in the holes of the Nuss bar to adjust the height to appropriately correct the deformity. The fourth case was Pectus Excavatum with Rib Flaring and had cross bars. The fifth case had a long Grand Canyon type deformity. Two Nuss bars were placed for this patient.

Mehmood Jadoon with Prof. Yuksel in his office

On Wednesday we did a busy out-patients clinic in morning. Consultation is brief and to the point as most patients are young and generally fit and well. Prof Yuksel is accompanied by his team in the clinic, one person enters data in computer. His secretary takes photographs of each patient. He likes to take 6 photographs. 1. Front. 2. Right oblique 3. Right lateral, 4. Back, 5. Left lateral, 6 Left oblique. A Pectus day was arranged for the afternoon. Patients, patientâ&#x20AC;&#x2122;s relatives, industry representatives, corset manufacturers and local media were invited. Professor Yukselâ&#x20AC;&#x2122;s Pectus team, which includes a Physiotherapist and a Psychiatrist spoke on the occasion. They briefed patients about their involvement with Pectus patients and what they can offer. It was a very successful evening. Prof Yuksel interacts at personal level with his patients, he discusses the anxieties in a

From right to left: Prof. Yuksel, Malih (visiting surgeon from Izmir) and Mehmood Jadoon. Theatre staff in the background

non-formal environment. Patients were very appreciative of this initiative. We again did five pectus cases on Thursday. I had the opportunity to perform two cases as operating surgeon. These were single Nuss bar for Pectus Excavatum. Procedures went very well. In the next door theatre, Cross bars and simple Nuss bar were performed. Our third case was a Nuss bar removal. I performed the case with one Turkish consultant. We both removed a bar each.

In the evening I was invited to Dinner in Senol-Kolcuoglu, a famous Istanbul restaurant which serves excellent Turkish food. On Friday Prof Yuksel operated on two patients who were referred with recurrent Sternal dehiscence. After routine refreshing of edges and placement of sternal wires two Nuss bars were placed as for Pectus excavatum. Pectus bars were used to reinforce sternal wires, they press the chest laterally and help sternum to heal. Prof. Yuksel is considering Nuss bar placement for patients with flail chest and patients who need chest wall reconstruction post chest wall resection for tumours. It was a very fruitful visit and an excellent example of collaboration between Thoracic Units of Nottingham City Hospital and Marmara University Hospital. I was the second person to visit Istanbul from Nottingham and we are thinking of expanding this interaction further. I had the opportunity to see a spectrum of pectus deformity cases. I learnt assessment, planning and insertion of simple Nuss bars, Cross bars, Multiple bars and Sandwich bars for mixed deformity. I also had the opportunity to see Corset for Pectus carinatum, Suction devise for Pactus excavatum and use of Nuss bars for Sternal dehiscence post cardiac surgery. I saw new places, made new friends and more importantly learnt new skills. I am very happy and satisfied with the outcome and learning from this visit and would highly recommend it to Thoracic surgery trainees. n


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The Christiaan Barnard I Knew Christiaan (Chris) Barnard, who led the surgical team that stunned the world by performing the first human heart transplant on December 3rd, 1967, literally became famous overnight. The daring operation captured the public’s imagination as no other before or since, and Barnard became one of the best known persons in the world. Richard Page, SCTS President-Elect, Chairman SCTS committee for ACCEA

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his was in part because heart transplantation had a dramatic and mystical aura about it, but was equally a response to Barnard’s youthful good looks and charismatic personality,

which naturally drew people’s attention to him (Figure 1). At one time, it was claimed that his name and face were the most recognized in the world – perhaps with the exception of the boxer, Muhammad Ali. Personally, having first met Barnard in the 1960s, worked with him for several years in South Africa and subsequently in the USA, and maintained contact with him until his death in 2001, I readily admit he was the most unforgettable character I have met in my relatively long life.

Figure 1: Christiaan Barnard at the time of the first heart transplant in 1967, when he was 45 years-old

It was when Barnard was paying a brief visit to Guy’s Hospital in London in the early 1960s to see something of the work of the innovative heart surgeon, Donald Ross, that I first ‘met’ him, though it can hardly be described as a meeting. I was then a final year medical student and was acting as the third and lowliest of the assistants helping Ross with an open heart operation. Barnard stood with the anaesthetist at the head of the operating table watching the procedure, and made interesting comments on the differences in Ross’s surgical technique from his own in Cape Town. I was struck by the energy and enthusiasm of this relatively young man – Barnard would have been barely 40 at the time - and by his intriguing South African accent.

“Barnard took me to visit his research laboratories, where his younger brother, Marius, was working, and I also joined him and his staff on a ward round to see the patients under his care.” >>


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Donald Ross (Figure 2), a South African himself who had been an exact contemporary of Chris Barnard as a medical student at the University of Cape Town, had been the first surgeon in the world to replace a diseased heart valve with a healthy valve from a deceased human subject (in 1962). In 1968, Ross was to become the first surgeon to perform a heart transplant in the United Kingdom, following Barnard’s lead a few months earlier. I first met Barnard personally a couple of years later - in the summer of 1965 when, having just completed an 18-month internship (junior hospital appointments) at Guy’s Hospital, I visited Cape Town as a ship’s surgeon. My brief sojourn at sea was a means of taking a break to see something of the world before teaching anatomy for a year in the USA. After graduating as a doctor, I had had the privilege of working under Donald Ross at Guy’s, and, on learning that I would be visiting South Africa, he recommended that I take the opportunity to visit Barnard’s department when my ship docked in Cape Town.

Barnard welcomed me and, somewhat to my surprise, seemed as pleased to talk with me as I was with him. Geographically isolated at the southern tip of Africa, he had little opportunity to discuss cardiac surgical matters with others in this field. Even though I had been only a very junior member of Ross’s team, I did know how Figure 2: Donald Ross, who, various surgical on May 3rd, 1968, problems were carried out the first heart transplant dealt with in in the UK London, and Barnard was interested to hear what I could tell him. Although I believe at that time there was a cardiac surgical service in Johannesburg, the nearest major centers to Cape Town were several thousand miles away in Europe or the USA. Barnard took me to visit his research laboratories, where his younger brother, Marius, was working, and I also joined him and his staff on a ward round to see the patients under his care. I well remember him discussing one patient with severe heart failure, and was surprised when, after we had moved away from the patient’s bedside, Barnard turned to me and said, “What this patient needs, of course, is a new heart.” I had heard a little about the work that one or two pioneering surgeons were carrying out on kidney transplantation in Britain at that time, but I had never heard of anybody considering heart transplantation. I agreed with Barnard’s opinion but, so far did I see this form of treatment as impractical at that time, I thought the remark had been made almost as a joke, as a fantasy for the future rather than the present.

In retrospect, it became clear to me that Barnard’s comment had been a serious one and that he had been contemplating heart transplantation as a realistic form of treatment for such patients certainly as early as the summer of 1965. It was little more than two years later that he took the world by surprise with the heart transplant performed on his patient, Louis Washkansky. My own personal interaction with him continued with a second brief visit to Cape Town in 1973 and then by working under him at Groote Schuur Hospital for several years in the 1980s. Having completed my surgical training, and being a member of the team at Papworth Hospital in Cambridge that initiated the heart transplant program in the UK in 1979, I moved to Cape Town to gain more experience in this field. Working with Barnard was like a breath of fresh air. He had an open mind, encouraged me in my research activities, and gave me

“Working with Barnard was like a breath of fresh air. He had an open mind, encouraged me in my research activities, and gave me great responsibility and independence in managing the clinical heart transplant program in the hospital.”


January 2018

great responsibility and independence in managing the clinical heart transplant program in the hospital. I look back and feel that my real career in heart surgery began when I went to Cape Town, and I have Chris Barnard to thank for this. However, earlier in his career, I am sure I would have found working with him more difficult. In those days, he was much more interested in ensuring that everybody worked in support of him, and less willing to allow his juniors some academic independence. I may have found life very frustrating, and my memories might have been significantly different. By the 1980s, however, he was prepared to delegate responsibility to others as he had never done before. I was fortunate to join him at this time when opportunities opened up for the junior members of his team. How will I remember Chris as a colleague and as a friend? As a colleague, he could

be demanding, expecting selfless attention to the patient’s care. No amount of effort was too much to bring a patient through an operation successfully. In his younger days, Barnard would hover around the patient’s bed, checking in and out of the intensive care unit or ward at frequent intervals, phoning his junior doctors every few minutes, never resting or letting his staff rest until the patient was safely on the road to recovery. As a friend, he could be great fun and immensely entertaining company, and, despite the acclaim and honors he had received the world over, in my opinion he never allowed himself to become arrogant, pompous, or conceited. He retained a certain humility, which was most noticeable when he was with ordinary people – farm workers, for example, or, especially, children. I never detected a hint of superiority or of condescension when watching him in their company – or in the company of doctors.

Chris Barnard lived life to the full. He had an enthusiasm for so many aspects of life – his clinical and research work, writing, public speaking, business ventures, meeting new people – that one sensed a joy of living in him – a joie de vivre – that you do not see in many. And this joy was infectious; I always enjoyed being in his company. Indeed, I usually felt uplifted just by contact with him. His admirers would surely say that the world would have been a worse place without him, his detractors that it might have been a better place. Nevertheless, I am convinced – for me, at least – the world would certainly have been a much less exciting and less enjoyable place. n

David Cooper was a surgical colleague of Barnard for several years in South Africa and subsequently in the USA. His biography of Barnard, ‘Christiaan Barnard, the Surgeon Who Dared,’ was published by Fonthill Media in November 2017.

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“Whatever you can do or dream you can, begin it. Boldness has genius, power and magic.” Johann Wolfgang von Goethe (1749-1832) And I may add:

“Magic is believing in yourself. If you can do that, you can make anything happen.”

Of Men And Mountains

(Retirement or Resurrection or Reincarnation)


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The Italian side of Mont Blanc (4809m)

Marian Ion Ionescu, Retired Surgeon

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t is said that in a long-ago season, inside a cave, deep into the dark valley of unrest, an ancient scroll had been discovered. It contained, in runic rhymes, an old Skalda from the Great Spirit: ‘Each human being will receive, sometime during life and certainly before retirement, an imaginary kaleidoscope’. When turned gently it shows athwart a myriad of images and an infinite variety of possibilities of living and enjoying life during our third, successive reincarnation. Some people look through the kaleidoscope early in life, some do it later and a few, perchance, may only glance at it because they have already decided what they want to do with their retirement. In my early teens it happened that I had been adopted by the mountains. It made me a fortunate and happy man. Years past, the great days of learning and understanding were followed by cutting and stitching in the hospital while carrying on my back a big bag of books, quite often having the feeling that alongside me, like a shadow, walked the goddess Fortuna. When coronary artery surgery reached about 70% of my surgical activity and when I could not find anything more to create or to improve, I decided to open the window towards the sky. Out there, powerful and cold, the sempiternal mountain, above our world, exposed to the elements, to the sun and the wind and the stars, superb in its grand snow-covered solitude, waited for me. I knew that I would have to give up on any other dreams I could have had. I knew that all those who approach it must be ready to abandon everything which life calls normal living, sometimes even life itself. In return, the mountain offers adversity, difficulty, danger and fear, and even the unattainable summit. But, in that world of beauty and magic, when the passion of mountaineering is rewarded by the success of the climb, the satisfaction reaches great intensity, the joy is just as great. Everything becomes an ecstasy like a flight

“When coronary artery surgery reached about 70% of my surgical activity and when I could not find anything more to create or to improve, I decided to open the window towards the sky.” above the clouds, an overwhelming explosion of light, splinters of rainbow, a kaleidoscope of colourful dreams. High up, in that world between rock and snow and the azure, one perceives vibrations inaccessible to the people on the flat land below. For all these, I felt a violent enthusiasm and extreme immoderation to become a real mountaineer. I looked at the time past and the improbable time left to me and I developed an almost vehement passion to use every minute of it in the mountains. I felt that age does not, in itself, limit the field of my dreams.

the destination, not necessarily the summit of the mountain, the second is that climbs are performed with the will of the mind as well as with the power of the body in almost equal measure. I shall not dwell here on the daily existence in the cramped conditions in small tents On the Rocheford ridge

The first premise of alpinism is that the climb is >>


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or in snow holes in temperatures far below freezing point because there are also blessings in the moments of solitude propitious for introspection. There, it is easier to make the connection between memory and oblivion. There, survival and success depend on teamwork, understanding and camaraderie, the masks drop, men are just men - not more, not less. I shall describe the feelings which I experienced at the time of climbs and expeditions, not those remembered now.

Abseiling somewhere

Mountain climbing is not only a technique, it is an experience built progressively, a kind of philosophy of knowing and understanding the mountain, it is something one lives with each day. Acquired knowledge and technical skills are essential. It is well known that the young climber is more exposed to danger simply because

he does not know enough in order to worry. The older one also should not draw too much confidence from his mastery of technique. That can prove to be a frail shield when climbing at high altitude. At heights above 5000 metres, progressive, correct acclimatisation is the only way to avoid very serious, sometimes lethal complications (acute pulmonary or cerebral oedema). To put it bluntly, among many other things, one needs luck. There are always objective dangers in the mountains. There is something mystical in true alpinism, something deeper at play between man and the mountain. The mountain is immovable, firm and unchangeable; what happens in the drama which men and the mountain play almost continually is the changes which occur in the climberâ&#x20AC;&#x2122;s spirit. The discoveries made about self during those long hours and days of concentration and struggle in solitude, when the soul is crushed by so much beauty, such awesome rock and ice giants around the climber. Having had some reasonable experience in mountain climbing even before retirement, I started, full of enthusiasm and anticipation, the great adventure, my third reincarnation at the age of 58. I climbed during the following twenty years from the Mont Blanc massif, across the Pennine Alps to


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“Quite often the summit is reached. There, an avalanche of thoughts and feelings flood the senses. The top of the mountains is indeed the place where we become prisoners of our dreams and where, I believe, eternity was created in our imagination, high on the snow covered peaks.” the Matterhorn area. I scaled most of the 4000 metre mountains and peaks and almost eveything of interest - ridges, couloirs, gullies, North faces etc. - in that beautiful and most exciting region of the Alps. As an example, I succeeded in reaching the top of Mont Blanc through seventeen different routes, mostly on the wild, abrupt and difficult Italian side of the mountain. During three expeditions to the Himalayas I managed to stand on top of five peaks (6000 - 7000 metres high), including the most beautiful and technically challenging Ama Dablam. A few forays in Alaska for the Denali massif and in Patagonia complete the long list of my climbing adventures.

dreams and where, I believe, eternity was created in our imagination, high on the snow covered peaks.

Quite often the summit is reached. There, an avalanche of thoughts and feelings flood the senses. The top of the mountains is indeed the place where we become prisoners of our

The most beautiful times of the day in the mountains are dawn and dusk when the horizon is ablaze and shadows are long, creating contrast and allowing the mind to wonder in that immensity about the frailty of life and its delicate beauty. It helps to make, in a special way, a mental connection between fantasy, illusion and reality.

Ama Dablam (6852m)

There, one would always wish to remain a little longer on the magic summit despite the advanced hour. In the wind of the heights and in solitude, bathed in the colours of a crepuscular light, one could dream among the clouds. It may seem strange but the realisation of a dream ends often in doubt. In fact, many important achievements begin with a dream and the doubt which follows, becomes the engine of creativity in mountain climbing as in other fields of activity.

To go back to the beginning, I find that the word retirement is a funny description. It is used for an exit, a liberation

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On the summit of Lobouce (6145m)

from something or somewhere. It might be acceptable for officialdom but in real life, for our souls and minds and dreams, for us, the many, it should be understood as a resurrection, a new beginning, a reincarnation. For me, the crepuscule of one activity was followed by the beginning of another one just as attractive, captivating and uplifting as surgery used to be. It demands the same technical precision and unfailing concentration, harnessing all the mental and physical energy to practice it safely. It requires the same dedication, perseverance and passion, the same sacrifices but carrying different risks, other privations. But now, away from my third reincarnation, I look back at the great days of mountaineering and I understand more and better the whole meaning of high-altitude climbing. It certainly is the highest, complete and most noble of passions. It gave me untold pleasure and great satisfactions, it was simply a dream come true but during the years of climbing I did not give much of myself to others. To call it by its true name it was an egotistic passion. Fortunately fate granted me a few more seasons beyond the climbing years. I do find now more time to shower more love, more friendship and more help on more people. In closing this saga, I go back to Johann Wolfgang von Goethe and ask: ‘What is my life if I am no longer useful to others’. n


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Mitral Valve Repair Training at the Bristol Heart Institute: A Fellow’s Perspective Hunaid Vohra, Consultant Cardiac Surgeon Daniel Burns, Bristol Complex Mitral Valve Repair Fellow

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itral valve repair has been considered for many years to be more of an art, only approachable in a safe and reproducible manner by a minority of surgeons in training. In the UK and abroad, surgeons have limited exposure to formal training in mitral valve surgery. Most must undertake advanced fellowship training to gain the required skills. The purpose of this report is to highlight the advanced training experience in mitral valve repair at the Bristol Heart Institute (BHI), as described in the following by our current mitral valve repair fellow.

aspects of cardiac surgery are covered. However, certain specialized operations are considered “fellow cases.” Complex mitral valve procedures would typically fall under this category. In fact, a typical Canadian trainee would likely have few mitral cases where they were the primary operator, most of these being mitral replacements. In terms of mitral repairs, trainees would likely perform the occasional component of a leaflet resection, placement of annuloplasty sutures, or placement of a ring. I completed my residency being

The benefits of training at the BHI are the high mitral case volume, the practice of minimally invasive mitral surgery, the collegial consultant surgeons, and a supportive and hard-working team of specialty registrars/fellows. Three highvolume mitral surgeons make up the mitral team: Mr. Franco Ciulli, Professor Raimondo Ascione, and Mr. Hunaid Vohra. The fellow works 1 on 1 with the consultant, allowing trust and a training relationship to be fostered. This also helps facilitate preoperative planning as well as the open discussion of the finer points of mitral surgery, whether straightforward or complex. Reconstructive techniques are tailored to the specific mitral lesion and resulting valve dysfunction, and include the full range of reconstructive techniques from simple rings to more advanced repairs using resections and/or artificial chords. There is a high volume of more routine cases as well, ensuring the fellow remains facile in less specialized surgery. Less specialized cases continue to challenge the experienced trainee by introducing off-pump coronary artery bypass grafting and minimally invasive aortic valve surgery. Senior trainees and fellows will be exposed to both of these approaches as the primary operator. Though negatives are few, the service does suffer from occasional staffing and case cancellation issues. However, this is not specific to a single centre in the current NHS environment.

“The benefits of training at the BHI are the high mitral case volume, the practice of minimally invasive mitral surgery, the collegial consultant surgeons, and a supportive and hard-working team of specialty registrars/fellows.”

Fellowship Report: I completed my cardiac surgery training in Canada (University of Western Ontario), receiving my specialist certificate June 30, 2017. Through discussions with colleagues, I was made aware of higher order training opportunities at the BHI. Unbeknownst to me, the BHI had recently introduced a formal fellowship in complex mitral valve repair. After speaking with the current mitral fellow, I was convinced that this was a program I should consider for fellowship training in mitral surgery. Cardiac surgery training in Canada is quite different from training in the UK. Canadian trainees spend 6 years in an integrated direct-entry residency beginning July 1, approximately 6 weeks after medical school graduation. Throughout residency, all

comfortable with the setup of a mitral valve case, either as an isolated or combined procedure. Minimally invasive mitral surgery was the default approach at Western, and as such higher degrees of participation in these cases was limited. During my final year as Chief Resident, my personal interest in mitral surgery was developing, but I was not yet competent. In the age of concentrating advanced procedures, including complex mitral repairs, in centres of excellence, additional training was clearly required.


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I am working primarily with 2 high volume mitral valve repair firms, and have already had the opportunity to assist and perform both simple and more complex mitral valve repair procedures. Teaching the complexities of mitral valve surgery is a daily affair in Bristol and the full immersion system in a high volume centre is not only gratifying for the surgeons performing the repairs, it is an invaluable experience for my future practice. The consultant surgeons are good at â&#x20AC;&#x153;giving away,â&#x20AC;? and my first case as the primary operator occurred my first day in theatre. On average, I am involved in 2-3 theatre days each week. In my 3 months at the BHI, I have been involved in 58 cases, 25

of which have been mitral operations. In this short time, the volume of mitral valve cases I have been exposed to has allowed me to develop an understanding of the finer points of mitral valve surgery. I was started with simple valve exposure and tying in rings, with gradual progression to performing the setup, exposure, annuloplasty sutures, resections / reconstructions, and related procedures such as tricuspid valve repairs and atrial ablations. Even when not the primary operator, I am always involved in a key component of the operation, ensuring my skills continue to develop. Importantly, I have also gained additional experience in the minimally invasive approach to the mitral valve, a

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modality becoming increasingly prevalent in the UK and standard of care in many centres internationally. Though this approach is requires a more advanced skill set compared with conventional mitral valve surgery, fellows are involved nonetheless. This ranges from exposing the femoral vessels and peripheral cannulation, to performing components of the valve repair using endoscopic instruments. As a fellow at the BHI, my skills have continued to develop beyond that of a newly qualified specialist surgeon. Seeing the progress I have made at 3 months of a 12-month fellowship instills confidence that I will be leaving Bristol a competent young mitral surgeon. n

Yorkshire Trainees Win Top European Cardiothoracic Knowledge Competition M Loubani, Consultant Cardiothoracic Surgeon

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wo Yorkshire Cardiothoracic Trainees have won the Cardiothoracic Masters Jeopardy Competition at EACTS in Vienna. Priyad Ariyaratnam (ST5 & NIHR Clinical Lecturer at Castle Hill Hospital, Cottingham) and Josh Lodhia (ST4 at St Jamesâ&#x20AC;&#x2122; Hospital, Leeds) entered the competition representing Castle Hill Hospital. They both passed an intense screening exam in August 2017 to qualify to compete against 5 other top scoring Resident teams from across Europe and Asia, to compete in the Jeopardy competition at EACTS in October 2017. The Annual Competition is based on the famous Jeopardy Competition Live at EACTS 2017

American TV Quiz Show, replacing general knowledge questions with Cardiothoracic questions taken from the American Board Exam Curriculum. Over two days, the team of Priyad and Josh answered questions ranging from the history of lung transplantation to the physiology of the heart; from the management of congenital cardiac lesions to the anatomy of the mediastinum. They won their semi-final against two other teams on the Sunday and qualified to meet the Madras Medical Mission Hospital from

India on the final day. They used excellent tactics and their knowledge to win the final and become the first UK winners of the competition. Their prize is an all-expenses paid trip to the STS Annual Meeting in Fort Lauderdale in the USA in January 2018 to compete Priyad receiving the award against the from the EACTS SecretaryAmerican General, Professor Domenico Pagano at EACTS Honorary Resident Lecture in Vienna Champions. We wish them the best of luck and hope they come back from America having beaten the Americans. n

Winners Podium (Priyad and Josh 3rd and 4th from left respectively)


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Robotic Mitral Valve Repair The Least Invasive Complete Repair In patients with degenerative mitral valve disease, the benefits of mitral valve repair over replacement are well established; repair confers superior survival and greater freedoms from endocarditis, thromboembolism and anticoagulant-related hemorrhage. Marc Gillinov, MD

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ealization of such results requires a complete repair, which entails multiple surgical maneuvers that virtually eliminate mitral regurgitation; this cannot yet be achieved via catheterbased technologies. Although the operative goal (complete repair) generates little controversy, the choice of surgical approach is hotly contested in patients requiring isolated mitral valve surgery for degenerative disease. Surgical options include full sternotomy, partial sternotomy, right thoracotomy, and robotic surgery. Among these, robotic mitral valve surgery is the least invasive, and, therefore, is often patientsâ&#x20AC;&#x2122; first choice. Recent experience demonstrates that the combination of careful patient selection and unwavering attention to surgical detail enable outstanding results with robotic mitral valve repair.

Patient Selection As with all cardiac operations, patient selection is integral to the success of robotic cardiac surgery. Complications (e.g. stroke, limb ischemia, failed repair) most often stem from improper patient selection. The decision to offer robotic mitral valve surgery is based upon the results of preoperative imaging studies, most importantly the CT scan and transthoracic echo (Figure1). Echocardiographic findings that militate against a robotic approach include mitral annular calcification, aortic regurgitation and significant left or right ventricular

dysfunction. In the presence of aortic regurgitation that is more than mild, myocardial protection is problematic; reliance on a percutaneously-placed retrograde cardioplegia catheter in such instances is dangerous, as such catheters periodically become dislodged. Mitral annular calcification complicates mitral valve surgery and increases surgical risk; patients with severe mitral annular calcification should be approached via sternotomy. Finally, the presence of

Figure 1. Algorithm depicting patient selection for robotic mitral valve surgery. AR, aortic regurgitation.

severe left or right ventricular dysfunction mandates a sternotomy approach in order to 1) shorten operative time and 2) optimize myocardial protection. A preoperative CT scan of the chest, abdomen and pelvis guides cannulation and perfusion strategies. The presence of aortoiliac atherosclerosis precludes safe retrograde perfusion via the femoral artery. In addition, the CT scan identifies the occasional patient with a discontinuous


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inferior vena cava, retroesophageal left subclavian artery, or persistent left superior vena cava; each of these findings informs the perfusion strategy.

Set-Up and Cannulation The Simple, Inexpensive Approach The patient is intubated with a double lumen endotracheal tube and the anesthesia team places a second catheter in the right internal jugular vein. The right femoral vessels are exposed to ensure that they are of adequate size for cannulation (7 mm diameter or greater) and a 3-4 cm right minithoracotomy working/ camera port is created in the right fourth intercostal space in the anterior axillary line. The 3 robotic instrument ports are placed in a triangular configuration around this working/camera port. With echo guidance, cannulas are placed via the right femoral vein, right femoral artery and, in patients with BSA > 2.1 kg/m2, in the superior vena cava via the right internal jugular vein. After establishing cardiopulmonary bypass, the aorta is occluded with a transthoracic clamp and the heart is arrested with a single dose of Del Nido cardioplegia (20 cc/kg). Cardioplegia is readministered at one hour if the crossclamp time is anticipated to exceed 90 minutes. The Complex, Expensive Approach The use of the endoaortic balloon for aortic occlusion (rather than a transthoracic clamp) enables the surgeon to reduce the working port incision size from 3-4 cm to 2 cm but increases complexity and cost. If the endoaortic balloon is employed, it is prudent to place a retrograde cardioplegia catheter via the internal jugular vein in order to ensure adequate cardioplegia. Bilateral upper extremity arterial lines are necessary to monitor distal balloon migration, which is heralded by a decline in right upper extremity blood pressure. Additional monitoring of balloon pressure and aortic root pressure are required in order to maintain proper balloon position. When suturing near the left fibrous trigone, systemic pressure should be reduced in order to reduce the balloon’s impingement on the surgical field. While surgeons achieve excellent results with endoaortic balloon occlusion, it adds complexity and cost.

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“Reports from multiple institutions document the safety and effectiveness of robotic mitral valve repair. In large series, operative mortality is less than 1% and major morbidity is similarly uncommon. Repair rates exceed 95%, and nearly all patients leave the operating room with mitral regurgitation that is graded as mild or less.” Mitral Valve Repair The mitral valve repair techniques applied with the robotic approach mirror those employed with a sternotomy, with only minor modifications to facilitate the less invasive chest wall incision. Posterior leaflet prolapse is managed via resection or creation of artificial chordae. Anterior leaflet prolapse is addressed by creation of artificial chordae. All repairs include an annuloplasty, and a flexible band is the preferred annuloplasty device as 1) it produces excellent results in patients with degenerative mitral valve disease and 2) it is easily manipulated within the left atrium. Annuloplasty fixation is achieved with a running suture technique or with interrupted sutures that are affixed with automatic titanium fasteners; the two techniques are equally rapid. The valve repair is assessed first with saline insufflation into the left ventricle and then with intraoperative echocardiography.

Safety and Effectiveness Reports from multiple institutions document the safety and effectiveness of robotic mitral valve repair. In large series, operative mortality is less than 1% and major morbidity is similarly uncommon. Repair rates exceed 95%, and nearly all patients leave the operating room with mitral regurgitation that is graded as mild or less. Because repair techniques are virtually identical to those applied

via sternotomy, late results are expected to equal the long-term results of mitral valve repair performed through a sternotomy.

Advantages of Robotic Mitral Valve Repair The surgeon’s primary goal is to perform a safe and effective operation that concludes with an excellent mitral valve repair. If preoperative testing reveals that this goal can be achieved less invasively, the patient enjoys several advantages. These include a lower risk of chest wall infection, reduced likelihood of requiring a blood transfusion, quicker recovery, and a superior cosmetic result.

Surgeon Preparation and Learning Curve Any surgeon skilled in mitral valve repair can transfer this expertise to the robotic platform and provide patients with the least invasive, complete repair. Pursuing the robotic platform requires team training; the team includes a dedicated anesthesiologist and a tableside surgeon comfortable with the robotic technology. Together, the surgeon and team negotiate a learning curve. After fifty cases, the surgeon will feel comfortable with the robotic platform. The learning curve reaches an asymptote at approximately 150 cases. Although this learning curve is somewhat lengthy, it does not compromise patients safety or repair effectiveness, and the ultimate result is a complete repair achieved through the least invasive approach. n


the 56 bulletin

The Heart Club As a preclinical medical student at Guy’s Hospital in 1965 I was fascinated by the work of surgeons. There was a glass dome over the theatre where Lord Brock operated; between lectures I would go and watch. Tom Treasure, Cardiothoracic Surgeon retired from Guy’s Hospital 2007

A

year later as a “dresser” on my first surgical I was bleeped to theatres to assist Lord Brock’s registrar Tony Dyde re-opening a repair of Fallot’s Tetralogy. He quizzed me on the anatomical features - I was probably the more surprised when I correctly listed all four, but my tutorial was halted by the arrival of a not too happy Brock. The next time I met Brock was in 1970 as a houseman when I assisted him with a lobectomy. As a student I had seen Barry Ross during his general surgical training operating on piles and decided that surgery above the

diaphragm would suit me better. I had wanted to be a physician and to that end I chose cardiothoracic surgery as my preregistration surgical job. Assisting Donald Ross and Alan Yates permanently turned me towards cardiothoracic surgery.

When the Guy’s cardiology offices were being cleared prior to the demolition of the old Hunt’s House in the 1990s, the cardiologist John Chambers found a bound volume chronicling meetings from April 1948 to March 1956 with “Peacock Club ” on the spine. Dr Maurice Campbell, Guy’s cardiologist and editor of the British Heart Journal had chosen to name the club after Thomas Peacock founder of the Victoria Park Hospital, later to become the London Chest Hospital. Peacock had described the tetralogy in 1855, 30 years before Fallot. Having no doubt about the significance of its contents I safeguarded the book. When the technology became available to me, I scanned the 109 pages of 47 consecutive meetings. The original volume is now in Written in Ian Hill’s handwriting is a sample of the minutes. The names of the Arthur Hollman the guest are notable as is the chair’s rebuff of the St Thomas’ surgeon “Pasty” Historical Collection Barrett’s interest in membership. The Club had discussed mitral stenosis before Brock’s first valvotomies in 1948 and had already published 100 cases in of the British the British Medical Journal so the comment here is perhaps “going public” on Cardiovascular Society. surgery which had so recently been regarded as “contraindicated”.

The Heart Club, published in September 2017, www.bookpublishing.co.uk/ tomtreasure contains a full transcript of the minutes, preserved unedited, but I hope with enough annotation to make the glossary informative. Most surgical history is retold with the benefit of hindsight so I have limited my explanations to what was in the text books and journals at the time the Club met. The subject of each meeting was decided and speakers were assigned well ahead. The Guy’s Medical Research Unit, set up to research shock during the WW2, turned its hands to measuring pressures and oxygen saturation to unravel the anatomy of the hearts of children born as “blue babies”. There is a record of the earliest days of angiocardiography and the acquisition of a Fairchild camera, wartime air surveillance equipment, which could take two still pictures per second. Ian Hill, Brock’s first senior registrar, provided the surgical skill to obtain vascular access for these hair-raising and sometime lethal investigations. He and later Ben Milstein were the Club secretaries and wrote up the minutes. The Club worked as a team. There was a core of about fifteen individuals meeting until about 11 o’clock in the evening; trainees, research fellows and visitors brought the list attendees over the years to 80 whose mini-biographies are in The Heart Club. Operating on the heart had been explicitly ruled out in the writing and teaching of the early 1940s. The operations on mitral stenosis in the 1920s are seen now as landmarks but there was a moratorium still in place, by clinical consensus, following Elliot Cutler’s 1929 paper, subtitled the “final report”. Of 10 operations in the 1920s, only Souttar’s patient from 1925 survived the decade. But then


January 2018

emerging from the war, two highly publicised surgical experiences reopened the possibility of heart surgery. The surgeons responsible were Dwight Harken and Alfred Blalock; Brock was closely involved with both. Harken had been at the Brompton in 1939 and had impressed Brock and importantly, Arthur Tudor Edwards. Dr Cutler, a committed generalist as far as surgery was concerned, had become Brigadier General of the U.S. Army Medical Corps in WW2. A surgical hospital for head and chest injuries was to be set up in the Gloucestershire countryside in preparation for the D-Day landings in June 1944. The Brompton surgeons had been central in establishing thoracic surgery as a specialty in the 1930s and managed to get their protégé, appointed surgeon in charge. Contrary to the judgement of senior American surgeons, Harken operated to remove bullets and

shrapnel in and around the hearts of injured soldiers. Brock had observed some of these operations and was there in 1945 when Harken presented an experience of 134 cases with 100% survival to the Association of Surgeons of Great Britain & Ireland. The heart was no longer off limits for surgery. Another product of the war was the exchange programme between Guy’s and John’s Hopkins. The first American visitor was Blalock for the month of September 1947. His already well-rehearsed subclavian to pulmonary artery shunt operation, devised with Helen Taussig and his technician Vivien Thomas, was performed without a death in 10 children with Fallot’s Tetralogy. Their work was received with acclamation at Royal College and International meetings held in London during Blalock’s time at Guy’s. His operation continued to be performed at

Guy’s with the full support of the cardiologists. Surgeons now had a place in the treatment of heart disease. Less well known, but clearly stated in the transcript of a lecture by cardiologist Maurice Campbell, published in Guy’s Hospital Gazette, was that he and Brock had been discussing the possibility of a direct operation on the pulmonary valve and the infundibulum since before 1946. Harken’s success operating within the heart, and Blalock’s in relieving cyanosis by an operation adjacent to the heart, was the evidence Brock needed to convene the Club in April 1948. Campbell was its chair and anchor man until his retirement and the Club’s demise in 1956. In the BMJ in 1952 they published their first 100 operations for mitral stenosis and in 1954 their first 100 “Brock procedures” on the right ventricular outflow tract. n

Upcoming Courses - 2018 22-23rd January

7-9th February

5-8th March

24-26th April

3rd-4th May

15-16th May

18-20th June

29th September

19-21st November

27-29th November

4-5th December

ST5A – Intermediate Viva Course

Pinewood Campus, Wokingham

ST6A and ST6B – Cardiothoracic Surgery Sub-Specialty Course

European Surgical Institute, Hamburg

ST7A – Revision and Viva Course for FRCS (C-Th)

Pinewood Campus, Wokingham

ST8A – Cardiothoracic Surgery Pre-Consultant Course

European Surgical Institute, Hamburg

ST3B – Operative Cardiothoracic Surgery Course

European Surgical Institute, Hamburg

ST5B – Non-Operative Technical Skills for Surgeons (NOTSS) Course

Advanced Patient Simulation Centre, St George’s Hospital, London

ST4B – Core Thoracic Surgery Course

Minimal Access Therapy Training Unit (MATTU), Guildford, Surrey

ST7B – Clinical examination course for FRCS (C-Th)

Papworth Hospital, Cambridge

ST3A – Introduction to Specialty Training in Cardiothoracic Surgery Course

MATTU, Guildford

ST4A – Core Cardiac Surgery Course

MATTU, Guildford

ST8B – Professional Development Course

Pinewood Campus, Wokingham

57


the 58 bulletin

United Kingdom Aortic Surgery United Kingdom Aortic Surgery (formally United Kingdom Thoracic Aortic Group), has been expanded to include colleagues from vascular surgery and vascular interventional radiology who are involved in the management of aorto-vascular diseases of the thoracic aorta. Alex Cale, Communication Secretary UK-AS

U

nited Kingdom Aortic Surgery (UK-AS) has been constituted to provide a national forum to facilitate collaboration of all those involved in the organisation and management of thoracic aortic disease; with an overarching aim of ‘improving patient care through shared learning, education and research’.

that this would be the best way forward similar to paediatric cardiac surgery. The programme would need consistent funding to facilitate it, and appointment into the fellowship should be by competitive interview. The structure of aortic training in the UK will be discussed at the next SAC meeting.

The seventh meeting of United Kingdom Aortic Surgery occurred at the Belfry near Birmingham in September, and was well attended with representatives from most of the centres in the country. Following a welcoming introduction from UK-AS Chairman Geoff Tsang, and the following agenda items were discussed in open forum.

The current national organisation for the treatment of acute thoracic aortic disease was debated. The motion was ‘All units should have an aortic dissection rota’. Alex Cale from Hull spoke for the motion and presented data from ongoing work in Yorkshire; supported by the Yorkshire Ambulance Service showing that it would be possible and safe for three centre (Leeds, Sheffield and Hull) to provide a service delivered by dedicated aortic surgeons by rota for the 5.3 million population of the county and such a reorganisation could save over 40 lives a year. Jonathan Unsworth-White from Plymouth spoke against the motion arguing that the networks would be impossible to establish

Re-imbursement for Aortic Surgery: An update on the HRG4+ re-imbursements for aortic surgery was given by Aung Oo and Manoj Kuduvali. Simple aortic tariff such as a modified Bentall procedure had gone down a little; but complex aortic surgery such as aortic arch and thoraco-abdominal aortic aneurysm op procedures will attract significantly higher tariffs for example TAAA will increase from £7K to £30K. The importance of accurate coding, especially complication and co-morbidity codes was emphasised, for example a FET procedure requires seven separate procedural codes to attract the maximum tariff of £24K.

National Aortic Surgery Fellowship: An overview of the Liverpool Heart and Chest Hospital aortic fellowship programme which has been running very successfully since 2011 received unanimous praise. The establishment of a national aortic fellowship programme was discussed and there was general agreement

Acute Aortic Dissection Rotas:

“The UK-AS meeting was felt to be needed annually as it was a unique forum to discuss operational, organisational and managerial issues.”

in certain parts of the country such as the South West, and it would be hazardous to move patients with acute aortic dissection between centres by ambulance. He also maintained that such procedures should be considered general cardiac surgery deliverable by all surgeons. After further lively debate, the motion was not carried; however the fact that there is a wide variance in outcome across the UK for surgery for acute aortic dissection, and in general the outcomes from the UK are poor compared to the rest of Europe and North America were agreed to be issues that required further investigation.

National Courses and Meetings: There are a number of excellent courses around the UK to give surgeons exposure to complex aortic surgery. Co-ordination of these efforts was discussed. Similarly, aside from the UK-AS meeting, there are three large aortic meetings and the need for improved co-ordination and cooperation to avoid duplication of effort was discussed. The notion of a single National aortic meeting was felt to be the aspirational position; with the current meeting organisers sharing the effort and hosting location. The UK-AS meeting was felt to be needed annually as it was a unique forum to discuss operational, organisational and managerial issues that are not traditionally discussed in large meetings with presentations and posters as the main focus.

Research and Publications from UK-AS: Gavin Murphy from Leicester gave an overview of current scientific research into diseases of the aorta and called for a more collaborative approach to gathering


January 2018

information and publications. For example current advances in genomic research in aortic surgery have the potential for multicentre collaboration to drive this research. Both Gavin and Giovanni Mariscalco will lead on this; and will contact centres to provide an update of a pilot project and seek expressions of interest to participate. The Southampton experience in the use of FET in Acute Type A dissection led to discussion regarding the potential for a multi-centre randomised control trial. The Distal Aortic Repair versus Conservative Therapy in Type A Dissection trial (DIRECTION) was an original idea put forward by Bob Bonser in the pre-FET era, and now being further developed by the Papworth team led by Pedro Catarino. Discussion centred on the benefits and risks of doing this extended procedure, as well as the absolute and relative indications. An update from Pedro is anticipated soon. It was felt that the UK-AS should collate the latest UK data relating to the use of FET in acute type A dissection, which consists of approximately 50 patients, and submit an abstract to SCTS and the NY Aortic

Symposium. In addition a national database of elective FET patients has been established with the help of Vascutek, and this data will form the basis of further group submissions on behalf of UK-AS to the AHA Aortic meeting in New York next spring.

Hybrid Techniques for Chronic Dissection: Ian Nordon from Southampton gave a balanced talk on options, merits and demerits of hybrid techniques. It is clearly difficult to focus solely on chronic dissection as case numbers for this pathology are not high, and most series are an amorphous group of various pathologies and indications. A hybrid approach in selected cases and in expert hands appears to deliver good results, but more time is required to observe long term results. The overall impression is that although hybrid approaches seem attractive, results are not very good compared to conventional surgery and consequently such therapy should be used with caution.

Endovascular Stenting in Chronic Dissection: Donald Adam from Birmingham presented

59

a review of existing series and literature and the Birmingham experience of endovascular repairs for Chronic Type B Dissection, and Bijan Modarai from London presented St Thomas’ endovascular experience for chronic Type B dissection. Discussion was facilitated by the presentation of two case studies showing successful staged endovascular therapy. An overview of the current development ascending aorta stenting and arch stenting showed that this technology was far from ready for widespread use.

Open surgery for Chronic Dissection – Aung Oo: Aung Oo presented an overview illustrated by his experience, and presented data from meta-analyses as a benchmark for any future intervention. Case presentations led to discussion around the basic techniques necessary for successful TAAA surgery, including circulatory support techniques. UK results from HES data were presented and discussed. After adjournment of the meeting some attendees availed themselves of the excellent facilities at the Belfry, at their own expense, following which a meeting dinner was hosted by UK-AS. The next satellite meeting of UKAS will be during SCTS Glasgow in March 2018, and the next annual meeting at the Belfry in September 2018. n

• NEW CONSULTANT APPOINTMENTS Name

Hospital

Specialty

Starting Date

Selvaraj Shanmuganathan

Nottingham City Hospital

Cardiac

June 2017

Hazem Fallouh

Birmingham Heartlands Hospital

Thoracic

September 2017

Mazyar Kanani

James Cook University Hospital

Cardiac

September 2017

• OTHER APPOINTMENTS Name

Hospital

Appointment

Starting Date

Shantanu Sinha

University Hospital of Wales, Cardiff

Locum Consultant (Adult Cardiac)

May 2017

Maziar Kanani

James Cook University Hospital

Locum Consultant (Cardiac)

March 2017

Vincenzo Pagliarulo

Nottingham City Hospital

Locum Consultant (Thoracic)

August 2017

Sendhil Balasubramanian

Nottingham City Hospital

Locum Consultant (Cardiac)

September 2017

Abdul Nasir

New Cross Hospital, Wolverhampton

Locum Consultant (Cardiac)

October 2017

Vaseleios Valtzoglu

University Hospital of Wales, Cardiff

Locum Consultant (Thoracic)

October 2017

Branko Mimic

Leeds Teaching Hospitals NHS Trust

Locum Consultant (Cardiac)

December 2017


the 60 bulletin

Obituary:

David Ian Hamilton Born, Stockton on Tees, 22nd June, 1931 Died, Merseyside, 6th October, 2017

Cardiac Surgeon Royal Liverpool Children’s Hospital and Foundation Professor of cardiac surgery, Edinburgh. President of the Society of Cardiothoracic Surgeons GB & Ireland 1993

Roger Franks, Retired cardiothoracic surgeon

D

avid Hamilton’s father was a civil engineer and brought up as a Quaker. His mother was a child of the manse. David was educated at the Quaker Leighton Park school in Reading and married Myra, also a child of the manse and it was against this background that he lived his life, worked and brought up his family. David was born in Stockton on Tees where his father, Jack Hamilton, as a civil engineer, had a special interest in bridge building. He had worked on the Tyne Bridge in Newcastle (the first person to cross on his motor-cycle during its construction), the Forth Road bridge and Wandsworth Bridge. He had served with the French Red Cross and Friends Ambulance Unit and later been awarded the George Medal for work in the defusing of a German, 1000kg bomb in West London. David’s mother was the daughter of a Presbyterian minister, Edinburgh trained nurse and amateur violinist. After Stockton on Tees the family moved to London and David attended Kings College junior school and then Leighton Park School in Reading. Throughout his formative years David developed a deep respect and affection for his mentors, in particular his father’s skills as a craftsman in wood and metal, at school those who instructed and inspired him at cricket tennis and rugby and subsequently those luminaries of the

1950s and 60s who taught him medicine, surgery and cardiothoracic surgery. At school he played rugby for the English Schoolboys in 1949; during National Service he represented the Royal Corps of Signals at rugby. Sport remained important throughout his life playing tennis with the family and friends and golf until his 80s. After National Service he went to the Middlesex Hospital Medical School, then in Mortimer Street, West London. Medical school was pretty conventional stuff of the time though as an ex-National Serviceman he owned a car. A sound base of clinical skills was installed in the pre-ultrasound and sophisticated imaging era. He went on to train in cardiothoracic surgery under the influence of Brock and Holmes Sellors and Watterston in London and Gerbode and Starr in the United States. He was appointed senior registrar and subsequently, in 1968 as consultant at Broadgreen Hospital in Liverpool. This appointment gave him the opportunity to expand his work into surgery for congenital heart disease at the then Royal Liverpool Children’s Hospital at Myrtle Street. This work was greatly aided by Gordon Jackson (Jack) Rees and the anaesthetic team and achieved a National and International reputation supported further by the anatomical studies

of congenitally, ill-formed anatomy of Bob Anderson and cardiologists Jim Wilkinson and associates. David himself claimed to be the inspiration for these now famous anatomical studies by having sunk a suture well into the conducting tissue in the very early days! The studies were also the origins of the now infamous, though greatly valued Liverpool Collection of anatomical cardiac specimens. David inspired and guided many trainees from home and abroad. He moved to Edinburgh as Foundation Professor of Cardiac surgery in in1986 until he and Myra returned to Merseyside on his retirement in 1993. David married Myra McAra in 1957. She was the daughter of the local minister when living in Wimbledon in his schooldays. Myra was a hockey and tennis player and golfer (golf was reported to be their first date) and trained as a physiotherapist. They were married for 60 years. She pre-deceased him by four months. In his later years David was troubled increasingly by Parkinson’s Disease but he and Myra were cared for in the same nursing home on the Wirral. Gentle and un-assuming, modest and self-disciplined and inspired by the Quaker values of strength without aggression, gentleness without weakness, they are survived by sons James, Alastair and Ross, another son Ian having died last year. n


Endoscopic Vessel Harvesting :

EVH and ERAH should be the standard of care

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the 62 bulletin

Crossword

Across

1/6 Tragic ruin, almost destroyed by pick axe (8,6) 9 Spare pen is able to be slipped in (6) 10 A compiler from Ulster not quite drunk in Provence (8) 11/22 Born in a bad year after the end of the Raj, settled on Rochester (4,4) 12 The police operation needs right transport (10) 14 Appropriate alternative to flight in store? (8) 16 See 18 18/16 What makes Tom feel a bit irritated? (4,4) 19 One of two sound producers, each about right on Beethoven’s third (8) 21 Somehow bear externally chirpy disposition under great pressure (10) 22 See 11 24 O for a holiday job! (8) 26 Instead of a threat (2,4) 27 Stick notice in this location (6) 28 A challenging report can be educational (8) Please send your solutions to: Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE The first successful solution received will win either a Bottle of champagne or fine olive oil. Congratulations to Jonathan Hyde for winning the August bulletin crossword competition for which he received a bottle of champagne

New Officer The society would like congratulate our new officer:

Down

2 3 4 5 6 7/25 8 13 15 17 20 23 25

Some silly craze for skin-tight garments (5) Think about Tory blueprint (11) Regular myth, rich in variety (8) Writer’s dramatic ending: fallen woman having no better alternative (9,6) Fault of girl’s heartless longing (6) Police agent’s chill-out time? (3,3) Real gold with next credit report (9) Local infestation by unknown people raised a threat to all (6,5) Buddy club in Tinseltown (9) Green Bond producer (8) Accommodate force (6) Note: 1 in 7 deadly ones is a plant extract (5) See 7

Recent Retirements Geoffrey Berg - Golden Jubilee National Hospital Jatin Desai - King’s College Hospital Mark Jones - Wythenshawe Hospital Kenneth Macarthur - Golden Jubilee National Hospital

Gavin Murphy Royal College of Surgeons Research Lead for Cardiothoracic Surgery

Ian Mitchell - Nottingham City Hospital Pala Rajesh - Birmingham Heartlands Hospital Nizar Yonan - Wythenshawe Hospital


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