Society for Cardiothoracic Surgery in Great Britain and Ireland
Two Craftsmen, Two Medals and an association
The Future of Cardiac Surgery Research p33
Mount Kilimanjaro: Rising to the challenge p52
Torrid times make good surgeons p58
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In this issue...
From the Editor
From the President
The SCTS Board of Representatives (BORS) - What is it all about?
83rd Annual SCTS-Ionescu University and CT Forum Meeting
Two Craftsmen, Two Medals and an association
Graham Cooper, Duke Cameron
Thoracic surgery audit update
Carin Van Doorn
SCTS Education report Jan 2019
28 SCTS Education tutors’ report
Carol Tan, Sunil K Bhudia
The Nursing and Allied Health Professional CT Forum at the SCTS Annual Meeting Helen Munday
SCTS 5th National Student Engagement Day Saad Khan, Tristan Creacy
42 The Second Edition of the SCTS
National Research Meeting
The Fifth Heart Research UK Aortic Masterclass Deborah Harrington
44 SCTS Ethicon Fellowship 2017/18
46 Something Nice
48 If I knew then, what I know now...
Luis Sérgio de Moura Fragomeni
Determining the Future of Cardiac Surgery Research
EACTS Post Graduate Nurses & Allied Health Professionals Day
Gavin Murphy, Tracy Kumar, Florence Lai, Sue Page, Bethany Tabberer, Katherine Cowan
SCTS Forum, Nursing and AHP Research round-up Julie Sanders
40 Cardiothoracic Interdisciplinary
24 Contribution for Congenital
Society for Cardiothoracic Surgery in Great Britain and Ireland
Trials Network (CIRN) Ricky Vaja
Mount Kilimanjaro: Rising to the challenge Maire Gilhooly
Bentall in Souzhou
United Kingdom Aortic Surgery
60 Patient Experience Matters
Minimally invasive cardiothoracic surgery - Where do we stand? Muhammad Asghar Nawaz
62 Astronomy: Another thing
to do in retirement Jatin Desai
64 Minor VATS procedures on
spontaneous ventilation anaesthesia: A novel technique Syed Qadri
Aortic Dissection Awareness Day UK 2018 Christina Bannister
66 SCTS Links with Heart Valve Voice
68 Thoracic Surgery - Swiss Style
Gerard J Fitzmaurice
70 “Every day is my birthday”
The Cardiac Surgical Site Infection (SSI) Network Meeting
The Candid Column: Torrid times make good surgeons
73 Obituary: Andrew Thomas Forsyth 74 Crossword
Heart Valve Voice and
The 10 Year Plan Heart valve disease is a little known disease but highly prevalent. Across the UK approximately 1.5 million people over the age of 65 are currently affected by it. Heart Valve Voice is the UK’s dedicated heart valve disease charity. Formed in 2013, we are a patient-physician charity, bringing together heart valve disease patients and those that treat the disease, including cardiologists, cardiac surgeons, physiologists, GPs and nurses. Heart valve disease is a little known disease but highly prevalent. Across the UK approximately 1.5 million people over the age of 65 are currently affected by heart valve disease and that number is only expected to grow as the number of people in this age bracket grows. The OxVALVE Study reported that the prevalence of heart valve disease will affect as many as 3.3 million people over 65 by 2056, representing a 122% increase. Sadly, many people with the condition go undiagnosed and access to effective treatment is variable across the UK. Our mission at Heart Valve Voice is to improve the diagnosis, treatment and management of valve disease by raising awareness of the need for timely detection and intervention ensuring that all patients receive appropriate care and support.
The NHS recently revealed their 10 Year Plan and it was great to see that a focus on heart valve disease has been in included. This announcement has come just ahead of the launch of our own Gold Standard of Care Report. Over the past year we have been collaborating with valve disease care specialists to produce a report that sets out the ideal process to achieve the perfect valve disease patient pathway. For patients with heart valve disease, a consistent patient pathway is key to ensuring that they receive the correct treatment at the right time. If heart valve disease is caught early enough then more severe complications such as heart attack or heart failure can be avoided. “We believe that the recommendations found in the NHS 10 Year Plan can really help to remedy the problem of under diagnosis and treatment,” said Wil Woan, Chief Executive of Heart Valve Voice. “By delivering optimal treatment of heart valve disease, you ensure that patients can get back to their lives rather than increasing the burden on the NHS. The report also discusses many
other important mission statements like improving population health, empowering people and introducing technology to redesign clinical pathways.” As February is World Heart Month we have chosen this time to launch the Gold Standard of Care report that will help to address the variations in the quality of heart valve disease services in the UK and improve patient outcomes, but will provide guidance for the NHS in delivering these services more efficiently. “The UK’s ageing population, and the increased risk of developing heart valve disease with age means that we are going to see a steep rise in the number of cases in the coming years,” said Mr Chris Young, Heart Valve Voice Chairman and Consultant Cardiothoracic Surgeon, Guys and St Thomas’. “Our Gold Standard report and the NHS report identify protocols across all levels of the healthcare system to make sure that these patients are diagnosed early and reach the appropriate secondary care team for treatment. This in turn will provide patients with a better quality of life and reduce the longterm cost burden on the NHS.”
The more we listen, the more lives we save. @HeartValveVoice w www.HeartValveVoice.com
From the Editor Indu Deglurkar, Publishing Secretary, SCTS
ime flies... the age old adage could not be more true as it is already time for the winter issue of The Bulletin. We have once again received plenty of wide ranging articles showcasing activities and interests of the members of SCTS. In the Presidential update, Richard Page thanks all the committee and subcommittee members and staff in the SCTS office, compliments the SCTS Research team and encourages Units or individuals with difficulties to seek advice from the SCTS. The Board of Representatives (BORS) meeting and the discussions around the GIRFT recommendations, the process and criteria of application to the SAC, the release of the Third National Thoracic Surgical Database with 35 years of data and the pitfalls of having a standard of a minimum number of operations per surgeon without taking into consideration the complexity of the case are described in various reports.
The joint article by Graham Cooper and Duke Cameron (both immediate past Presidents of SCTS and the AATS) is truly a captivating piece of history and a tale of two Presidential medals of leading global Societies in Cardiothoracic Surgery. The sheer physical and mental resilience to scale Kilimanjaro and the magnitude of
The report from the Education Secretary, Sri Rathinam, outlines the huge benefits derived by the members of SCTS from the generous Fellowship grants and the success of the human factors team training supported by the stellar work done by the SCTS staff. The team’s effort as reported by Uday Dandekar at improving professional development for non NTNs is commendable. There are plenty of other updates from the UK-Aortic Surgery meeting, Ethicon and Ionescu Fellowships, AHP programme and the Research Network. Keith Buchan’s article “Torrid times make good surgeons” is a candid column voicing individual opinion and carries an important message. The unforgiving nature of the work that we do mandates that the whole team shares the responsibility to meet the governance requirements as patient safety is paramount. Space………the final frontier! Mr Desai literally has stars in his eyes with his space odyssey after taking to Astronomy after retirement. Socrates had said that “Man must rise above the Earth-to the top of the atmosphere and beyond- for only thus will he fully understand the world in which he lives.” It is a fascinating subject and one cannot help but reflect that it is perhaps the innate nature of the Specialty to constantly explore and take on new challenges. On that note, I wish you all a happy and relaxing holiday period as we march into the New Year. I am keen on receiving articles that address service improvement so that we can learn from the most efficiently functioning centres in the UK. I look forward to your suggestions and feedback and can be contacted at firstname.lastname@example.org n
“The joint article by Graham Cooper and Duke Cameron (both immediate past Presidents of SCTS and the AATS) is truly a captivating piece of history and a tale of two Presidential medals of leading global Societies in Cardiothoracic Surgery.”
Helen Munday & Maire Gilhooly are on cloud nine and beyond following their amazing and inspirational conquest to scale Kilimanjaro (Page 52)
the achievement is unquestionable. I am sure Helen Munday & Maire Gilhooly are on cloud nine and beyond following this amazing and inspirational conquest. Hearty congratulations to the duo from SCTS! Prof Moghissi’s quiet pride in meeting a patient who had undergone a Bentall’s operation, having worked with the pioneer himself is evident in the excerpt from his memoirs. Prof Fragomeni’s sentiments in his article is something that most of us can relate to in our own journey within a foreign health care system.
the 8 bulletin
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From the President My reflections of my first few months as President are that although the SCTS is a complex and multi-faceted organisation, it is run almost entirely by the efforts of its members. Richard Page
ll of the visible outputs of the SCTS – the educational courses, the activity and outcomes publications, the Research and Annual meetings to name but a few are only possible because of the time and enthusiasm that colleagues too numerous to mention dedicate to their activities on behalf of the SCTS. This is despite everyone having very busy professional and personal lives. Over the last few months the representation on the SCTS subcommittees and Board of Representatives has been updated. The work carried out in these committees is vital to ensure that the SCTS Executive is fully informed about all aspects of our speciality and can send out the right messages. The SCTS office receives enquiries from all sources on a daily basis and the value of being able to access all layers of the organisation for the rapid responses that are increasingly required cannot be underestimated. I now have a much better understanding of the workings of NICOR and have developed some sympathy for the limitations that the staff working there are under, especially given the reduced funding that all national clinical audits are now receiving from central government. The move of the NICOR contract from UCL to Barts has been very traumatic for the small team of NICOR staff and, as often
happens, the uncertainty causes resignations and the new members of staff who are brought in as replacements need time to understand their roles. I am optimistic that assuming we are now entering a period of stability, the reputation of NICOR within the SCTS will improve, especially with regard to timely and helpful publication of activity and
seconded to St Georges to provide clinical leadership, and I wish Steve all the best with his endeavours. The staff in the SCTS office are busier than ever. Isabelle, Tilly, Letty and Emma are always helpful and available, and when things are busy all four are in the habit of working well beyond their contracted hours. This particularly applies to SCTS Education which over the last 12 months has absorbed all the work in the administration of the increasing number of courses, which was previously undertaken by Ethicon. Despite the size of the task the feedback I receive from the faculty and delegates of the courses is excellent and clearly things are working very smoothly. As always special thanks go to Mr Marian Ionescu for his long-term support of SCTS Education. By the time this Bulletin is published a vastly expanded number of SCTS-Ionescu Fellowships will have been advertised, which will include new categories for the benefit of all SCTS members. The SCTS is extremely lucky to have such a generous benefactor in Mr Ionescu and I know this is appreciated by everyone. One of the perks of being SCTS President is that I am invited to lots of varied meetings, most of which are thoroughly enjoyable. A particularly highlight was the Aortic Dissection
“Special thanks go to Mr Marian Ionescu for his long-term support of SCTS Education. By the time this Bulletin is published, a vastly expanded number of SCTS-Ionescu Fellowships will have been advertised, which will include new categories for the benefit of all SCTS members.” outcomes, and the accessibility of the data to SCTS members for research projects. Sadly, this summer has seen another episode of poor publicity for cardiac surgery, on this occasion at the Unit in St Georges, with substantial press coverage and suspensions of surgeons. As always the causes of the problems are complex and multifactorial, but the lessons learned relate to team working and leadership, rather than poor quality surgery per se. As always the SCTS is available to help all its members whenever there are problems, either personally or in their hospitals, and I sincerely hope that things are improving at St Georges. I am really pleased that Steve Livesey, a very senior and experienced cardiac surgeon at Southampton, has been
the 10 bulletin
Awareness Day, a patient-led organisation which is helping to drive forward improved care of patients with aortic dissection and other life-threatening aortic conditions. There were lots of very brave patients in the audience with stories to tell, and 100% behind the SCTS in making changes to services for the better. A service specification for thoracic aortic surgery is being developed by NHS England, emphasising networks of care and the draft specification was discussed at the meeting. Although NHS England were uncomfortable about this, it was clear that patient engagement at the start of these processes is extremely helpful and also very powerful in making sure momentum for change is maintained. Another excellent meeting was the annual SCTS Research Day, organised by Gavin Murphy and the team in Leicester. This was only the second such meeting and already it is at risk of being so successful that it outgrows its origins. The presentations were broad-ranging
and covered all aspects of cardiothoracic surgery, and included nurses and AHPs as well as surgical trainees. Senior colleagues will remember the Cardiac Research Club from decades past, and the meeting which Gavin organises on behalf of the SCTS Research Committee has helpfully led to a rebirth of the original aims of the Club, which is to act as a forum for cardiothoracic research, perhaps less-imposing and more interactive than the presentations at the annual meeting, which the Research meeting compliments. More difficult are the ponderous progress of the changes to be made in the cardiothoracic surgical training curriculum, led by Rajesh Shah on behalf of the cardiothoracic SAC. Although there is an acceptance by all stakeholders that it is now not possible to train in all aspects of our complex and varied speciality to the standard required of an NHS consultant, the hurdles that must be negotiated to make the changes are formidable. Nevertheless I am confident that the change will be
accepted by the GMC in the near future, which will be of substantial benefit to trainees and the future workforce. A word of thanks to surgical care practitioners in cardiothoracic surgery. This profession has been in existence for over twenty years and SCPs are now indispensable colleagues in our speciality. Although training and assessment is now largely standardised, the uniquely skilled members of this professional group are still not subject to formal regulation, and are vulnerable to the vagaries of management within their own hospitals, from whom they receive variable support. Hopefully things will change soon; the SCTS and Surgical Colleges are lobbying government to ensure that professional regulation is introduced, probably via the GMC. This message will probably reach you in the middle of the annual NHS winter crisis, but this time with the looming issue of Brexit. Despite the difficulties, I hope that wherever you are working you can still be proud of the service you give to our patients. n
SCTS Dinner 2018 SCTSAnnual ANNUAL DINNER Monday 19th Monday 11th September March 2019
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the 12 bulletin
The SCTS Board of Representatives (BORS) What is it all about? Narain Moorjani, Honorary Secretary
he main aim of the Board of Representatives (BORS) is to enable effective twoway communication between each Cardiothoracic Surgical Unit in the UK & Ireland with the SCTS Executive. This allows dissemination of information from the Society to all surgeons, trainees, nurses and allied health professionals throughout the country regarding the important matters that the SCTS Executive and Sub-Committees are dealing with but also enables a direct point of contact for individual cardiothoracic surgery practitioners to seek advice and help with local issues that may have a bearing on the practice of cardiothoracic surgery nationally. Furthermore, the Board of Representative Annual Meeting provides the platform for promoting and sharing quality improvement and best practice in cardiothoracic surgery through networking and interactive discussions.
Membership The membership of the BORS includes appointed Unit Representatives and members of the SCTS Executive. It is expected that each Unit that provides cardiothoracic surgical services in the United Kingdom & Ireland should have a representative in the BORS. The Unit Representatives are selected by majority vote from an internal election amongst consultant cardiothoracic surgeons working in the Unit. They will have a term of membership of 3 years, which is renewable for another 3 years with the support of colleagues in their Unit, up
to a maximum of two terms (6 years). Each Unit should also have a named Deputy, so that if the appointed Unit Representative is not able to attend a meeting, the Unit will still be represented. Consideration can also be made within each Unit whether to have individual adult cardiac, thoracic and congenital cardiac surgical representation.
Responsibilities of Unit Representative The main aim of the Unit Representative is to be the point of contact between the Society and the Cardiothoracic Surgical Unit or department that they represent. This will allow the Society to effectively communicate with their Unit and colleagues on matters discussed at a national level. In addition, the Unit Representative would be expected to assist the SCTS in enquiries relating to practice, workforce and other topical issues; to support the SCTS in promoting engagement with educational events, research projects, fellowships and other opportunities; to produce a short annual report, including major events in the Unit and an up-to-date list of surgical staffing; to share examples of best practice and quality improvement projects with the other Units and the SCTS to improve the delivery of care for patients undergoing cardiothoracic surgery in the United Kingdom and Ireland; and to attend the annual BORS meeting, which is usually held at the Royal College of Surgeons, London in September, and the Annual Business Meeting, which is usually held in March at the SCTS Annual Meeting.
BORS Annual Meeting (September 2018) At this year’s BORS Annual Meeting there were some fantastic presentations of some of the proposed changes to cardiothoracic surgery practice that will affect all units. The primary focus of the meeting was to discuss the major recommendations of the ‘Getting It Right First Time’ (GIRFT) report and, in particular, the implications and challenges of implementation for all units around the country, especially in relation to geographical variations. The first presentation was on the suggestion that ‘Acute aortic syndrome patients are only operated upon by a rota of acute aortic syndrome specialist teams’, where the benefits of centralising thoracic aortic surgical practice were discussed and the improved results in the regions that have already introduced this but also some of the challenges in other regions of the country. This was followed by a presentation on the GIRFT recommendation that ‘Patients being treated with stage 1 lung cancer receive VATS or robotic-assisted lobectomy as the treatment of choice’. This prompted an interactive discussion especially in light of the fact that we are still awaiting the results of the UKbased VIOLET trial, which compares the outcomes of VATS versus open lobectomy. One of the most interesting sessions was on the GIRFT recommendation of ‘Ensure that every patient is reviewed by a consultant pre- and post-operatively and that this happens seven days a week’, as the discussion was opened by an eloquent insight from a patient’s or relatives’ perspective with regards to the importance of continuity of care and direct contact with the consultant that has performed the operation when balanced with
the practicalities of implementation. The final presentation of the day was on how to manage an emergency cardiothoracic surgical referral, such as a Type A aortic dissection, when the intensive care unit is full, where the receiving Cardiothoracic Surgical Unit should make arrangements to ensure the patient is put at the centre of the all subsequent discussions. In addition, presentations from the SCTS subcommittees were given, detailing all of the excellent work that is taking place, including the education programme of fellowships and courses and nationally co-ordinated research trials. Overall, it was a fantastic meeting that highlighted the opportunity for the sharing of best practise, discussion on how to tackle local issues at a national forum and the ability for Unit Representatives to learn about the current projects of the Society to disseminate back to their hospitals. We would strongly encourage you to engage with your Unit Representative (table 1) to ensure active lines of communication remain open between the Society and Units nationally.
“The primary focus of the BORS Annual meeting was to discuss the major recommendations of the ‘Getting It Right First Time’ (GIRFT) report and the implications and challenges of implementation for all units around the country.”
Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) Unit Representatives Country
Unit rep first name Unit rep last name Deputy name
England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England England Ireland Ireland Ireland Ireland Ireland Ireland N Ireland Scotland Scotland Scotland Scotland Wales Wales
Basildon Birmingham Birmingham Birmingham Blackpool Blackpool Brighton Bristol Bristol Bristol Cambridge Coventry Hull Leeds Leeds Leeds Leicester Liverpool Liverpool Liverpool Liverpool London London London London London London London London London London London London Manchester Manchester Manchester Middlesbrough Newcastle Newcastle Norwich Nottingham Nottingham Oxford Oxford Plymouth Sheffield Southampton Stoke Wolverhampton Wolverhampton Cork Dublin Dublin Dublin Dublin Galway Belfast Aberdeen Edinburgh Glasgow Glasgow Cardiff Swansea
Basildon University Hospital Birmingham Children's Hospital Heartlands Hospital Queen Elizabeth Hospital Victoria Hospital (Cardiac) Victoria Hospital (Thoracic) Royal Sussex County Hospital Bristol Heart Institute Bristol Royal Hospital for Children Bristol Royal Infirmary (Thoracic) Royal Papworth Hospital Walsgrave Hospital Castle Hill Hospital Leeds Children's Hospital Leeds General Hospital St James' Hospital Glenfield Hospital (Cardiac) Glenfield Hospital (Thoracic) Alder Hey Hospital Liverpool Heart & Lung Hospital (Thoracic) Liverpool Heart & Lung Hospital (Cardiac) Evelina London Children's Hospital Great Ormond Street Hospital Guy's Hospital Hammersmith Hospital Harefield Hospital Kings College Hospital Royal Brompton Hospital (Congenital) Royal Brompton Hospital (Thoracic) Royal Brompton Hospital (Cardiac) St Bartholomew's Hospital St George's Hospital St Thomas' Hospital Manchester Royal Infirmary Wythenshawe Hospital (Cardiac) Wythenshawe Hospital (Thoracic) James Cook University Hospital Freeman Hospital (Cardiac) Freeman Hospital (Thoracic) Norfolk & Norwich University Hospital Nottingham University Hospital (Cardiac) Nottingham University Hospital (Thoracic) John Radcliffe Hospital (Cardiac) John Radcliffe Hospital (Thoracic) Derriford Hospital Northern General Hospital Southampton General Hospital Royal Stoke University Hospital New Cross Hospital (Cardiac) New Cross Hospital (Thoracic) Cork University Hospital
Inderpaul Natasha Maninder Moninder Carmelo Manoj Amit Franco Andrew Tim Ravi Jitendra Mike Omar Betsy Richard Gavin Apostolos Rafael Steve John Conal Ben Juliet Prakash Fabio Donald Andreas Simon Rashmi Shyam Robin Michael Edward Rajesh KS Mazyar BC Dharmendra Marc Adam Mohammad Mario Dionisios Clinton David Clifford Adrian Patrick Ahmed Kishore Seyed Karen Mark Vincent Mark Reuben Hussein Vipin Kasra
Mater Misericordiae University Hospital (Cardiac) Mater Misericordiae University Hospital (Thoracic)
Our Lady's Children's Hospital St James' Hospital University Hospital Galway Royal Victoria Hospital Aberdeen Royal Infirmary Royal Infirmary of Edinburgh Golden Jubilee National Hospital Royal Hospital for Children University Hospital Cardiff Morriston Hospital
Birdi Khan Kalkat Bhabra Raimondo Purohit Modi Ciulli Parry Batchelor Da Silva Parmar Cowen Jaber Evans Milton Murphy Nakas Guerrero Woolley Chalmers Austin Davies King Punjabi De Robertis Whitaker Hoschtitzky Jordan Yadav Kolvekar Kanagasabay Sabetai McLaughlin Shah
Uday Trivedi Serban Stoica Doug West
Carin Van Doorn
Keng Ang Ram Dhannapuneni Michael Shackcloth
Tom Routledge Jon Anderson
Vassilios Avlonitis Franco Sogliani
Rammohan (Ram) Felice Granato
Kanani Ramesh Agrawal Van Leuven Szafranek Hawari Petrou Stavroulias Lloyd Hopkinson Barlow Levine Yiu Habib Doddakula Javadpour Redmond Redmond Young DaCosta Jeganathan El-Shafei Zamvar Shaikhrezai Andrew (Chuck) McLean Indu Deglurkar Afzal Zaidi
Please contact the SCTS if there any changes to your Unit Representatives
Stephen Clark Stephen Clark Selvaraj Shanmuganathan Emmanuel Addae-Boateng
Zeb Chughtai Donna Eaton
Kieran McManus Kelvin Lim John Butler
SCTS ANNUAL MEETING 2019 10-12 MARCH
QE CENTRE LONDON W1 SCTS IONESCU UNIVERSITY SUNDAY 10TH MARCH
A DAY OF EDUCATIONAL SESSIONS
MAIN MEETING PROGRAMME MONDAY 11TH MARCH TO TUESDAY 12TH MARCH
CONGENITAL SURGERY – TEAM DEVELOPMENT ABSTRACT PRESENTATIONS AND INVITED GUEST LECTURES
SCTS CT NURSE FORUM
SUNDAY 10TH MARCH TO TUESDAY 12TH MARCH INTERACTIVE TEACHING WETLAB DAY (SUNDAY) FOR NURSES AND ALLIED HEALTH PROFESSIONALS DISCOUNTS AVAILABLE TO GROUP BOOKINGS – BUY 5 GET 1 FREE
ANNUAL DINNER MONDAY 11TH MARCH UNDERGLOBE UP TO 18 CPD POINTS EARLY BIRD REGISTRATION RATES NOW AVAILABLE TO REGISTER OR VIEW THE DETAILED PROGRAMME PLEASE VISIT WWW.SCTS.ORG Reproduced by permission of Geographers’ A-Z Map Co. Ltd. Licence No. B8297. ©Crown copyright and database rights 2018 OS 100017302
Society for Cardiothoracic Surgery in Great Britain and Ireland
83rd Annual SCTS-Ionescu University and CT Forum Meeting Clinton Lloyd (on behalf of the meeting team)
egistration opened at the beginning December 2018 for the 83rd Annual SCTS-Ionescu university and CT Forum meeting to be held 10th–12th March 2019 in London at the QEII Centre located opposite Westminster Abbey and the Houses of Parliament. This excellent venue will host the Ionescu University on the Sunday and main SCTS meeting and CT Forum (Nursing and Allied Health professionals) on the Monday and Tuesday. New techniques in Cardiothoracic surgery, updates and controversies in all aspects of care will be covered and we have another exciting faculty of invited European and American guest speakers over the course of the
three days - this is your chance to meet them and pick their brains in their area of expertise. We have had over 470 abstract submissions, with over 200 accepted for oral presentation during the main meeting and over 170 accepted for poster presentation. All abstract submitters were notified of their outcomes in early December and we look forward to their presentations at the meeting. Thank you to all of the reviewers for their help with abstract marking and I would encourage all members of the society to be actively involved in the running of the meeting - we will be approaching a number of you to help chair and co-ordinate the sessions.
The plenary session will be themed as Congenital Surgery with Sir Ian Kennedy invited as one of guest plenary speakers. See https://scts.org/annual-meeting/ for links to the meeting and registration – please note that early bird registration ends on 1st Feb 2019. The conference dinner will be held in the Underglobe – beneath Shakespeare’s Globe Theatre and we look forward to providing another memorable evening of entertainment. Please contact Isabelle Ferner at email@example.com for any administrative queries and we look forward to seeing you in London 2019. n
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the 16 bulletin
SAC report Rajesh Shah, SAC Chair Cardiothoracic Surgery
at Magee once said to me: “Lad, if you wish to make a difference in training try and get involved in the SAC.” He was right. It is one of the most satisfying job one can do. As several SCTS members have approached me in recent times showing interest in the SAC (Specialist Advisory Committee), I will outline the work SAC does and the process / how you can make a strong application. SAC works on behalf of JCST and all 4 Royal Colleges. SAC is responsible for: a. b. c. d. e. f. g.
Trainee matters including enrolment and support Certification: CESR CP/CCT/CESR Out of Programme activities and LTFT training Curriculum development, including academic surgery Logbook development Simulation training Quality Assurance i. Annual Specialty Report ii. JCST trainee survey
h. i. j. k.
iii. Quality indicators iv. CCT guidelines National Recruitment (in conjunction with Lead Deanery/LETB) • Job descriptions • selection criteria • selection process Effective communication with stakeholders Externality Credentialing
The process of appointment is by way of application when vacancies arise, which are advertised through SCTS. Members of the SAC are senior members of the profession who have made a significant contribution as below: • Training / Education: eg. member of STC, Programme director, examiner for MRCS / exit fellowship, faculty standard setting, organising teaching courses, contributing to National Education courses, question writing, education degree, leadership position in education etc. • Appropriate attitude: leadership/team
working, track record of achievement/ contribution to management at trust level • Surgical expertise: exceptional achievement in specialty, research, audit • College/specialty association contribution: SCTS trustee, subcommittee member, college tutor/role. • Support from your medical director including reasonable expenses. The applications are scored independently by all members of the SAC against fixed criteria and the top scorers are appointed for a five year term. The SAC chair can also co opt members to do work on the SAC for specific National training related projects eg SCTS Education secretary. I would recommend discussion with any member of the SAC or myself for any interested member. Competition is exceptionally strong and please do not get disappointed if you are not successful on your first attempt. Should you have a project/idea related to influence/improve training at the National level, please do get in touch to discuss.
6th SCTS Cup On behalf of the SCTS Meeting Organisers, we have great pleasure in inviting you to participate in the 6th SCTS Cup to be held in London on Saturday 9th March 2019. The 5-a-side contest is going to be a fantastic way to kick off next years 83rd annual meeting! We are also pleased to announce Heart Valve Voice as the title sponsor for the SCTS CUP 2019! The tournament is as usual open to everyone who is associated with the SCTS and we encourage you to represent your deanery, institution, department or corporate group. The format will be a first round league and then a knock out competition. The matches will be held in central London and will commence late afternoon. This is to accommodate travel arrangements for all who wish to arrive the same day.
Registration of teams To participate, just create a competitive team. Individual players are welcome and will be accommodated on the day. Please submit your deatils (Team Name, Deanery/Company, Institution, Lead Contact, Email-address, Phone number) to firstname.lastname@example.org. Please ensure that your application is returned no later than 31 January 2019. Details regarding the format of the tournament will be emailed to all team captains after the closing date.
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The back of the AATS presidential badge
Two Craftsmen, Two Medals and an association: The History of the Presidential Badges of The American Association for Thoracic Surgery and The Society for Cardiothoracic Surgery
Graham Cooper, immediate Past-President, SCTS Duke Cameron, immediate Past-President, AATS
n Friday 14th July 1950, an emergency meeting of the Executive Committee of the Society of Thoracic Surgeons of Great Britain and Ireland1 was held in the Guild Hall, Bath. The meeting had been called by president Alexander Graham Bryce2 after receiving a letter from Dr Brian Blades, secretary of the American Association for Thoracic surgery (AATS). This letter announced the formation of a travelling fellowship for the study of thoracic surgery in the United States or Canada with a value of $10003. The Society of Thoracic Surgeons of Great Britain and Ireland had been invited to nominate the first recipient of the fellowship. Present at the meeting were the president, G Bryce, secretary OS Tubbs and committee members PR Allison, VC Thompson, A Logan and LL Whytehead. They decided that the privilege of selecting the candidate should rest with the Executive Committee. The fellowship was advertised to all members and associate members of the Society and also announced in the British Medical Journal on 12th August 1950 (figure 1). One year later, on 18th July 1951, the Executive considered the four candidates who had applied and ‘after long and careful consideration it was unanimously agreed to recommend LL Whytehead.’4 In 1952 and
1953 the Executive Committee selected the second and third recipients of the fellowship. However, at its meeting on 11th November 1954, in light of comments from Sir Russell Brock that ‘a number of approaches had been made to him with regard to elements of dissatisfaction that had been felt in America concerning Fellows’, the Executive decided to begin interviewing candidates for the Fellowship. The following year the Society heard from the AATS that these rumours had no substance. From the minutes, one can almost hear the sigh of relief Figure 1: British Medical Journal - 12th August 1950 when the rumour was dismissed. From that point onward, It was not surprising that there was a good the selection of the travelling fellow was relationship between the two professional the first standing item of business at most societies, as many of the senior members of Executive Committee meetings. the specialty in Great Britain had undertaken at least some of their training in America5.
“The commission for the design and making of the Badge and Chain was given to Stanley G Morris. He was one of the country’s leading designers and craftsmen and one of the few who had the skill to design as well as fabricate.”
In November 1955, the Executive Committee formed a sub-committee to discuss how the British Society could show its gratitude for the generosity of the AATS. Their report from 23rd February 1956 described three options: • A similar reciprocal scholarship • A shorter reciprocal scholarship • A simple gift of a chain of office for the President of the AATS The final option was selected, probably because of financial considerations. >>
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The Presidential Badge and Chain of Office for the AATS The twentieth Annual Meeting of the Society of Thoracic Surgeons of Great Britain and Ireland was held at the Institute of Engineers in Cardiff on the 2nd and 3rd November 1956. At the business meeting, there was the usual approval of the previous minutes, confirmation of officers, and presentation of accounts. The first item of new business was the proposed design of the Presidential Badge and Chain of Office to be given to the AATS; the design was shown and accepted. The cost was to be met by a one-time assessment of £2 for full members and £1 for associate members6.
Figure 2: AATS Badge
Stanley G Morris The commission for the design and making of the Badge and Chain (figure 2) was given to Stanley G Morris. We have no records about the commission or how Stanley G Morris was selected. However, at the time he was one of the country’s leading designers and craftsmen and one of the few who had the skill to design as well as fabricate. Stanley G Morris lived from 1919 to 2010 and was a fourth generation silversmith from Birmingham. He trained at the Birmingham School of Jewellery and Silversmithing and School of Art. During his training, he was supported by prestigious Junior and
Senior scholarships from the Worshipful Company of Goldsmiths. In 1947 he set up his own workshop in Birmingham. Much of his work was ecclesiastical; examples can be found in many churches across the country. Morris achieved national recognition when his ‘Olympic Symbolic Torch’, designed and made with Bernard Cuzner, another renowned Birmingham silversmith, won Bronze Medal in the 23rd Olympiad Arts Competition in 1948. His work was also showcased at The Festival of Britain in 1951. He created pieces for many prestigious people including a cup presented by Queen Elizabeth, the Queen’s mother, to the flower growers of London and a bowl presented to Princess Margaret. His last major commission, in 1992, was to build the Westland Aviation Trophy, presented to the best all round student on the Rotary Wing Course at the Empire Test Pilots’ School. The Presidential Badge and Chain of Office was presented to Dr Cameron Haight, AATS President, by JL Collis7, Secretary and GA Mason8 Vice-President of SCTS at the Annual Meeting in Chicago Illinois between 4th and 7th May 19579 (figure 3). The Chain of Office contained 17 links; after each annual AATS meeting, a link on the chain was engraved with the president’s name and year of term. In 1973 Morris made a second Chain of Office, as the links on the first were full (figure 4).
The Presidential Medal of the Society for Cardiothoracic Surgery In planning the Presidential Medal to be given to SCTS, the AATS wished to recognise William Harvey. On 1/8/1600, Harvey was elected as the British representative to the world’s leading medical school at the University of Padua. Each representative or ‘consiliarius’ had a coat of arms, symbol or Stemma engraved on a tablet in the Great Hall of the University. Harvey chose as his Stemma an arm and hand holding the torch of truth; this forms the centrepiece of the design of the Presidential Medal. Two serpents, associated with Aesculapius, the Greek God of medicine, entwine the torch (figure 5).
Figure 3: The Presidential Badge and Chain of Office was presented to Dr Cameron Haight, AATS President, by JL Collis, Secretary and GA Mason Vice-President of SCTS
Allan Adler The task of making the medal, in 14 carat yellow gold, was given to Allan Adler, who like Stanley G Morris, was the leading
Figure 4: In 1973 Morris made a second Chain of Office, as the links on the first were full
“Both the Presidential Badge and Chain of Office and Presidential Medal remain in use today. The AATS Badge is worn by the President during official duties at the Annual Meeting and of course during the Presidential Address.” silversmith in America at the time. Allan Adler lived from 1916 to 2002, and initially worked as a building contractor. In 1938 he married Rebecca Blanchard, the daughter of Porter Blanchard one of America’s foremost silversmiths. He served a two year apprenticeship with Porter and set up his own business in Los Angeles in 1940. His shop Sunset Boulevard attracted many stars, including Katherine Hepburn, Errol Flynn and Michael Jackson. Adler became known as Silversmith to the Stars. He made a coffee urn for John F Kennedy and a silver hairbrush for Winston Churchill. Adler’s biggest thrill, which he likened to Paul Revere’s midnight ride10,
was to design and make lapel pins for the crew of Mercury 7, the first Americans in space. Like Stanley Morris, Allan Adler was a talented designer as well as a craftsman. After the war, despite increasing automation, Adler continued to work by hand. This tradition is continued today by his grandson Danny Parsell. The medal was presented at the SCTS Annual Meeting in 1978 at Leeds. The delegation from the AATS consisted of J. Gordon Scannell, Myron W. Wheat and Lyman A. Brewer. They were met at the airport by Sir Donald Ross and Marian Ionescu. Given the value of the Presidential Medal, Brewer and Ionescu
hurried into London to deposit it with Barclays Bank for later safe transport to Leeds11. The presentation was made to the President of SCTS H.R.S Harley12 at the meeting on Friday 29th September.
The Badge and Medal in 2018 Both the Presidential Badge and Chain of Office and Presidential Medal remain in use today. The AATS Badge is worn by the President during official duties at the Annual Meeting and of course during the Presidential Address. The design of the badge is the official letterhead of the Association and will of course be familiar to readers of the Journal of Thoracic and Cardiovascular Surgery. The SCTS medal is worn by the president at the Societies’ annual business meeting and during the biannual presidential address. The medal is currently valued at £13,550 (US $17600). The medal contains a hallmark dated 1988 by a company called Argenta Design who have now ceased trading but were based in London. The hallmark identifies that the gold is 9 carat. We have had the medal independently weighed and the medal is indeed 9 carat. There are two possible explanations for this. First, the original >>
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history and display of these symbols of our mutual admiration and respect. It seems fitting to retell the story of their history, if only to celebrate the deep ties between our two professional organisations. n
Acknowledgements The following have all provided valuable help in researching this article: l
Eleni Bide and Sophia Tobin at The Goldsmiths’ Company
The Royal College of Surgeons of England Archive
Stephanie Higgs, niece of Stanley G Morris
Dauvit Alexander, School of Jewellery, Birmingham City University
Isabelle Ferner, SCTS
Bill Maloney, AATS
References 1. The Society changed its name to Society for Cardiothoracic Surgery in Great Britain and Ireland in 2007 2. Alexander Graham Bryce, 1890-1968, Thoracic Surgeon, Manchester was instrumental in the founding of The Society of Thoracic Surgeons in 1933 and was President 1950 – 1951. 3. About $9,500 or £7,500 in 2018. Figure 5: SCTS Medal
The SCTS medal is worn by the president at the Societies’ annual business meeting and during the biannual presidential address.
4. Lawrence Layard Whytehead, 1914 to 2005, was associate member representative on the Executive Committee in 1950 and was working as senior registrar at Guy’s Hospital in 1951. He became consultant at Brook Hospital after his fellowship and in 1955 emigrated to Canada. 5. Smith RA. Development of lung surgery in the United Kingdom. Thorax;1982:37:161-168 6. £1 in 1956 is worth about £17, $22 in 2018.
medal may have been lost and the current medal is a replacement made in 1988 by Argenta Design. However, there is no mention of loss of the medal or obtaining a replica in the SCTS Executive minutes of this period. We believe that it is unlikely that such an occurrence would not have been recorded in the minutes. The second and more likely explanation is that the hallmark was added in 1988 after the company Argenta Design valued the medal and that the documentation describing it as made of 14K yellow gold is wrong. A hallmark is not required to be stamped on all gold goods in the United States of America.
Conclusion The notes prepared by the AATS in the presentation of the Presidential Medal refer to the ‘deep bond of friendship between the two societies, their early histories and the profound impact that they have had on the development of thoracic surgery’. The British sentiment was similar, and the Executive Committee clearly held their colleagues in the American Association in high regard. In 2019, a Presidential Badge and Chain of Office and Presidential Medal may seem anachronistic but both the AATS and SCTS have taken great pride in the
7. John Leigh Collis, 1911 to 2003, Thoracic Srgeon, Birmingham. President SCTS 1973. 8. George Alexander Mason, 1901 to 1971, Thoracic Surgeon Newcastle. President SCTS 1959. 9. We believe that we have correctly identified the individuals in the photograph. 10. Paul Revere, 1734 to 1818, was a renowned Boston silversmith best known for his midnight ride to warn the colonial militia of the approach of British Forces during the American War of Independence. 11. Marian Ionescu, personal communication. 12. Hugh Rosborough Swanzy Harley, 1912 to 2002, trained at Guys and the Brompton and was consultant at the United Cardiff Hospitals.
Thoracic surgery audit: the next steps For thoracic audit geeks, this Christmas brings the prospects of two big parcels of thoracic data. Doug West, Thoracic Audit Lead
or starters, the Society’s Third National Database Report is being released. It updates our analysis of the thoracic registry, adding in the 2010-15 data to make a total of 35 years of remarkably complete national data. The SCTS registry is an exceptional resource in worldwide thoracic surgery, telling a story not just of change but of transformative improvements in care. While the number of operations performed and patients receiving potentially curative treatment has risen, perioperative risk, pneumonectomy rates, futile thoracotomy and other markers of surgical quality have consistently improved. The working lives of our predecessors, and the care available to their patients over three decades ago bears little resemblance to what SCTS members and their teams experience and can offer today. Reflecting on the returns myself, I’m very proud not only of what our previous and current colleagues have achieved clinically, but also of their commitment to collecting and publishing data openly, so that our specialty could advance as it has. In addition to the returns, the report contains data from the 2014-17 SCTS database project. In some ways the predecessor of LCCOP, this project includes far more in depth data from 14 UK hospitals than was previously available through the returns. This has allowed us to look at issues like stage migration in lung cancer resections, length of stay and the utilisation of investigations such as FDG-PET scanning.
Lastly, we report some exploratory work that the Society has done together with the College of Surgeons Clinical Evaluation Unit, looking at whether routinely collected NHS data, in this case the Hospital Episode Statistics, can be used to audit thoracic unit outcomes. Why do this? We know that clinicians are busy, inputting data is time consuming and yet there are already large volumes of data collected routinely in the health service. Using this data to audit clinical outcomes could reduce the burden on clinicians of data collection. Download the report and see for yourself if this approach could work. When you are done with the Database Report, the 2018 LCCOP report will be released soon, probably in early 2019. Again, this year we have been working with the audit provider the National Lung Cancer Audit to develop this important project for units in England. Now that one year survival is reported, there have been discussions about whether 90 day mortality is still needed, or is 30 day mortality reporting sufficient? Certainly 30 and 90 day mortality are closely correlated in LCCOP, suggesting that little extra information is gained. For this year however they have remained in. We have however changed our approach to resection rate reporting. The Society believes that this is an important metric in assessing the quality of surgical care. This year’s measure takes the resection data of all the MDTs
that a surgical unit covers, and pools them to provide a single resection rate for that unit. It does mean that MDTs covered by two surgical centers, nearly one in ten of the total, are shared across the two surgical centers, but overall we hope that this will be a more intuitive way to report this data. Length of stay remains in, but this year we have added 90 day readmission rates to set this data in context. The readmission rates we report, which cover all cause admissions across the NHS, are perhaps higher than we might expect, suggesting that there may be a “tail” of morbidity in the weeks after surgery which perhaps we could be more aware of. LCCOP identifies statistical outliers in the three mortality outcomes, both positive and negative. We hope that this identification of units with good outcomes helps to spread good practice, but also that units at the other end of the spectrum are supported to improve when necessary. To this end, we have updated our advice to outliers this year, and issued a template response document to help units structure their response to on outlier notification. An outlier notification from LCCOP or other national audits is often a difficult experience, but the process of team reflection and formulating a response should improve the quality of care. So there is plenty of data to digest this year. The real test is whether this data can help clinical teams to drive improvements in the future that are equal to those achieved in previous decades. n
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Congenital Cardiac Surgery It is just over a year ago, since NHS England announced its decision for the commissioning of the congenital cardiac services following the evaluation of the self-assessments of congenital cardiac centres against the new Standards. Carin Van Doorn, Chair of the Congenital Committee
ot all Standards had to be met at that time, but firm plans had to be in place for full compliance by 2021. All paediatric cardiac surgical centres remained albeit some with special measures. In the North West there was a temporary lack of adult congenital surgery services due to the closure of Manchester, but in recent months the Liverpool Heart and Chest has started adult congenital cardiac surgery and is gradually building capacity. The preferred NHS England model for specialist services is increasingly through a network model, as is also specified in the new Standards. Over the last 12 months most regions have been developing their congenital cardiac delivery network consisting of Level 3 (locally commissioned) centres, feeding into Level 2 (cardiology centres) with at the centre a Level 1 (cardiac surgery) centres. The aim is to deliver a seamless patient journey across the network and throughout the life-time of the patient with congenital heart disease which is achieved, amongst others, by improved communication, shared protocols, and education. The Standard of a minimum of 125 operations/surgeon/year (averaged over three years) remains a topic for debate, particularly as estimates suggest that there may not be enough growth in the number of congenital cardiac operations to achieve compliance for four surgeons working in each of the current 10 centres in England. The number of operations is used as a measure of surgical expertise, but it has been argued that – paradoxically – it may be the young inexperienced surgeons clocking up the numbers with quick simple cases, while senior surgeons taking on complex cases that may take up an all-day list could be at risk of not making the numbers. In addition, these surgeons may be further penalised by double scrubbing to assist junior colleagues, for which they currently do not get credit.
Lack of PICU capacity is a major thread to achieving the required annual surgical activity particularly as – in contrast to many adult cardiac intensive care units – most children’s hospitals have a mixed PICU. There is a national shortage of PICU beds and capacity is increasingly under threat, not just during the bronchiolitis season in the winter but now all-year round. Although the recommendations of the GIRFT report about the advantage of ring-fenced adult cardiac ICU beds has not been formally tested in the paediatric arena, the general feeling is that dedicated cardiac PICU beds will be of benefit. Over the last year NHS England has launched a national review of PICU and specialised surgical services, which also includes transport and ECMO services. The SCTS is amongst the many stakeholders present, but has not been possible to have a dedicated cardiac PICU work stream. The review is progressing slowly, but information so far indicates that there will be no expansion of PICU capacity but in-stead a rationalisation of the use of PICU with for example, patients requiring long-term ventilation treated outside the PICU environment. In addition the aim is to strengthen HDUs in selected district hospitals to enable a larger number of children to receive surgical treatment closer to home and unburden the large workload in specialist Children’s Hospitals. Care will be delivered via regional networks supported by transport services. The exact service specification of the regional networks is likely to be guided by geographic factors and available skills, rather than national standards. To test this model, two test sites went live last month, the South East network and Yorkshire-Humber network, with a view to gather extensive data and differing models of care in these areas. The long-awaited results of the National Congenital Cardiac Audit for 2014-17 were
finally published in November 2018, showing excellent results and no statistical outliers amongst the Centres. After plans by Nicor to do away with on-site data validation were shelved after strong professional opposition, this audit remains the only validated national congenital cardiac audit in the world. However, financial constraints and a desire by NHS England to align all Nicor run cardiovascular audits have resulted in a less detailed presentation of mortality, which remains centre – rather than individual – surgeon based. Centre performance in paediatric cardiac surgery is also monitored using Variable Adjusted Life Display charts, that depict actual versus predicted 30 day mortality and also show unplanned reinterventions. All Level 1 Centres now possess the necessary software to continuously populate their own VLAD charts and must review these at their monthly audit meetings as part of the commissioning Standards. Recently, it was noted that most centres consistently outperformed the predicted mortality, and the risk model has now been recalibrated to bring actual and predicted mortality in line again. There is currently no risk model to help predict expected mortality for adult congenital cardiac operations, but research into the development of these has now been started. Further changes to the National Audit are expected in the near future, driven by a desire to measure the quality of the service at various times during the patient pathway. These may not necessarily be the outcome measurements that surgeons require to improve the treatment of their patients. Ongoing dialogue with the auditors and access to the data to perform both short and long-term follow-up analysis outside the national audit are mandatory to ensure that the audit also continues to guide developments that improve surgical outcomes. n
SCTS Education report January 2019 Sri Rathinam, SCTS Education Secretary
he Education Team have had an exciting, challenging and very gratifying six months in delivering the goals which we set ourselves. Each and every section lead has delivered success and the management of the NTN portfolio in house has been very smooth. The administrators Letty Mitchell and Emma Ferris have worked relentlessly to run all the courses very efficiently. Although ours is a small specialty organisation, we probably run more educational events across all membership categories than any other surgical specialty. It is not a small feat to run six courses over a six week period in November to December alone. A big thank you to both of them!
SCTS-Ionescu Collaboration The SCTS membership has immensely benefitted from the collaboration between the SCTS and Mr Marian Ionescu with his generous contributions to the society for educational activities over the years. Mr Ionescu has offered the society donations specifically stipulated for various purposes. He has supported the SCTS-Ionescu University which
has evolved into an educational event par excellence where well known eminent speakers have delivered a great educational programme. As a surgeon, educator and trainer Mr Ionescu has seen the value of fellowships in the development of trainees and consultants; he has supported the SCTS to offer various fellowships to the multidisciplinary team. I had the pleasure of meeting Mr Ionescu with Mr Page to discuss our partnership in the Educational activities of the SCTS. We had very fruitful discussions relating to the management by the SCTS of the funds donated by Mr Ionescu, and as a result we were delighted that the SCTS was able to gain increased support from Mr Ionescu for SCTS Education. The SCTS-Ionescu Additional Exceptional Fellowships for 2018 had a great response and the awardees will be decided by the time this issue is printed. We are delighted to invite applications for SCTS-Ionescu Fellowship awards for 2019 with a closing date of 15th February 2019.
The Marian and Christina Ionescu Travelling Fellowship for a consultant (1 award of £10,000) l
SCTS-Ionescu Consultant Fellowship (1 award of £10,000) l
l SCTS-Ionescu NTN fellowship (1 award of £10,000)
SCTS-Ionescu Non NTN fellowships (2 awards of £10,000) l
SCTS-Ionescu Non NTN fellows, small travel awards (2 awards of £5,000) l
SCTS-Ionescu Nursing and Allied Health Professional Fellowships (4 awards of £5,000) l
SCTS-Ionescu Medical Student Fellowships (4 awards of £500) l
The Success of the recent Team Human Factors Education Day enabled us to seek his support to Team Education Days in the future. For me personally it was an eye opening journey meeting a pioneering surgeon who is such a great supporter of the SCTS. Our discussions prior to the formal business meeting spanned a variety of topics including the four phases of his life, Surgery, Innovation, Climbing and Helping others. ‘I am here to help the membership through the society’ is what he reiterated during our meetings. Our discussions ranged from Hannibal of Carthage, Oliver Cromwell to the Great masters of Renaissance to the river Styx. >>
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“When we were rationalising our fund resources to run our courses without compromising on quality we stumbled on to hidden jewel called Ashorne Hill. As a charity and provider of bespoke facilities, they were excellent in welcoming us, being receptive and accommodating to our demands.” Ashorne Hill Partnership
Every closed door offers us a new opportunity and new hope! When we were rationalising our fund resources to run our courses, without compromising on quality, we stumbled on to hidden jewel called Ashorne Hill. A custom built grade II listed building with a new state of art conference facility in the heart of England at Leamington Spa in Warwickshire. As a charity and provider of bespoke facilities, they were excellent in welcoming us, being receptive and accommodating to our demands and needs in a cost effective manner. We have held our first event and the success has led us to negotiate a great deal for our courses in 2019. The venue offers on site accommodation, gourmet lunches and dinner, and is set in 35 acres of landscaped garden and woodlands.
Consultant Education: The First SCTS Team Human Factors was held in the Harefield Hospital. We had a robust interest when we invited teams to apply to be part of the team training day to address team working, interaction and better cohesive performance. After a diligent selection process a Thoracic team from Birmingham Heartlands Hospital led by Mr Hazem Fallouh and the Leeds Paediatric Cardiac Surgical Team led by Carin Van Doorn were invited to the course. The course was a great success and we will be offering this twice next year. Further to the success of our last year’s Consultant education event, we are hoping to have a second event addressing another aspect from the survey of our consultant members. This will be held
again on the Saturday before the annual meeting focussing on “Introduction of Innovation and New Techniques into clinical practice”. NTN Portfolio: The courses have run smoothly in 2018 in spite of organisational and logistical challenges and a big Thank you to Carol and Sunil as tutors and Letty and Emma in the office who made the transition to in house management a great success. Susan Cipriano, the Head of JCST, attended our ST3 boot camp and was very complimentary in our vision and execution of the portfolio of courses. We would like to remind our NTNs to look out for the dates and book their leave as it is disheartening to have trainees not attending these important courses. In 2018 we moved a few courses to the Abbott Facility to reduce running costs.
Non NTN portfolio: The Non NTN members had the first Residential course held in Ashorne Hill. The two day course, with overnight accommodation, was held on the 2627th November 2018. The first day comprised of cardiac and thoracic wet labs and the second day topical lectures followed by MDT scenarios. The initial feedback has been very good. We aim to run this again next autumn, and of course there will be the professional development course in the spring. We thank Mr Kalkat for his sustained efforts in the last five years to spearhead this section of SCTS education. We wish him all the very best in his role as meetings secretary.
“Further to the success of our last year’s Consultant education event, we are hoping to have a second event addressing another aspect from the survey of our consultant members.”
Medical Students: The University of Birmingham team in partnership with SCTS Education put up a great show with the medical students cardiothoracic careers day. The local student leads Tristan Creasey and Saad Khan were perfect hosts, taking all aspects into consideration under the guidance of Mr Tim Jones and Mr Ehab Bishay. Well done Team Birmingham. A big thank you to Aman Coonar, who delivered yet another special event. AHP: AHPs have been offered additional exceptional fellowship opportunities like all other members. Tara Bartley and Bhuvana Krishnamoorthy are spearheading the AHP portfolio. The new courses like the Nurse Prescriber Course, the SCP
course, Advanced Cardiac and Thoracic Course and Band 5,6 Nurses Course with great success. We are pleased to report the industry support is robust in supporting and sustaining this portfolio. The AHPs also had the opportunity to partake in the CALS course. Operative Video prize: We welcome NTNs and non NTNs to submit videos for consideration for the
SCTS-Ionescu Oscars which will be awarded in the Annual meeting. Every success relies on people’s passion, motivation and commitment; we have great section leads, faculty, and administrative team. All of this would not be possible without our industry partners’ support in our endeavours in educational and training by offering logistics and financial support. I wish you all a prosperous 2019. n
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SCTS Education tutors’ report 2018 has come and gone by quickly, and we have had another successful year of delivering all twelve NTN courses for SCTS Education. Carol Tan, SCTS Thoracic Tutor Sunil K Bhudia, SCTS Cardiac Tutor
e cannot express our gratitude enough to all our course directors and faculty for their commitment and time, and more importantly, for bearing with us this past year as we took over the role of all logistical arrangements of running the courses. This was much more work than we had anticipated, but would not have been possible without the appointment of Emma Ferris to join Letty Mitchell as a second educational administrator in April 2018, and we are very grateful to Graham Cooper and Richard Page who both supported this appointment.
In order for SCTS education to continue delivering courses free to SCTS members, we are grateful to Ethicon (Johnson and Johnson) for their continual support over the past few years, and also welcome our new industry partners including Abbott Medical, Medistim, Edwards, Atricure, LivaNova, Vascutek, Medtronic and Cardiosolutions this past year. With the changes in financial support, we have looked at cost efficiency with delivering the courses without compromising on quality or content. The venue of some of the courses was therefore changed this year
as a cost saving measure, with relocation of the ST3A, ST4A and ST4B to the facilities of Abbott Medical in Solihull. As a more central location, this appeared to be more convenient for many faculty members, some new, to get to. For 2019, we will be holding the majority of the UK courses at Ashorne Hill in Leamington Spa, which is a comprehensive training and conference facility with in-house guest rooms and restaurant. Trainees and faculty will have the opportunity to interact and network without the need to leave the venue for the duration of the course!
SCTS Education NTN Courses in 2019 • 14th – 15th January 2019 Intermediate Viva Course (ST5A) Ashorne Hill, Leamington Spa
• 6th – 8th February 2019 Cardiothoracic Surgery Sub-Specialty Course (ST6A and ST6B) European Surgical Institute, Hamburg
• 20th – 21st May 2019 Non-Operative Technical Skills for Surgeons (NOTSS) Course (ST5B)
• 14th – 16th October 2019 Introduction to Specialty Training in Cardiothoracic Surgery Course (ST3A)
Advanced Patient Simulation Centre, St George’s Medical School, London
Ashorne Hill, Leamington Spa
• 6th – 7th June 2019 Operative Cardiothoracic Course (ST3B)
• 26th – 28th November 2019 Core Cardiac Surgery Course (ST4A) Ashorne Hill, Leamington Spa
European Surgical Institute, Hamburg
• 4th – 7th March 2019 Revision and Viva Course for FRCS(CTh) (ST7A)
• 17th – 19th June 2019 Core Thoracic Surgery Course (ST4B)
Ashorne Hill, Leamington Spa
Ashorne Hill, Leamington Spa
• 25th – 27th March 2019 Cardiothoracic Surgery Pre-Consultant Course (ST8A)
• 28th September 2019 Clinical Examination Course for FRCS(CTh) (ST7B)
European Surgical Institute, Hamburg
Royal Papworth Hospital
• 3rd – 4th December 2019 Professional Development Course (ST8B) Ashorne Hill, Leamington Spa
SCTS Education NTN courses are now SAC agreed and NTNs are expected to attend these. Regional TPDs will be made aware of the dates for courses with the view that study leave can be allocated to the trainees ahead of time. There are a few exceptions for non-attendance and these include being on Out Of Programme Research/Experience, and maternity/ paternity leave. Otherwise, trainees who miss out on their allocated place on a course for other reasons e.g. annual leave or service commitments will not be allocated a place the following year. Course dates and venues for 2019 have now been confirmed and we urge trainees to plan ahead and book their study leave as soon as possible. Emma and Letty will make contact with trainees prior to the course via email and need to confirm number of attendees and requirements for accommodation etc. We therefore encourage trainees (and faculty!) to respond to emails as soon as possible to assist with administration. In addition to the NTN courses, courses continue to be run for Medical students/Foundation doctors (Introduction to Cardiothoracic Surgery), Core trainees (Essentials in Cardiothoracic Surgery) and SAS doctors (Cardiothoracic Surgery Update)
each year. The 2-day Cardiothoracic Surgery Update Course for SAS doctors was for the first time a fully residential course and included a day of wet-lab training, and was well received both by delegates and faculty. With the increasing recognition that failure of team work and communication has been implicated in patient outcomes and patient safety issues, SCTS education for the first time, ran a Multidisciplinary Simulation course. This aimed to highlight the interaction between behavioural human factors, team skills and performance, and was held at Harefield Hospital in October 2018. From several team applications, two teams were selected to attend - a cardiac multidisciplinary team from Leeds led by
Ms Carin van Doorn, and a thoracic team from Birmingham led by Mr Hazem Fallouh. The faculty was made up of trained human factors course personnel from Harefield Hospital (Shahzad Raja – Consultant Cardiac Surgeon, Simon Mattison – Consultant Anaesthetist, Paul Harris – Consultant Anaesthetist, Clair Mullins – Deputy Theatre Manager, Mark Bowers – Interventional Cardiology and Theatre Manager, Wayne Hurst – Associate Nurse Director and Sunil K Bhudia – Consultant Cardiac Surgeon). Feedback from both teams has been positive and we expect to continue to run this course at least once, if not twice a year, with funding received from Mr Marian Ionescu. n
New Consultant Appointments - September 2018 to August 2019 Name
Aberdeen Royal Infirmary
Papworth Hospital, Cambridge
Royal Victoria Hospital, Belfast
Golden Jubilee National Hospital, Glasgow
King’s College Hospital, London
Nottingham City Hospital
Wythenshawe Hospital, Manchester
Hammersmith Hospital, London
St Bartholmews Hospital, London
Other Appointments Name
Leeds Teaching Hospitals NHS Trust
Locum Congenital Consultant
Royal Brompton Hospital, London
Locum Congenital Cardiac Surgeon
Glenfield Hospital, Leicester
Locum Adult Cardiac Consultant
Mr Ali Al Sharraf
Glenfield Hospital, Leicester
Locum Adult Cardiac Consultant
Royal Infirmary of Edinburgh
Locum Cardiothoracic Consultant
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The Nursing and Allied Health Professional Cardiothoracic Forum at the SCTS Annual Meeting Helen Munday, SCTS Nursing and AHP Representative
s always at this time of year, planning for the 2019 Cardiothoracic Forum (CT) at the SCTS annual meeting is well underway and 2019 will see the meeting take place in the QEII Centre in the heart of Westminster, London from the 10th – 12th March. The CT Forum stream at the SCTS University on the Sunday, ahead of the main meeting, is now very well established and has grown in popularity year on year, evidenced by the increasing attendance and favourable feedback. This informal day emulates the two day advanced cardiothoracic course in a condensed format with two half-day sessions dedicated to cardiac and thoracic knowledge and skills. It is an interactive wet-lab day for nurses and AHPs to experience putting in chest drains, replacing heart valves and performing bypass surgery, as well as skills stations for cardiac pacing, radiograph interpretation, CT imaging and ECG recognition. All stations are led by an extremely enthusiastic and knowledgeable multidisciplinary faculty where the focus is on “have a go” and “no such thing as a silly question”. It’s a very enjoyable, highly practical day which offers excellent educational value. I am extremely grateful to the entire faculty, especially Tara, Bhuvana and Chris without whom the day simply would not happen, and also the company representatives for their on-going support and participation in the university day. The CT Forum programme is taking shape and as well as the cardiac and thoracic specific sessions, we are planning features around health and wellbeing, quality and safety, transplant reflections and surgical site infection management. Abstracts were submitted from a range of nurses and allied health professionals
1st Cardiothoracic Theatre Practitioner Course December 2018
and by the time this edition of the Bulletin is published, authors will have received an email advising if their paper was accepted for oral or poster presentation. The theme of the main plenary session is to be around developments in congenital cardiac services and we are delighted that Jo Quirk, Lead Nurse for Yorkshire and Humber Congenital Heart Disease Network and Chair of the British Adult Congenital Cardiac Nurses Association, will be one of the invited speakers in the session after the coffee break on Monday when the Forum joins the main meeting. We will be hearing from one of the 2018 winners of the SCTS Education Ionescu Nursing and AHP Fellowships: Clinical Research Nurse Juan Carlos Quijano-Campos from Royal Papworth Hospital will be presenting his work about surgical treatment pathways for ILD patients, in collaboration with Imperial College London.
Chris Dain, Surgical Care Practitioner at the Queen Elizabeth Hospital Birmingham unfortunately had to defer his visit to Sweden to learn skills to undertake no-touch saphenous vein graft harvest so this will be presented at the 2020 meeting. The advert is currently open for the 2019 Fellowship award and the winners will be announced at the meeting in London. We are extremely grateful to Mr Ionescu for his generosity in support of this educational opportunity to visit cardiothoracic centres and I strongly recommend that you consider applying in the future. Please also advertise the opportunity within your organisations. We were incredibly fortunate this year to receive an additional exceptional fellowship which will support at least four successful applicants with up to £5000 each to visit a cardiothoracic centre either in the UK or abroad, with the aim of enhancing and furthering their career in the specialty.
New member to the meeting team I am delighted to welcome Daisy Sandeman to the meeting organisers team. Daisy is a Clinical Nurse Practitioner in the Cardiothoracic Unit at the Royal Infirmary of Edinburgh and brings a wealth of experience to the role. As well as currently undertaking her PhD, Daisy was a previous beneficiary of an Ionescu Fellowship award and is member of the Scottish Intercollegiate Guidelines Network (SIGN). Daisy’s appointment to the meeting committee will allow me to step back from some of the meeting organisation to free up time to support the education and research initiatives within the SCTS, as well as the opportunity to visit other centres and help spread the word about the SCTS for nurses and allied health professionals and the benefit of associate membership. If you would like me to visit your centre to talk about any of this, please do get in touch with me at Helen.email@example.com or firstname.lastname@example.org
SCTS Nursing and AHP Education Portfolio Update (on behalf of Tara Bartley and Bhuvana Krishnamoorthy) For any new members who are receiving the Bulletin for the first time, I would like to bring to your attention, the education portfolio delivered by the SCTS Nursing and Allied Health Professional Education Team, in conjunction with Cardio Solutions and Abbott. The 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: l
The SCTS Advanced Cardiothoracic Course
SCTS Core Principles Cardiothoracic Band 5 and 6 Course
Developing an Advanced Allied Health Professional Practitioner Service Course
The Theatre Nurse Course
Surgery Skills in Cardiothoracic Surgery
SCP Revision Course
Non-medical Prescribing in Cardiothoracic Surgery
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 facilities and amenities close by. 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 course represents significant value for money at just £20 per delegate.
Details for all the 2019 courses will be emailed to members and added to the SCTS website. 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. Please do not hesitate to contact me if you have any questions or wish to get involved with the work of the SCTS – hmunday@ nhs.net or please visit the website www.scts.org n
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EACTS Post Graduate Nurses & Allied Health Professionals Day 20th October 2018
Tara Bartley, SCTS AHP Education Portfolio Lead, EACTS AHP Organising Committee
his year’s EACTS meeting was held in Milan. The atmosphere was vibrant and there was plenty to educate and challenge. The Post Graduate Nurses & Allied Health Professionals Day was held on the Sunday and was well attended by colleagues from the UK, Ireland and throughout Europe. The programme committee; Richard van Valen from the Netherlands, Pernille Cromhout from Denmark, Tara Bartley & Christina Bannister from the UK, and Doa ElAnsary from Australia created an engaging day including a plenary session and a selection of interesting papers from abstract submissions. The day began with a session on Enhanced recovery after surgery where we heard about examples of how ERAS programmes have improved the pre operative condition of patients and the positive impact on the patient experience and patient flow. This was followed by a number of stimulating talks on guidelines for pain management; and the history of thoracic surgery, is smaller always better, reviewing new techniques of minimal access. We then had a review of the role of the Surgical Care Practitioner, in pre, Peri, post operative care which looked at the importance of evidence based care, audit and research for role advancement etc. There was also a comparison of the variation of roles in different hospitals and other countries. Both Dr. Bhuvaneswari Bibleraaj and Teresa Hardcastle gave papers celebrating of how far the SCP role has developed in the UK & Ireland. Finally Pernille Cromhout shared her overview of a ‘Year in
review Cardiothoracic surgery”. After lunch we were privileged to hear the very best of papers that had been selected from abstracts submitted. I am delighted to say that of the five papers two were from the UK. This year’s SCTS CT Forum best paper: Chest radiographs after cardiac surgery: is one too many? K Smith1; E L Senanayake1; H Luckraz2; 1 Heart & Lung Centre, The Royal Wolverhampton NHS Trust, UK; 2 Heart Centre, American Hospital Dubai, UAE, United Arab Emirates. Kathryn Smith, Cardiothoracic Nurse Practitioner shared the work the team from Wolverhampton and herself have undertaken critically reviewing if the number of Chest X rays we expose our patients to can be reduced while maintaining excellence. The Trainee Advanced Clinical Practitioner team from Brighton presented The impact of an Advanced Nurse Practitioner (ANP) Ultra sound service in the post operative cardiac surgery patient. H. Maseyk1, L. Bardsley1, J. Johnston1, O. SanchezRey1, T Bartley1, N. Hutchinson2, R.Kong2 Cardiac Surgery department, Royal Sussex County Hospital NHS Trust, Brighton, UK. Joe, Heidi and Louise presented the work
comparing clinical findings of chest ultra sound compared with chest radiology. A pilot study would suggest this is a quick, reliable way to review lung fields in the post operative patient and can reduce human and financial resources. The other papers were of a high standard and included, standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy (Sternal Management Accelerated Recovery Trial): a randomised trial by the team from Kuala Lumpur; Negative pressure woundtherapy in children after cardiac surgery, an innovative concept R. van Valen from Rotterdam; the Quality of life after coronary bypass - a multicentre study of routinely-collected health data in the Netherlands; and Comparison of Activity Forces Between Patients Who Follow Traditional Sternal Precautions Versus Those Who Use a Unique Post-sternotomy Discharge Education Model: Keep Your Move in the Tube a joint study from the team from Australia, USA & Malaysia. The day finished with a workshop entitled From Evidence to Translation: “keep your move in the tube”. This session looked at the post operative moment of patients, promoting mobilisation but keeping patients trunk within planes of movement. I would like to thank the EACTS staff and colleagues for an excellent meeting and would encourage you all to attend in 2019 when the meeting will be held in Lisbon. n
Determining the Future of Cardiac Surgery Research Establishing the Heart Surgery Priority Setting Partnership Gavin Murphy, Tracy Kumar, Florence Lai, Sue Page & Bethany Tabberer, Heart Surgery PSP Project Team members, Glenfield Hospital; with Katherine Cowan, Senior Advisor to the James Lind Alliance
he Heart Surgery Priority Setting Partnership (PSP) is an ongoing national project to determine the most important research priorities in cardiac surgery over the next decade. A collaboration between the University of Leicester and the NIHRâ€™s James Lind Alliance, with funding from Heart Research UK, this project aims to bring together patients, carers and clinicians in order to benefit future cardiac surgery outcomes and help the progression of modern medicine. Currently, research often overlooks the shared interest of patients and clinicians who deal with surgical issues and perioperative concerns on a daily basis, and therefore priorities considered important by these individuals may not be addressed by research. In an original project designed to address this mismatch, the Heart Surgery PSP will identify gaps in current clinical knowledge by establishing the Top 10 research priorities from patient and clinical perspectives. The project is split into two phases; Consultation (Initial Survey; analysis) and Prioritisation (Second Survey; final workshop).
2017, the Board of Heart Research UK agreed to fund the project with a grant of ÂŁ80k, for funding of key staff and resources to ensure the success of the PSP. The PSP is managed by an interdisciplinary steering group composed of clinicians, patients and carers, and is chaired by an independent Chairperson appointed by the James Lind Alliance. Researchers, who are not clinically active, and industry are excluded from the process, as they have existing
opportunities to influence the research agenda. This ensures that the process is robust, representative, free from competing interests and transparent. The Heart Surgery PSP project launched in March 2018 at the SCTS Annual Meeting in Glasgow with the release of the Initial Survey, available both online and in paper format for delegates to complete. The survey was atypical in so much as respondents were not expected to
Launching the PSP The Heart Surgery PSP was established following a workshop in February 2017, which sought to develop a national research strategy for cardiac surgery. In November >>
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answer questions – rather, they were requested to ask them. In order to establish the Top 10 research priorities, we needed to hear the concerns of those at the frontline of cardiac surgery; patients and clinical staff. By providing an opportunity for respondents to voice their opinions and priorities, we will be able to identify questions respondents would like to see addressed by research that have not been answered thus far. Following attendance at the SCTS Annual Meeting, we needed to extend our outreach beyond the clinician demographic. We achieved this by sharing the Initial Survey at outpatient clinics, patient support groups, ward visits and dissemination via Steering Committee channels. We also began a social media campaign in order to advertise our project and provide a direct link to the Initial Survey online, ensuring access to the survey was digitally available to those we were not in face-to-face contact with. Launching the Initial Survey proved a challenge – asking non-experts (i.e. the non-clinician demographic) to potentially influence research priorities was perceived as a daunting task by many. Patients were often content with their treatment – and therefore had no concerns they wanted addressed by research, or felt underqualified to propose research questions. We navigated these challenges by discussing with the patients if they could recall any questions about their surgery
which had remained unanswered at the time of their operation, or if anything had occurred to them retrospectively when considering post-operative impact on their daily lives. From this, patients often felt more comfortable and betterequipped to respond to the Initial Survey once it was fully understood what was being requested of them. For example, during a conversation a patient stated that they wished they had known whether pre-surgery dietary modification or fitness could have helped them get better faster. This translated into the research question theme ‘perioperative behaviours (nutrition, exercise) influencing postsurgical recovery times.’ This approach enables patients and carers to articulate their needs and we believe increases the chances that the
PSP will accurately reflect the needs of all stakeholders. Each respondent was requested to provide two questions which they would like to see addressed by research. We aimed to receive at least 1,000 questions by the closure of the Initial Survey on Tuesday 30th November 2018. As of 4th October, there were 561 respondents to the survey, from whom 965 research questions were submitted. The questions covered all aspects of heart surgery dealing with coronary artery disease, valve heart disease, aortic vascular disease as well as surgery for arrhythmia. Respondents included patients (21%), care givers (7%) and healthcare professionals (66%). Sixty five percent of respondents were men, 82% were aged 30-69 years, and respondents were from all regions of the UK. Healthcare professional respondents reflected the multidisciplinary nature of a heart surgery team and included nurses (nurse practitioner, theatre and research nurses), allied health (cardiac physiologists, perfusionists, dieticians, etc.) and doctors (cardiothoracic surgeon, anaesthetist, intensivist, etc.). Among the doctors, 47 were identified as cardiothoracic surgeons/surgeons.
Going forward Following closure of the Initial Survey, several steps are required prior to launching the Second Survey, where
“The Heart Surgery PSP was established following a workshop in February 2017, which sought to develop a national research strategy for cardiac surgery. In November 2017, the Board of Heart Research UK agreed to fund the project with a grant of £80k, for funding of key staff and resources to ensure the success of the PSP.”
â€œLaunching the Initial Survey proved a challenge â€“ asking non-experts (i.e. the non-clinician demographic) to potentially influence research priorities was perceived as a daunting task by many.â€? the questions raised will start to be prioritised. First, members of the Steering Committee with expertise in evidence synthesis clean the questionnaire data, removing out-ofscope questions, and creating a list of summary questions based on the categorised raw survey data (thereby avoiding replicas). These questions are then compared against published evidence, for example from the Cochrane Library, to exclude those questions where high quality evidence exists. The result is a long-list of questions for interim prioritisation that form the basis of the Second Survey. Here, patients, carers and clinicians will be asked to select their priorities from this long-list, enabling the full list of questions to be ranked in order of importance. The results of the second survey provide a short-list for the final priority selection
process. This is undertaken at a dedicated one-day workshop facilitated by James Lind Alliance. Using a Nominal Group Technique, the workshop will involve a series of group discussions and ranking exercises. Participants will comprise a range of around 25 patients, carers and clinicians, including a small number of patients and non-patient members of the PSP steering committee. In addition, key
stakeholders including representatives from research funders, professional associations and patient groups will attend as observers to ensure the fidelity of the process. From this, the Top 10 priorities are selected. The results are then provided to research funders and patient groups to inform commissioning and funding of the national research programme going forward. The results will also be disseminated via publication in a peer reviewed journal, and via national patient groups, charities and workshops. The Second Survey will be launched at the SCTS Annual Meeting in Westminster, London in March 2019. Please follow our Twitter handle, @ HeartSurgeryPSP for updates on the project and the direct link to the Second Survey following its launch in March 2019. n
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SCTS Forum, Nursing and Allied Health Professional - Research round-up Julie Sanders, Director Clinical Research, Quality and Innovation, St Bartholomew’s Hospital
e are delighted that Nursing and Allied Health Professional (NAHP) research development continues to go from strength to strength. The SCTS Forum Nursing and Allied health professional Research Group (SCTS NARG) has welcomed new members and is growing continuously. For new SCTS Forum members we incorporated the NARG application at the time of joining the SCTS Forum, making the process more streamlined and highlighting the group from the outset. For more information or to offer your expertise to the SCTS NARG, please contact me. l
The second National Cardiothoracic Research meeting, occurred in Leicester on 3rd November. Nursing and AHP representation at the meeting was increased from last year and it was fantastic to have the meeting opened with a presentation from an AHP, Zoe Barratt-Brown. It was an informative meeting highlighting some great work being conducted around the country, as well as highlighting the progress to date establishing the Cardiothoracic Interdisciplinary Research Network. l
The SCTS Cardiothoracic Interdisciplinary Trials Network (CIRN), a network to help deliver a portfolio of multi-centre clinical trials that address important research questions, aims to have a trainee and nursing/AHP representative at each centre. We are also working with the West Midlands Research Collaborative, Royal College Surgeons and the NIHR to introduce ‘Associate PI’ roles so a junior doctor, nurse or AHP can be part of the formal trial leadership at each site. This is an innovative role, aiming to support and develop potential research PIs of the future. We are still looking for a nurse/AHP representative for the l
“The second National Cardiothoracic Research meeting was an informative meeting highlighting the progress to date establishing the Cardiothoracic Interdisciplinary Research Network.” following sites, so if you are interested in being involved for your centre, please do contact me: Basildon and Thurrock Belfast l Blackpool l Central Manchester l Golden Jubilee l Guys and St Thomas’ l Heart of England l Hull and East Yorkshire l Leeds l Plymouth l Royal Victoria l l
University Hospital Bristol
At the SCTS Annual Scientific Meeting 2019 the SCTS Forum will host NARG and CIRN breakout meetings, so please register for the meeting and we look forward to seeing you in London in March.
New research funding schemes from the BHF for Nursing and Allied Professionals For the first time, the British Heart Foundation (BHF) have launched two new research funding schemes for nurses and allied professionals:
Research Training Fellowships (PhD): https://www.bhf.org.uk/ for-professionals/information-forresearchers/what-we-fund/researchtraining-fellowships-for-nurses-andallied-health-professionals l
Career Development Fellowships (postdoctoral): https://www.bhf.org.uk/ for-professionals/information-forresearchers/what-we-fund/careerdevelopment-research-fellowships-fornurses-and-allied-health-professionals l
The call for applications is likely to open in January 2019, with an expected closing date for the first round at the end of April 2019 (unconfirmed at time of writing). This is a fantastic opportunity for anyone interested in, or already undertaking, a clinical academic pathway. I am very happy for anyone who may be interested, to get in touch with me if you have any questions or need support. The SCTS NARG website: https://scts. org/narg/. For any further information on the above, or to join the SCTS CIRN, please contact Julie Sanders, SCTS Forum lead for Audit and Research at email@example.com n
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Cardiothoracic Interdisciplinary Trials Network (CIRN) Ricky Vaja, Associate SSL
ince its launch in March 2018, the CIRN has continued to gain momentum and currently has over 80 members including NTNs and non-NTNs, nurses and allied healthcare professionals (AHP). In addition to support from the SCTS, this initiative is supported by the Royal College of Surgeons (England) through the Surgical Trials Initiative and the University of Leicester’s Clinical Trials Unit. The SCTS executive committee has approved our Terms of Reference as stated below:
Terms of Reference Name of group: Cardiothoracic Interdisciplinary Research Network (CIRN). Objective: To provide the infrastructure for motivated healthcare professionals interested in Cardiothoracic Surgery research to collaborate, design and deliver high impact multi-centre clinical studies that will change practise. Stakeholders: The CIRN has emerged through engagement with the Royal College of Surgeons England Surgical Trials Initiative, the Academic and Research Committee of the Society for Cardiothoracic Surgery in Great Britain and Ireland, the British Heart Foundation, and the University of Leicester’s Clinical Trials Unit. These groups have developed complementary research strategies that promote interdisciplinary research in cardiac surgery. Membership: This is free and open to all with an interest in Cardiothoracic Surgery including students, foundation doctors, nonnational & national training number trainees, clinical/research fellows, consultants, nurses and AHP, perfusionists and basic scientists. Leads: Ricky Vaja (Associate SSL), Luke Rogers (Associate SSL), Prof Julie Sanders (Nurses and AHP Professional Lead), Prof Gavin Murphy (Surgical Specialty Lead)
Governance: The CIRN reports to The Society for Cardiothoracic Surgery for Great Britain and Ireland via the Academic and Research Committee, and to the Royal College of Surgeons of England via the Surgical Specialty Leads Committee. Project Steering Committee: An overseeing group of individuals (interdisciplinary where possible) will direct each individual project. This group of individuals will be responsible and accountable for all of the work undertaken as part of the project whether or not they have done the work personally. Corporate Authorship: Collaborative research projects involve hard work from a large number of people and listing all contributors on a publication in the traditional way may not always be feasible. To overcome this, the CIRN will adopt corporate authorship. This will mean all publications from the network will be published under one author: The Cardiothoracic Interdisciplinary Research Network. All contributors will then be listed in full in an appendix. The appendix will also contain a detailed description of each named individual’s contributions. We believe this approach will recognise the contribution of every individual no matter how small. In addition, we believe this approach will ensure the sustainability of the CIRN for many years to come. To be considered as an author within the designated “Cardiothoracic Interdisciplinary Research Network” (CIRN) corporate authorship group researchers must also fulfil the following criteria: I. Substantial contributions to the conception or design of the work, including the acquisition (PI, Associate PI, recruiting, consenting patients, collecting research data), analysis, or interpretation of data for the work
II. Drafting the work or revising it critically for important intellectual content III. Final approval of the version to be published IV. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The “Cardiothoracic Interdisciplinary Research Network” will, by default, be the sole author of all publications resulting from projects commenced by CIRN. All individuals involved will be required to hold current Good Clinical Practise accreditation. Associate Principal Investigator (PI) Scheme: The Associate Principle Investigator scheme has been proposed by members of the West Midlands Research Collaborative (WMRC) as a mechanism to encourage, train and recognise trainees, nurses and allied health professional involvement in highquality research. It has already been ratified by the RCS and is currently under review by the NIHR. The scheme involves ensuring a trainee, nurse or allied health professional will work alongside a principle investigator to deliver a clinical trial at their Trust. This will then be formally recorded both within the trial documents and the individuals’ personal NIHR account following ratification by the local PI, Chief Investigator and a minimum commitment of 6 months. When this is combined with a project being delivered by the CIRN, individuals will be named as per the outline of corporate authorship above with clearly identification of their duties and responsibilities as associate PI in the Appendix of all work produced. Communication: l
Monthly teleconference call to include all members of subsequent steering committees
Updates via mailing list of associated members
Twice yearly meeting of Leads and Steering Group Committees (SCTS Annual Conference & SCTS Research Day)
Funding: The Surgical Trials Initiative, Royal College of Surgeons of England, and the Society for Cardiothoracic Surgery in Great Britain and Ireland.
Methodological support: University of Leicester’s Clinical Trials Unit CIRN offers an exciting opportunity for those interested in cardiothoracic surgery, irrelevant of prior experience, to get involved with leading the future of cardiothoracic surgery research. We invite you to get in touch if you wish to be involved in any projects, have an idea for future research or simply have a question about this new initiative as follows:
Cardiothoracic Interdisciplinary Research Network Contacts Cardiothoracic Surgeons (NTN’s, nonNTN’s, Fellows, Trust grades, Foundation Doctors, Core Trainees & students): Luke Rogers (firstname.lastname@example.org) Ricky Vaja (email@example.com) Nurses & Allied Health Professionals: Julie Sanders (firstname.lastname@example.org) n
SCTS 5th National Student Engagement Day Birmingham - 24 November 2018 Saad Khan & Tristan Creacy
he 5th SCTS National Student Engagement Day was held in November 2018 in Birmingham. We welcomed 146 delegates from across the British Isles, with an even split of medical and school students. The day commenced with inspiring and exciting talks by cardiothoracic surgeons giving an insight into training pathways, work-life balance, and the various cardiothoracic subspecialties. We also heard about the work of a military trauma surgeon. The morning ended with a congenital cardiac morphology demonstration and an emotive talk from a patient and her mother about their personal experiences of congenital heart disease. In the afternoon practical workshops took place, allowing individuals to “step into the shoes of the surgeon”. Medical students were taught basic suturing, aortic anastomosis, lung stapling, and chest drain insertion, alongside an informative session on medical research and electives. Meanwhile, school students were given an admissions talk by Dr Clare Ray, the Medical school lead for Outreach & Widening Participation, followed by a former Medsoc president talking about “real medical school life”. They also had the opportunity to try their hands at basic suturing and basic life support, all taught by Birmingham medical students.
The day was a fantastic success, providing an inspiring and unique opportunity for both medical and school students to gain a flavour of the exciting and evolving world of cardiothoracic surgery! Quote from medical student: “Cardiothoracic surgery is really cool” Quote from 6th former: “I wasn’t sure, but now I am, and I really want to go to Birmingham Medical School”
Lead Organisers: Saad Mahmud Khan and Tristan Creasey Organising Committee: Harindi Loku Wadgue, Sashini Iddawela, Winnie Lam, Mohini Panikkar, Maggie Guruswamy and Sophie Pettler Speakers: Stephen Rooney, Ivan Yim, Nigel Drury, Tim Jones, Adrian Crusean, Ehab Bishay, Natasha Khan, Suren Arul and Clare Ray Supervision: Mr Timothy Jones and Dr Adrian Crucean n
SCTS STUDENTS programme of activities SCTS STUDENTS at SCTS 2019 Main Event - Sunday 10th March 2019, London MERITS Investigation – find out more at https://royalpapworth.nhs.uk/merits Multi-centre Evaluation of Renal Impairment in Thoracic Surgery is being run in collaboration with SCTS STUDENTS and allows students to learn about and get involved in a meaningful multi-centre audit PAT MAGEE ABSTRACT programme – posters and oral presentations at SCTS 2019 SCTS-IONESCU STUDENTS Elective fellowships We are keen to advertise any suitable events. Find out more through our facebook page: www.facebook.com/cardiothoracicsurgerycareersday/ WATCH OUT FOR THE APPLICATION TO HOST SCTS 2019 NATIONAL STUDENT ENGAGEMENT DAY
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The Second Edition of the SCTS National Research Meeting Glenfield Hospital hosted second SCTS National Research meeting on 3rd of November 2018 in Leicester and warmly welcomed over 70 attendees. Marius Roman, MD (Cantab)
his meeting was opened and overseen by Mr. Richard Page – President of the Society for Cardiothoracic Surgery in Great Britain and Ireland. The event was a great success and highly praised by the senior academics and delegates alike, with a high participation of doctors and allied healthcare professionals. This meeting has clearly answered four essential questions in Cardiothoracic Surgery Research in the UK: 1. Who is conducting the highest quality research?; 2. How to network and explore opportunities with National Research Meeting senior researchers?; 3. How to Prize winners 2018 engage successfully with the Cardiothoracic Interdisciplinary a national trainees’ trials initiative, while Research Network (CIRN)?; and encouraging all junior doctors, allied nurse 4. How to get involved with the National practitioners and medical students to get Research Programme? engaged in this initiative. The meeting was split in four main The session of Cardiothoracic Surgery sessions and has showcased excellent video presentations took place and were well keynote speakers such as: Prof. Tom received, while the Posters were appraised Treasure, who spoke on the history based on their methodology, outcome and of RCTs in Thoracic Surgery and the relevance. During the lunch session the MARS Trials (Thoracic Surgery); Mr. allied healthcare professionals have received Enoch Akowuah, who detailed how to a presentation and update on research develop a portfolio of trials in minimally opportunities from Prof. Julie Sanders. invasive cardiac surgery (Adult Cardiac The meeting culminated with the Surgery); Prof. Massimo Caputo, who awarding of four prizes for best presented gave an insight on the RCTS performed in research and consisted of free registrations to Congenital Surgery, with an emphasis on the 2019 SCTS Annual Meeting in London. The Thermic and Oxic Trials (Congenital These were awarded to Mrs. Zoe Barrettand Transplantation Surgery). Prof. Brown (Royal Papworth) - Thoracic Surgery Julie Sanders, Mr. Luke Rogers and Mr. session, Dr. Carla Lucarelli (Imperial Richard Wilkin (General Surgery trainee) College) - Transplantation/Congenital gave an update and detailed the recent Surgery session, Mr. Douglas Miller progress made in the development of
(Glenfield) - Cardiac Surgery session; Dr. Shwe Oo/ Dr. Eva Symicka (Liverpool Heart and Chest) - best Video presentation and Mr. Chris Bond (Birmingham Children’s Hospital) – best Poster. The organising team including Sue Page, as well as the local research team were highly praised for the professional and meticulous organisation of this event. The excellent feedback received will further improve the quality of future meetings. Once again, the SCTS National Research meeting has consolidated the importance of research networking and collaboration between Cardiothoracic Surgery researchers. It provided an excellent opportunity for trainees and healthcare professionals to get a firsthand taste and get involved in the highest quality ongoing research in the field of Cardiothoracic Surgery. n
The Fifth Heart Research UK Aortic Masterclass Deborah Harrington, Consultant Cardiac & Aortic Surgeon, Liverpool Heart & Chest Hospital, Aortic Masterclass Course Director
n 23rd November, Keele University Anatomy & Surgical Training Centre played host to the 5th Heart Research UK Aortic Masterclass, entirely funded by Heart Research UK. This year we focused specifically on surgery for Acute Type A Aortic Dissection in line with other ongoing efforts to improve outcome for dissection patients including regional service reorganisations and the Think Aorta campaign. Aortic surgery is an area of subspecialisation uncommonly encountered by the majority of cardiac surgeons. In most UK centres it is difficult to train in aortic surgery due to both case complexity and low volume. Most senior cardiac surgical trainees will never perform arch replacement or dissection surgery, and most recently appointed Consultants will have had only limited exposure to such cases. The aim of this course was to provide a unique opportunity to gain hands on
experience of techniques for dissection surgery and to perform total arch replacement in a human cadaveric model, supervised by an expert Faculty. The Masterclass was aimed at both Consultants and senior trainees in cardiac surgery who were already operating independently. We were delighted to have an excellent Faculty, including our SCTS past President Mr Graham Cooper from Sheffield, Mr Jorge Mascaro from Birmingham and Mr Pedro Catarino from Papworth. The course began with presentations and discussion on cannulation strategies for aortic dissection, and then practical tips and tricks on the technical aspects of aortic arch replacement. The remainder of the day was spent in the operating room where course delegates worked in pairs each supervised by a Faculty member. All delegates were able to perform
Cardiothoracic Surgery Update and Wetlab for SAS Doctors 26th and 27th November 2018 Uday Dandekar
a complete total arch replacement assisted by their colleagues. The day ran very successfully and we were grateful to the participants for their positive feedback. We were also grateful to Terumo UK who supplied a whole range of grafts allowing us to select the most appropriate for each situation. We are also indebted to Kevin Austin from Wetlab for supplying the instruments and CLS Medical for SACP cannulae. Thank you to all the delegates for being excellent participants and Faculty for their time & expertise. Keele University Anatomy & Surgical Training Centre were fantastic hosts and we congratulate them on their excellent facilities. They also invited some local medical students to observe the course which was a great opportunity to inspire the next generation of aortic surgeons. Finally, a huge thank you to Heart Research UK for their ongoing support in improving outcomes for our aortic patients. n
he non-training middle grade staff- Specialty and associate specialist (SAS) doctors are integral part of work force of Cardiothoracic Surgery. Over the last few years, the education committee of SCTS has embarked on delivering educational and professional development activities for these doctors. Two SCTS funded courses a year- clinical update and professional development course are being offered for SAS doctors. For the first time a wet lab component was added to the 4th clinical update course held as a two day event at the sprawling Ashorne Hill facility in Leamington Spa on 26th and 27th November this year, supported by industry (Edwards and Medtronic). The course directors Maninder Kalkat and Uday Dandekar were joined by National Faculty, SCTS Education secretary and Tutors in delivering didactic lectures, MDT, interactive discussion and conduct of wet lab. The SAC chair addressed the delegates and apprised them of current work force and other important issues. The course was attended by 20 delegates from various units across the country. The feedback for this course has been excellent. The SCTS will continue to support the educational activities and professional development for SAS doctors and will encourage them to engage with wider cardiothoracic community. n
the 44 bulletin
SCTS Ethicon Fellowship 2017/18 Cardiac Surgery in Toronto, Canada: Past, Present and Future
Cardiac surgery in Toronto offers a world class surgical environment. Based on the foundations of innovation and training excellence, patient care is at the forefront of cardiac surgery globally. Ishtiaq Rahman MD, FRCS C-Th, Fellow in Cardiovascular Surgery, St Michaels Hospital and Li Ka Shing Knowledge Institute
t has been a career defining privilege to have had the opportunity to hone my clinical and operative skills under the guidance of internationally respected surgeons. Following a competitive selection process, I was grateful to Dr David Latter, Chief of Cardiac Surgery at the Terence Donnelly Heart Centre, St Michaels Hospital and Li Ka Shing Institute for Knowledge, for the fellowship offer. I was equally appreciative of the SCTS for the generous support by way of a SCTS/Ethicon Fellowship Award. [https:// vimeo.com/album/4898024 (password: uk)].
laid the foundations for innovation and shaped the development of cardiac surgery over the last 70 years. Early advances by Emeritus Professor of Cardiac Surgery, University of Toronto, and former AATS President Wilfred Gordon Bigelow, OC, (1913-2005), introduced the concept and technique of hypothermia (1952) making open heart surgery possible. Professor Bigelow co-developed the first external heart pacemaker, with Toronto Cardiothoracic Surgeon John Callaghan, and electrical engineer John Hopps (1950).
With an enviable history of academic achievement and clinical success Toronto has
My one year fellowship was based downtown at one of Torontoâ€™s leading and
largest University Teaching Hospitals. The Terrence Donnelly Heart Centre, Division of Cardiac Surgery at St Michaels Hospital comprises five staff surgeons (consultant equivalent) performing 1100 adult cardiac surgical cases annually. With three fixed OR sessions per week I performed approximately 100 open-heart cases (CABG; AVR; MV and TV surgery) as first operator and built a solid foundation in complex (valve-sparing root replacement; total arch replacement) and redo cases. My interest in redo surgery led me to the Toronto General Hospital to learn from Dr Tirone David, whose practice seemed exclusively to be high-risk redo (mainly mitral) surgery. As St Michaels has one of the largest experiences in sutureless aortic valve implantation it was interesting
to see how they had progressed this technology to the redo aortic valve setting. The learning experience at St Michaels was not limited to the OR. The ‘fast track process’ from OR through the 16 bed ICU to ward care on the first postoperative day was facilitated by the comprehensive work-up, optimization, and planning by the staff anesthetist-led pre-admission clinic. The outcome was a slick patient journey to early discharge and near zero cancelations. Overall working life was busy with a one in four on-call commitment and the working environment was typically Canadian warm, friendly and collegiate with a strong training ethos designed to prepare trainees for independent practice. Academically I led a range of projects: ‘A systematic review and meta-analysis of del Nido versus conventional cardioplegia in adult cardiac surgery’; ‘Redo sutureless aortic valve replacement with Perceval bioprosthesis for prior sutured aortic valve replacement - a retrospective evaluation’; ‘TAVR for severe aortic stenosis and papillary fibroelastoma in a high-risk setting’; and ‘Abdominal aortic occlusion following large left atrial mass embolization’. One of my favourite sessions was the Friday morning joint staff and fellow/ resident surgeons teaching. The first hour was interactive with focus on fellow interpretation and management of referrals followed by a second hour of didactic external speaker presentations. These sessions were a wonderful opportunity to benefit from the rich experience of senior staff surgeons in the management of difficult cases for independent practice. Learning is an integral part of the St Michael’s Fellowship, actively encouraged by the division who offer a generous bursary. I was fortunate to spend time at the Toronto General Hospital observing complex aortic and mitral valvular cases. Dr James Cox enlightened on the MAZE procedure and Professor Bart Meuris, Leuven discussed pre-clinical animal models. I visited the Cleveland Clinic Mitral Valve Symposiums (NYC) and the 98th meeting of AATS (San Diego, CA). In return, I offered my services for medical school OSCE examinations and was invited to be part of the MD admissions panel.
The Future Emboldened by this rich experience, I have returned home with an ability to bring more options to complex problems, together with new practical solutions to challenges in our healthcare system. I would encourage UK trainees to complete a fellowship in Toronto where the hard and soft skills (clinical; managerial; leadership; cultural; and educational) are transferrable to the NHS. Moreover I have enjoyed making international connections and have established life-long relationships with the staff surgeons in Canada which I hope to enhance by visits to UK centres and the SCTS meeting. With more than one hundred languages spoken, Toronto is Canada’s largest city, an economic hub and no
stranger to visitors. It has a rich and diverse identity and offers a ‘foodies’ paradise. It is safe, welcoming and has much to explore. Message from Dr David Latter, Chief of Surgery: ‘As the Division Head of Cardiac Surgery at St Michael’s Hospital I am proud of the educational environment we have created here. The richness of the educational environment is due in large part from the clinical fellows themselves. We are blessed to have clinical fellows from countries from around the world, who each bring a unique back-ground and a set of skills that enhance the dialogue, collegial atmosphere and clinical care that we deliver to our patients. The clinical staff and all of our health care co-workers learn and benefit as much from our international clinical fellows as the clinical fellows do from us. We would welcome the opportunity to have another worthy cardiac surgery clinical fellow from the UK.’ n
“Learning is an integral part of the St Michael’s Fellowship, actively encouraged by the division who offer a generous bursary. I was fortunate to spend time at the Toronto General Hospital observing complex aortic and mitral valvular cases.”
the 46 bulletin
Something Nice Around this time last year, as I was putting the plans in my head about a potential audit project I would like to carry out, there in my inbox was a message from the Society regarding an opportunity to be involved with the NICE scholarship programme. Elaine Teh, Thoracic-themed Cardiothoracic ST, Southwest Deanery
ntrigued, I read the email and the link on NICE. The scholarship programme is part of NICE’s wider engagement programme. It is a 12-month programme where the scholars are ambassadors for NICE and supported in an improvement project within a local organisation. As my potential project involves various professionals intimately connected to lung cancer pathways within my trust, I thought what better way to validate my project than being a NICE scholar and ambassador. It has a more substantial weight to it when I present my project as a NICE-supported project, than one concocted in the confines of my own head. But, there is no gain without pain. The application form takes some time and thought to complete, and rather thorough references were required from 2 referees. It involved a bit of chasing and hassling of my bosses and lots of time and consideration to complete the application form that consisted of quite detailed aspects of my professional credentials and a project proposal. Once shortlisted, I was invited to attend an interview, and as part of the interview to present my proposed project. The interview was right in the middle of my night shifts. On this occasion, it turned out to be a blessing in disguise as armed with adrenaline coursing through my bloodstream, my passion for the project became greatly amplified and contagious. I was awarded the scholarship for the period of April 2018 to April 2019. The first 4 months of the scholarship involved a monthly workshop in NICE with various themes. The first session was an induction workshop, getting to know other scholars and fellows and their projects. It
was a fantastic experience. I thoroughly enjoyed engaging with other professionals and specialties. There were a few doctors in the group, but majority were nurses and allied health professionals. The projects undertaken by each scholar and fellow were extremely diverse, yet throughout our time together, we shared and learnt about common themes and barriers. Contrary to my expectations, not all the workshops were dedicated to our quality improvement projects. There was quite a lot of sessions introducing the inner workings of NICE and its various departments. We were also offered different opportunities to be involved with NICE – anything is possible, we just have to ask. For example, a popular choice was to attend a guidelines development meeting as an observer. We have the opportunity to connect with our regional NICE field worker and get to know various people within the region and the trusts who are involved with NICE engagement and implementation. One of the major perks of the scholarship was the opportunity to attend the annual NICE conference. It is unlike other scientific conferences I have attended. As with NICE pathways, it shifts my perspective in caring for the individual patient – from diagnosis, preoperative assessment and optimisation to the latest technology in perioperative and postoperative care that will give the individual patient the best outcomes, to having a bird’s eye view of the pathway for the patients i.e in the structure and available resources locally to ensure that the best care is available and standardised to all patients. The theme of the conference was rather diverse, and ranged from basic science
and implementation to clinical practice to technology and innovations. It really opened my eyes to the need for healthcare professionals such as clinicians and nurses to engage with scientists, policy-makers, industries, as well as to embrace technology and change. As I enter the second half of the scholarship programme, I am in the process of completing my audit loop. I have managed to present the audit results at various forums and had the opportunity to discuss with the Lung Cancer Lead regarding ways to improve the pathway. I had great plans to engage the wider community including primary care and Lung Cancer MDTs from our referring hospital but unfortunately this did not happen. But, I have taken the first small steps towards improving the general pathway. Another important lesson I learnt from the programme is to be realistic about what is achievable in a 12-month period. Not everything had to be done during the time of the scholarship, but it is important to consider how to ensure the project can be sustained and continue to impact care beyond the scholarship programme. It is important to keep the conversation going. All in all, I have thoroughly enjoyed my scholarship and very grateful to be given the opportunity. It has really helped me focus on a different aspect of training, to realise that I have a role to play in improving the pathway of care for our patients. This scholarship has reinforced to me the constant need to keep my eye on the gold standard, work out ways to implement the gold standard within the confines of local resources to ensure that all patients have access to equal, standardised and good quality care. n
Channel 5’s Operation Live with
Mr Kulvinder Lall
On 14 November, Channel 5 provided a rare opportunity for television viewers by inviting them in-side an operating theatre at St Bartholomew’s Hospital. Inside the theatre consultant cardiac surgeon, Mr Kulvinder Lall, performed open heart surgery on patient Kamal, aged 69. The surgery involved Mr Lall replacing an aortic valve for his patient, a surgery that many of our patient ambassadors have been through themselves. The series hopes to take the mystery out of surgery and show in real time what happens when pa-tients go into the operating theatre. The open heart surgery was performed step by step on live TV by Mr Lall and his team, with Mr Neil Roberts, consultant heart surgeon from Barts, on hand to talk the audience through each stage of the operation. The live operation gave viewers an insight into the team involved in such an intricate surgery and how well they work together. Once the heart had been accessed and taken over by the perfusionists, Mr Lall and his team set to work replacing the aortic valve. As Mr Lall explained, Kamal presented with symptoms of heart valve disease including breathlessness and fatigue and due to their severity, he was referred for an aortic valve replacement. Patients who have /HeartValveVoice
severe aortic stenosis and are left untreated are at a very high risk of heart failure and death. What The Operation was able to show was how far treatment for heart valve disease has come over the years and how precise the work is that teams like the one at Bart’s Heart Centre perform. Viewers got to see the expert work of Mr Lall and his team and got a first hand insight into the tech-nology available to give patients a renewed quality of life. Credit must also be paid to the patient and their family who generously provided the opportunity to have this life changing surgery filmed for us all to see. Interviews with Kamal and his daughter showed how important this life saving surgery was to Kamal and the people that mean the most in his life. This was an excellent insight into the patient experience and what to expect from treat-ments such as this for both the patients and their loved ones. “It was an amazing opportunity to be able to give the public an inside look at what goes on behind the
Mr Kulvinder Lall Consultant Cardiac Surgeon, St Bartholomew’s Hospital
theatre doors,” said Mr Roberts. “It is our hope that by televising lifechanging surgeries like aortic valve replacements, we can highlight that life-saving treatments are available and can dra-matically change lives in a matter of hours. I am very grateful to Mr Lall and his brilliant team as well as the amazing patient for allowing us to televise an important event such as this and hope that more people see that treatment for severe heart valve disease is vital. There is also brilliant work being done across the UK by organisations like Heart Valve Voice to bring awareness and a quality of life back to valve disease patient’s lives”
The more we listen, the more lives we save.
the 48 bulletin
If I knew then, what I know now... B
“It is difficult to look further than you can see…” Winston Churchill
The set up
Luis Sérgio de Moura Fragomeni, Professor of Cardiothoracic Surgery, University of Passo Fundo, Brazil
eing the son of a surgeon made the initiation into cutting and sewing easier than usual. Since the first year of Medical School I would follow his steps in theatre where at the tip of his finger there was always an anatomy puzzle. Around the 3rd year of Medical School I had in mind to go to England after graduation. There was no explanation for that, since there was no incentive about Great Britain, the common path was North America. Medical teaching was all in Portuguese and I realised that I would have to quickly learn the English language which was done with great difficultly through reading, writing notes and conversations with an English lady. With Mrs. Boyes I would discuss British way of life, history, politics. This preparation in general knowledge would make all the difference on my arrival to the UK, in June 1977. Perhaps it was my insistence after reading articles in the BMJ and continuous inquiring with the British Council that I was given the opportunity by Mr. W.P. Cleland to start as a RSO at the Brompton Hospital in London.
Suspicious beginning This is a point that I insist that other youngsters, like I was at the time, need to have the patience and resilience to wait until locals understand that you are there for real. If you are not from that environment, without a strong tradition of the schools you attended, the questioning of your knowledge can be a huge barrier to success. With time, patience and help available however, you can surpass this gate and enjoy your stay.
Help available It is crucial to believe that there will always be someone willing to help and proper integration means everything for success. My guiding angel was Stuart Jamieson, who became a close friend and soon to become one of the leading cardiac surgeons in the world. Richard Firmin, my brother in arms in theatre and wards, also gave me the safety of a family that we share until today.
Lessons received Patience, hard work, night on night off shifts, the opportunity of doing and redoing things
will give you the chance to believe that you are ready to start a new period, the period of independence. When, on my last week at the Brompton, Mr. Cleland told me that I should be patient, that it would take around ten years to be smooth in surgery, I thought he was out of his mind. Ten years? Not possible. Today, 38 years later, I realise, doctors never graduate.
Independent surgery in Brazil I soon understood that independency in surgery was far beyond Mr. Paneth´s three principles of surgery; one: put the patient in the right position; two: make the right incision; three: stop the bleeding. A step further than this is making the effort to do your best for the patient, having the stress of bearing the responsibility for their life and the dependence of the many around them. To be calm when one tells the family that despite all efforts the patient did not survive. Time will ease this burden but it will never be without personal consequences.
Teaching It is imperative that we learn from the experienced teacher but understanding that even the less experienced has something to offer. Mr. Stuart Lennox was a just and severe mentor, let little space for error on your part but also had the ability to understand
your anxiety and often adapted his beliefs considering that you could, sometimes, be right. When I think I am too rigid with a colleague or junior staff, I remember his hidden lessons.
America My year in cardiothoracic transplantation in Minnesota (1987-8) with Stuart Jamieson was a consolidation about the importance of living in different environments and how this can enhance you as a doctor and as an individual. We must show the effort to get these opportunities but we also must praise those fine Institutions that agree on taking us as part of their program. Robert Bonser was a Transplant Fellow there, and with his gifted mind, was of great help then and later even more so with regard to aortic surgery. He was also a cherished lifelong friend.
listening to the patient using the stethoscope, feeling a distal pulse, observing the patient in detail. In time, practice will improve your results; personal experience will count more than the evolution of equipment. When wrong: think retrospectively. When right: think retrospectively. As proof of the benefits of this integration, on many occasions, Stuart Jamieson, Richard Firmin, Robert Bonser, operated in our hospital in south of Brazil, selected cases despite the limitations we might have here.
Responsibilities We are responsible for our choices, being prepared, and giving efforts. But Institutions also have theirs in selecting us, teaching us, improving us. They will possess meaningful knowledge and we will spread it with responsibility to the future generations.
The long and winding road
Throughout the years we have experienced progressive change in techniques, number of procedures, results. There has been ratification in learning; we have added necessary skills to the specialty. But we still must aim in transferring this knowledge. Teach what is really worth it, continuous attention to the patient and not just the disease. There is still no modern equipment that can replace
After having travelled a long road, I could ask what I would have done differently. I believe that not much. Time can be inexorable but also rewarding and joyful. We must continue to shape our life not with force imposed externally, but impelled from within. I believe that the meaningful thing is not the arrival but the enriching experiences on the voyage itself. And I am still walking... n
Upcoming SCTS Courses in 2019 Date/s
Surgical Skills in Cardiothoracic Surgery Course
ST5A – Intermediate Viva Course – Ashorne Hill, Leamington Spa
SCP Revision Course, Manchester
ST6A and ST6B - Cardiothoracic Surgery Sub-Specialty Course – European Surgical Institute, Hamburg
ST7A – Revision and Viva Course for FRCS (C-Th) – Ashorne Hill, Leamington Spa
ST8A – Cardiothoracic Surgery Pre-Consultant Course – European Surgical Institute, Hamburg
ST5B – Non-Operative Technical Skills for Surgeons (NOTSS) Course – Advanced Patient Simulation Centre, St George’s Hospital, London
ST3B – Operative Cardiothoracic Surgery Course – European Surgical Institute, Hamburg
ST4B – Core Thoracic Surgery Course – Ashorne Hill, Leamington Spa
Surgical Skills Course, Manchester
ST7B – Clinical examination course for FRCS (C-Th), Papworth Hospital, Cambridge
ST3A – Introduction to Specialty Training in Cardiothoracic Surgery Course – Ashorne Hill, Leamington Spa
ST4A – Core Cardiac Surgery Course – Ashorne Hill, Leamington Spa
ST8B – Professional Development Course – Ashorne Hill, Leamington Spa
the 50 bulletin
Towards Improving Quality Metrics in Cardiothoracic Surgical Critical Care Hisham Sherif, MD, FACS, FICS, FACC, FAHA, Cardiac Surgery (ret.), Newark, Delaware, USA plan to develop measures of success of management, the healthcare team should proceed with asking the fundamental questions, along these lines:
“The only man I know who behaves sensibly is my tailor; he takes my measurements anew each time he sees me. The rest go on with their old measurements and expect me to fit them.” George Bernard Shaw
3. Is it “doable”? Risks? Resources needed? Realistic expectations? Balance of utility versus futility.
1. What is the Goal of management? What are we trying to achieve? Improve survival? Improve quality of life? Symptom palliation?
4. How do we get there? A step-wise, phase-specific Process-of-Care “road map”.
2. For whom? The informed and empowered patient as the leader of the healthcare team and central decision maker.
“The good physician treats the disease; the great physician treats the patient who has the disease” William Osler
ardiothoracic surgeons remain committed to providing high-value care for their patients. Value in health care is defined as high-quality care combined with a positive patient experience at a reasonable cost. Defining “Quality” in healthcare has not been an easy task. One of several definitions introduced is from the Institute of Medicine: “The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. The Agency for Healthcare Research and Quality (AHRQ) further elaborates: “Doing the right thing for the right patient at the right time in the patient’s disease process, towards the right (best) outcomes using the right (optimal) balance of healthcare services”. These “Health Services” are now increasingly defined in business and corporate terms as “Service Lines” where patients are seen as “customers”; the definition of Quality is “The totality of features and characteristics of the service that bear on its ability to satisfy the stated and implied needs”, according to the International Organization of Standardization. Thus, quantifying quality means measuring the degree of success in meeting this objective. In formulating such a
5. How do we know we’re there? Compare results to expectations/goals. 6. Why can’t we get there? Barriers. Failure points.
Figure 1: An overview of the expected results along each step during the management of cardiothoracic surgical patients
7. How can we do it? Safer? Better? Easier? More efficiently? More often? This list of questions translates into the well-recognized framework for organizational success, especially in complex, high-risk environments. Modified for cardiothoracic surgical critical care, this framework is proposed as: l
Assess Patient Needs
Establish patient-specific goal(s)
Identify steps in management process
Identify risk(s) of each step in management
Implement each step in process - at the appropriate time
Monitor effects of process at each step
Quantify results (Survival, change in functional status/Quality of Life, morbidity)
Based on the platform described above, Figure 1 details the steps along the course of cardiothoracic surgical patients to reach the ultimate goal of a sustained, improved quality of life without intervention-related complications. Each step is a “road marker” where results of management are quantified and measured against the expected or planned goals, defined earlier in the patient’s pathway. These measurements are the basis for quantifying the quality (or rather value) of care delivered by the healthcare system.
“Cardiothoracic surgical critical care remains the crucial central phase of transition from surgery, through stabilization and optimization, towards a sustained and robust recovery.” making towards improving the value of care and optimal resource allocation. The analogy of the patient seeking treatment being similar to a customer seeking a specific service (e.g., car repair, a new wardrobe for a new job, kitchen remodeling, etc.) remains frequently cited. The patient knows precisely the change in his/her health status as a result of disease or injury, and how it impacts the expected survival and quality of life, and is usually very specific about the desired outcome of the suggested/ available/offered intervention, based on their own wishes and values. The patient also hires the healthcare team to provide their technical and professional services towards reaching these goals. In doing so, the patient makes a substantial investment - in terms of risks accepted, loss of productivity during management and of course financial burden, and is quite interested in seeing a commiserating outcome, especially in the
long-term. Appropriately, patient-centered care has been firmly established as the foundational requirement for a respectful, responsive healthcare system that provides better outcomes at lower costs. Thus, an intervention that is “technically and statistically successful” (according to current metrics of no mortality or morbidity within 30 days, for instance) but does not meet the patient-defined long-term goals cannot be considered an appropriate measure of quality. This is especially relevant in congenital and pediatric cardiothoracic surgery, and also in innovative technology with unknown long-term results. In developing a realistic, considerate responsive clinical management plan for the cardiothoracic surgical patient, we should borrow the famous question from the business world: “Where do you see yourself in 5, 10 years?” n
Cardiothoracic surgical critical care remains the crucial central phase of transition from surgery, through stabilization and optimization of cardiopulmonary function, towards a sustained and robust recovery. Figure 2 further elaborates on this principles of measuring quality in this specific environment. By defining the desired and undesired results, it becomes possible to utilize the wellestablished methodology of process mapping and root cause analysis to identify steps within each phase that contribute to success in meeting these objectives versus preventing it. The fundamental principle of setting patient-specific, phase-specific goals of management, and the definition of successful outcomes at each step, allows all members of the healthcare team (patient, clinicians, administrators) to effectively share decision
Figure 2: A proposed list of “road markers” as goals of management during cardiothoracic surgical critical care, comparing expected results to potential “failure points”
the 52 bulletin
Rising to the challenge In June 2018, Nursing and AHP representative; Helen Munday and society member; Maire Gilhooly from Royal Papworth Hospital successfully achieved what many consider to be one of the ultimate challenges, climbing Mount Kilimanjaro.
Maire Gilhooly, Royal Papworth Hospital
limbing Kilimanjaro had been a lifetime goal for both of us and the only delay in getting there was actually finding the time to train and fit it in with busy work and home schedules!” Standing at an impressive 5895m, it was always going to be an incredible physical challenge but both of us had not appreciated, until we were there, how much of a mental challenge it would be. Knowing the reality is that a third of people who attempt to climb Kilimanjaro fail, mostly this is down to altitude sickness, something which is very difficult to prepare for, but that is what makes this challenge more exciting and terrifying all at the same time! We were also told that being really fit did not always equate to a successful summit so again, it makes it difficult to gauge the right level of training. Kilimanjaro is unique as a free standing mountain and volcano, but also because of the many changes in climate and landscape as you ascend. The base of the mountain is a lush rain forest, littered with green foliage which was the ideal canopy for hiding those ‘urgent’, and often frequent calls of nature’. As you climb higher you travel through harsher; drier; barren landscapes, none of which were particularly good at providing us with any degree of privacy when nature called. Once you reach the last few hundred meters to the summit you reach the snow, ice and glaciers that line the volcano rim. There are seven different trekking routes to choose from but Helen and I chose the Lemosho route. We chose this route as it is one of the longer routes and we felt it would give us more time to acclimatize to the altitude, which, along with a daily supply of Diamox we felt would give us the best chance of success. We were in a group of 23 trekkers with the added advantage of having an experienced trek leader and trek doctor with us for the entire expedition. Our doctor was kept busy with routine daily medical inconveniences (blisters,
sunburn, stomach upsets) which, though not life threatening, could impact on the success of the trip for the individual. However, on summit night she was required to treat serious medical emergencies from two of the group (hypoglycaemia and acute cerebral oedema). Without her timely interventions, an oxygen cylinder, additional porters to race the individuals back down the mountain, it could have been a very different outcome for our two group trekkers. We had an army of porters and guides to help us achieve our goal; 89 extra people in fact! These individuals were the true heroes of Kilimanjaro. Their unwavering cheerfulness and friendship for the whole trip was simply amazing. Some had managed a staggering 400+ summits in their working lifetime as guides, porters and chefs. Their chant of “Pole Pole”; which means slowly slowly, became their, and our mantra and was essential in helping us get through the daily
trek, though seriously, Helen and I had no intention of walking quickly! These amazing people were there with a hot drink to wake us in the morning, a song to sing us out of camp each day to get us going, and then there to carry our gear to the next camp and to have it all ready for when we arrived exhausted and hungry. How we relished the hot drink and popcorn for snack time every day – and who would have thought you could bake a birthday cake on the mountain – but they did for
my birthday and it was the perfect end to a day which had seen us overcome one of the biggest challenges for us on our journey – scaling The Barranco Wall, hanging on and hugging ‘Kissing Rock’ – what a day! The memory will live on for a very long time of being above the clouds, of feeling completely shattered at the crater rim, only 45 minutes left to walk, a hot drink in hand, ahead, the view of sunrise over Africa at six in the morning, of glaciers glistening in the morning sunlight, of bitterly cold hands and numb finger tips at the summit whilst waiting for the obligatory summit photograph, but also of friendships made, of a challenge well met, something which neither of us will ever forget. Was it worth it? Yes, every single moment from start to finish! And yes, we would recommend it to anyone. n
the 54 bulletin
Bentall in Souzhou* *A page from the memoirs of Professor Keyvan Moghissi
n 2011, the Yorkshire laser Centre, to which I am the Honorary Clinical Director, hosted a group of Physicians and Scientists involved in Photodynamic Therapy (PDT) in China. They were more specifically interested in photodiagnosis (fluorescence imaging) and fluorescence guided therapy for cancer. They reciprocated with an invitation to me to visit and lecture and to demonstrate PDT in a number of the teaching hospitals in China, notably the University Hospital of Guangzhou. On the very last day of my visit, it was suggested by two of my hosts and friends, Professor Zheng Huang and Professor Xuili Wong who had accompanied me everywhere during my visit that we should have a day off to visit the ancient city of Suzhou where there are a number of UN Heritage sites such as “Classical Gardens”. Suzhou is a small city in the southeast China which has 8-10 million inhabitants. One part of the city has been preserved and kept the way it was centuries back, whereas the other parts are the usual ultra modern contemporary China. On the 21st August 2013 Xiuli drove us to Suzhou from Shanghai, a mere 100 miles. She had arranged an official guide, a historian, who took us to many sites, including the historic houses and gardens. Soon after arriving to Suzhou, Zheng had to go to the local university hospital to see a friend; he was to join us for lunch. However, about midday he called Xiuli, asking us to join him at the hospital, as the cardiac surgeon of the hospital was keen to see me and invite us for lunch. Xiuli had already booked a restaurant and I was more interested to see the old part of the city. Therefore, Xiuli and I continued with our exploration of the city, had a delightful lunch and then went to the hospital. This was ‘Suzhou 1st Hospital’ whose Director of Cardiac Surgery was Professor Zhen Ya Shen (Zhen). I was slightly uneasy as, for the first time in
“When I was senior registrar at the Hammersmith hospital in the late 1960s one of my chiefs was Professor Hugh Bentall who designed the operation. My contribution to the operation at the time, was to attach the prosthetic valve into the vascular graft to make it a functioning ascending aorta and valve.” my visit, I was dressed casually and strange as it may seem, I was uncomfortable. At the hospital I was led to the Professor’s office who greeted me cordially. He was very proud, with justification, to present the range of cardiac operations he and his team were performing and how they recorded results and followed up their patients. Prof Zhen Ya Shen had been trained in USA and his American-English was perfect. I was listening to him intensely, but the acuity of my hearing became several times enhanced when I heard that one of the operations he was performing at the rate of 3-4 per week was the Bentall Procedure. When I was senior registrar at the Hammersmith hospital in the late 1960s one of my chiefs was Professor Hugh Bentall who designed the operation. My contribution to the operation at the time, was to attach the prosthetic valve into the vascular graft to make it a functioning ascending aorta and valve. On hearing the name Bentall, I asked Zhen if he knew who Bentall was and/or anything about the background of the operation. The answer was that, “Bentall was an
American Surgeon” but he did not know which city. I was very proud to upgrade his knowledge that, in fact, Prof Hugh Bentall was a British surgeon at Hammersmith Hospital in London and my Teacher (Chief) and that during my time with him the initial design of the operation which bears his name had been completed and he was adding certain refinements to the technique. One of the refinements was to use a homograft aortic valve instead of the mechanical prosthesis. On hearing my narrative, Zhen asked me to accompany him to the Intensive care unit to see a woman he had operated on 3 days previously, in whom he had replaced the route of the aorta and aortic valve using the Bentall’s technique for aortic aneurysm and severe valvular incompetence. Professor Keyvan Moghissi’s book: ‘Off My Chest - Tales of a Cardiac Surgeon’
We proceeded to the ICU where I saw the patient. Zhen started to introduce me to the patient in Chinese and the women opened her arm and smiled and spoke in Chinese. “I am honored to see you, Professor, who had worked with the surgeon who has been responsible for me to be alive and healthy again”, she said. She insisted on having some pictures with me and Zhen to show to her family. This was easily done by my host using his mobile telephone. This picture (Figure 1) is amongst my most precious souvenirs of the Chinese trip. Note: Hugh Bentall (1920-2012) was a remarkable cultured man who was fully trained in all aspects of cardiothoracic surgery at the North Middlesex and London Chest Hospital. He became the first Professor of Cardiac surgery in Britain in 1965 at the Royal Post Graduate Medical School (Hammersmith Hospital) in London. One of his contributions to training Cardiothoracic surgeons was participation
Figure 1: Picture of Cardiac Surgery, Intensive Care Unit, of Suzhou Hospital. (l-r) Professor Zhen Ya, Cardiac Surgeon at the hospital; Professor Moghissi; Patient who had Bentall operation three days previously
in the establishment of a Senior Registrar Rotation post between 4 major hospitals in London, namely: Harefield, Hammersmith, Middlesex and the Great Ormond Street Children hospitals. I was the first appointee of the “Rotation”. As Surgeon, Bentall was precise, meticulous, and respectful to his junior. He had a good sense of humor, and above all he was a “fair and an international” man. On a more personal basis, he helped me a great deal when I was first appointed in Hull with the mission to establish an Open Heart Surgery Unit in Hull. His help included his presence in an evening organized by the then B Group Hull Hospital Management Committee to support my undertaking. In 1974 I carried out my first Bentall operation at Castle Hill Hospital in Hull. n
In partial fulfilment of the SCTS-Ionescu Medical Students’ Travelling Fellowship Tinrui Toh Dates: 18/6/2018 – 13/7/2018 Visiting Centre: Papworth Hospital, Cambridge, United Kingdom Department: Cardiac and Thoracic Surgery Supervisor: Mr. Samer Nashef Dates: 16/7/2018 – 3/8/2018 Visiting Centre: National Taiwan University Hospital (NTUH), Taipei, Taiwan Department: Cardiovascular Surgery Supervisor: Mr. Chih-Hsien Wang
decided to pursue my electives in two countries – the UK and Taiwan, as I hoped to first experience cardiothoracic surgery from a local centre’s perspective, and then widen my global perspective of not just the specialty but also the healthcare system in Taiwan, a developed nation and a forerunner in healthcare in Asia.
Papworth Hospital is a leading centre and has a long history of pioneering heart and lung procedures in the UK. I was encouraged and given the opportunity to participate and assist in a number of procedures, from vein harvesting, aortic valve replacement to VATS lobectomies. I also gained research experience on the elective, together with Mr Nashef and Mr Osman, we investigated outcomes following emergency type-A acute aortic dissection surgeries among octogenarians. On teaching, I attended lectures on topics such as ECMO, pulmonary endarterectomy, endocarditis, and case-based-discussions of complex cases. I also made good friends, and continue to stay in touch with the trainees at Papworth, who went the extra mile to guide me on successfully getting into a training programme.
In Taiwan, beyond the typical experience that one would get from a cardiothoracic elective, I had the opportunity to see complex robotic cardiac surgeries using the DaVinci system, hybrid procedures, and also experienced a completely different form of healthcare reminiscent of the US and Japan. Most cardiac surgeons in NTUH are academically inclined with backgrounds of PhD. It was a truly immersive experience in a research-heavy, excellently funded, hardworking and clinically excellent cardiovascular centre! Limited by word count, this is the very least that I can say about my electives. Overall they were truly fantastic experiences and exceeded my every expectation. On a plus point, I made great friends along the way, in two awesome cities, made memories that will last a lifetime. I thank the SCTS and Mr Ionescu for supporting me during my elective! n
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United Kingdom Aortic Surgery United 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’. Alex Cale. Communication Secretary UK-AS
he eighth meeting of UK-AS occurred at the Belfry near Birmingham in September, and was very well attended with 54 representatives from most of the centres in the country. Following a welcoming introduction from UK-AS Chairman Geoff Tsang, the following agenda items were discussed in open forum.
UK-AS Structure and Education The future of the group including registering as a charity with financial accounts, and formalised membership with subscriptions was discussed. This was approved by a unanimous vote with an agreed annual membership fee of £50. Once charitable status is confirmed by the Charities Commission, a bank account will be opened and members asked to subscribe by direct debit mandate. Membership will include attendance at the annual meeting, access to WhatsApp based MDT forum, and email address. There was agreement to use the membership fee to support annual meetings of UK-AS, particularly in supporting newly appointed Consultants with an interest in aortic surgery. It was agreed that further discussion were required regarding opening up the UK-AS to allied specialties such as Vascular Surgery and Intervention, and this would be desirable. Over the last year UK-AS has further developed its role in SCTS Education, the EACTS Academy 2018, and supporting RCSEd Webinars.
UK-AS has also been involved supporting SCTS with GIRFT recommendations for aortic surgery, and supporting NHSE in developing service specifications for Aortic Surgery in the UK. Representatives from Aortic Dissection Awareness group whole heartedly supported this groups initiative to focus on aortic surgery in the UK which is aligned to the Awareness groups activities on behalf of the patients undergoing aortic surgery.
Service Specification for treating Thoracic Aortovascular Disease in the UK A presentation was heard from Rachel Bell, Consultant Vascular Surgeon from St Thomas’s Hospital, who is leading the group configuring service specifications for aortic disease in the UK. Rachel explained that unreasonable variation in quality of service provision for thoracic aortovascular surgery in the UK was driving this review together with recommendations contained in the Getting it Right First Time (GiRFT) report on Cardiac surgery published earlier in the year. Rachel explained that she was tasked by NHSE with setting up a Joint CRG between Cardiac and Vascular surgery to develop service specifications for aortic disease with the aim of reducing the observed regional variation, improve quality, and improve patient and family experience by providing clear referral and management pathways. Mark Field, Consultant Cardiac and Aorto-vascular Surgeon from Liverpool,
then gave a presentation on the draft service specifications, the detail of which cannot be addressed in this article. However the principle is a hub and spoke model with less complex procedures performed in all centres, with complex procedures particularly in the Distal Arch and the Thoraco-Abdominal aorta being concentrated in specialist centres (DATA centres) and there are likely to be will have stringent service guidelines associated with this. It is anticipated that there will be general grouping of all centres into local aortic networks (LANs). Mark emphasised that the organization of services for treatment of acute aortic syndromes is fairly flexible as long as it meets the general principles of organizing into LANs and can offer the procedures and management with a history of good outcomes. The structure of this will be left to local arrangements i.e local solutions for local problems. The progress being made in Yorkshire to develop a LAN and acute rota were discussed and widely accepted as a very positive initiative. It is anticipated that all centres providing these treatments should have links to a LAN and a specified DATA centre with the ability and potential to refer more complex cases to more experienced or DATA centres. A discussion was had regarding the management of Acute Type B aortic syndromes. This is an area with the most variable practice presently and the greatest potential for regional variation, it was agreed that this reorganisation would a very
good opportunity to improve management in this group of patients.
Non-syndromic Thoracic Aortic Disease (ReST Study) Riccardo Abbasciano on behalf of Giovanni Mariscalco from Leicester talked about screening for non-syndromic thoracic aortic disease highlighting an unmet need in this area. He gave an update on the ReST Study, led by Giovanni Mariscalco, which is an evaluation of feasibility of screening relatives of patients affected by non-syndromic thoracic aortic disease. Diane Barker, a Consultant Cardiologist at Stoke, gave a talk on genetically triggered thoracic aortic aneurysms. She gave an overview of both syndromic and non syndromic aortopathy, and highlighted clinical work and benefits provided by the aortic clinic in Stoke
UK FET data (Frozen Elephant Trunk) Geoff Tsang from Southampton gave a brief overview of the current UK FET in Acute Type A Aortic Dissection experience (previously presented in various meetings) and repeated the request to all centres to send their data on FET to Giovanni Mariscalco in Leicester for preparation for submission to AHA next year. Aung Oo from Barts gave an update on UK FET for Chronic Dissection experience,
and stated that little data available and was difficult to extract. The possibility of Research Fellow from Barts who could travel to other units to extract the data was discussed and it was anticipated better data would be available for the UKAS meeting at SCTS in March 2019.
DIRECTION Trial Pedro Catarino from Papworth gave an update on the DIRECTION Trial. The proposal is randomisation to conservative (ascending aorta or hemi-arch) or aggressive (total arch and FET) approach to the arch in ATAAD. There was plenty of lively discussion about numbers needed, outcomes, and who should be investigators. It was agreed that this concept originally proposed by the late Bob Bonser was good and should be developed into a workable trial, or at least a registry. This led to a discussion regarding setting up such a database for FET in the UK. Potential help from charities such as HRUK was felt to be a good avenue to explore, and the pros of cons of using HES data were debated. The need for sustainability in the long term and maintaining the database, with the legal implications of GDPR, data protection, and consent was emphasised.
Adult Ross Surgery (Ross v AVR Trial) Mario Petrou from Oxford gave a brief history and description of the Ross
Procedure, including indications and contra-indications illustrated with cases from his own practice. He showed data confirming the excellent long-term durability of this therapy, and suggested that many more of these operations should be carried out in the UK. Serban Stoica then gave an overview of the Ross procedure concentrating on the pros and cons of the operation and proposed setting up the Ross vs AVR Trial.
Aortic Root Surgery Ulrich Rosendahl from the Brompton gave an update on their experience with PEARS, and Maciej Matuszewski from Wolverhampton their experience with aortic annuloplasty using the Lansac Ring, both showing promising results. Loganathan Balacumaraswami gave a talk on when not to do a David Procedure and Cesare Quarto presented his experience with the Ozaki Procedure, both very informative talks.
Next meeting dates After adjournment of the meeting attendees availed themselves of the excellent facilities at the Belfry, at their own expense, following which a meeting dinner was hosted and funded by UK-AS. There will be a business meeting at SCTS London Monday 11th March 2019, and an Annual meeting at the Belfry on Saturday 7th September 2019. n
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The Candid Column:
“Torrid times make good surgeons” This is a saying that has stuck with me and which was offered to me by a now retired surgeon as a form of consolation at a time when I was bemoaning my misfortune with a fatal patient outcome. Over my 17 years as a Consultant I have had many occasions to reflect on his maxim. Keith Buchan
t has been refreshing to read David Richens’s Getting it Right First Time (GIRFT) report 1 which recommended (amongst other things) a move away from surgeon specific mortality to unit mortality as the key quality indicator for our work. It is about time we put in place systems that promote mutual support between all the stakeholders in a Cardiothoracic unit so that they work together to obtain the best outcomes possible. Sam Nashef’s book “The Naked Surgeon” makes the point that a cardiac surgeon’s results are worst just before he goes on annual leave and best just after he returns 2 . Whilst this observation could be turned into an argument for taking frequent holidays, the reality could also reflect poorer post-operative patient care after the operating surgeon has gone on leave. Reporting of unit-specific outcomes rather than surgeon specific ones would put extra onus on colleagues to pay close attention to the post-operative care of an absent colleague’s patients. The December edition of “The Surgeon” carries a perceptive article debunking the current fad for measuring the quality of clinical practice by the fulfilment of targets 3 . It pits the concept of “target centred care” as being the opposite of “patient centred care”. Whilst targets are meant to measure a small sample of a clinician’s clinical practice so that the outcomes there can be
generalised to the entirety of his practice, what happens in reality is that the target becomes the main thing and everything else becomes of secondary importance. In our Cardiothoracic environment there is continual pressure to try and modernise our surgical techniques in line with latest
In other words, we will be obliged to inform patients when we have not done a procedure before or perhaps when we have only done it once or twice. One of our colleagues has appeared on national TV to decry the dampening effect such changes are having on innovation in our specialty in this country 4 . It is not clear how to resolve the paradox. Like all paradoxes, it will never be completely soluble but there will always be a way to reduce the magnitude of the consequences of surgical innovation through improved dialogue with colleagues/ management and greater corporate responsibility for outcomes. It is not always easy to work on these aspects of our work and for some of us it can be a torrid task. If that is what it takes to be a good surgeon in today’s world then we should not hesitate to get involved. n
“Within the last year, laws have been passed to make a duty of candour towards patients obligatory on all doctors. In other words, we will be obliged to inform patients when we have not done a procedure before, or perhaps only done it once or twice.” developments. But new technology can have negative consequences for the pioneers when things do not go according to plan. These two features of modern UK Cardiothoracic practice give rise to a paradox. On the one hand, providing the innovation is successful, fame and fortune potentially await the surgeon. Alternatively, should it all go wrong, the opposite destiny could await him. Within the last year, laws have been passed to make a duty of candour towards patients obligatory on all doctors. Whilst this is usually interpreted as applying retrospectively to errors that were made and owning up to them, it will also be applied prospectively.
1) http://gettingitrightfirsttime.co.uk/ cardiothoracic-surgery-report/ 2) The Naked Surgeon. Samer Nashef. Scribe Publications (2015) p158-159 3) “Right on Target?” OM Farhan-Alanie, DF Howie, J O’Reilly, J MacNair. The Surgeon (2018) 16:355-358. 4) https://www.youtube.com/ watch?v=DNoxmgehswQ
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Patient Experience Matters The Leicester Thoracic Surgery Patient Experience Day (TSPED) Hayley Pike
aring at its best” is our trust’s motto and we as a team strive to offer the best possible care to our patients who go through challenging times in their lives with cancer diagnosis and major operations. Patient experience and patient related outcome measures are an integral part of health service provision in the modern NHS. This mostly is done by surveys and feedback cards as a ‘message to Matron’. This however takes away the personal touch - The Leicester TSPED was established by the Thoracic Nurse Specialists (TNS) to address that gap in engagement and to provide an alternate method in engaging with patients and their experiences. The Thoracic Nurse Specialists (TNS) at the Glenfield Hospital work hard alongside the Thoracic service to ensure our patients experience is as positive as possible. Over the past six years we have held an annual TSPED, designed in a way that captures the whole patient journey from clinics, admission, discharge postsurgery and follow up. As a team we acknowledge that patients all have unique experiences of our service and different expectations. The aim of the TSPED is to enable us to learn, plan and create a more effective service for our future patients and their families. We wanted to capture a variety of experiences; so to facilitate this patients were invited randomly by selecting every 5th person from the ward admission book between the months of August 2017 – March 2018. We invited 100 previous patients in total – asking for their participation and consent. Patients were given the option to bring along a significant other to accompany them to the event. We also took the opportunity for patients to highlight any special requirements for the day i.e. oxygen or dietary needs.
Of the 100 invitations sent, we had 51 responses with 18 patients giving their consent to be involved, all intended to come along with a significant other. On the day two patents cancelled. The TNS were delighted with the turn out, an improvement on previous years and testament to how valuable and important our service is to our patients that they take the time to attend such events. The TNS, Hayley Pike, Sarah Taylor and Joanne Jones facilitated the day along with contributions from our Consultant Thoracic Surgeon, Mr Ang, Ward Sister, Rebecca Halpin and Head of Nursing, Sue Mason. We had a semi structured agenda to provide a framework for discussion without inhibiting patient creativity. The main themes discussed throughout the day included: l
communication and Information giving
ward environment, facilities, routine
Thoracic Nurse Specialist service
discharge process and clinics
We wanted to identify the positive aspects of the patients experience but also areas that could be improved upon. We worked in groups, each with a facilitator present to highlight focus points. It was an informal and friendly atmosphere that prompted lots of healthy discussion. On the whole, patients were very complementary of the service, stating that the ‘staff are fantastic’ & provide a ‘5 star service’. All felt that they were kept informed throughout their stay in hospital and that communication was excellent. One particular area patients felt we could improve on was to have more TNS presence on the ward, rather
than just in clinics. This is something that, as our service grows, we are keen to implement. It would insure we capture all patients, not just those admitted through clinics, and that all patients have the same access to services available. Relatives commented on how welcomed they felt and how flexible the team were with visiting hours. This was really positive to hear, especially since as one of the changes following last year’s TSPED was the visiting hours, which has obviously been well received. If any, the main area our patients felt could be improved was the discharge process, throughout the discussion we explained the reason for the lengthy discharge (prescribing, dispensing, nurse checks) and that for patient safety this is not something that should be rushed – giving this explanation and the opportunity for patients to understand the complexity of the process aided understanding. We think this is an example of how communication is the key to success. Following the event, an action plan was put together and disseminated to all staff. Patients who attended the day also had a copy forwarded to show that we have taken their shared experiences and made positive changes. Our service found the feedback to be very useful, providing us with points of celebration and action. It was enjoyable to meet with previous patients and their significant others, and encouraging to receive such a positive response. We are extremely proud of our annual event, which would not be possible without the kind support of charitable funds, nor the dedication of our team. Other specialities within the trust have also recognised how valuable this event is and have begun to introduce patient experience days for their areas. n
Minimally invasive cardiothoracic surgery - Where do we stand? Muhammad Asghar Nawaz, MBBS, MRCS, FCPS, FRCS CTh, ST8, North West Deanery UK
inimally invasive cardiothoracic surgery (MICS) has recently seen a tremendous evolution worldwide; however we do not perceive it developing at the same pace in the UK. Contrary to this, we notice the budding physicians in our sister specialties of cardiology and respiratory making significant innovative progress. TAVI has established from surgical turn downed to high risk to intermediate risk and now making its way to lower risk population that the ESC/ EACTS 2017 guidelines favor TAVI for age ≥75 with Euroscore II ≥4 as class 1 Level B. The first TAVI in the UK was performed in King’s London in 2009 and in just 9 years this service has recognized nationally and being performed routinely mostly by our interventional colleagues. The MitraClip is penetrating too, though, has not got the same seat as TAVI yet but who knows if we keep on crawling with our same tortoise pace. Have we evolved that far in surgery? Despite the fact that AVR has been performed with upper partial sternotomy for long time (also the inception of sutureless valve) it hasn’t made that much evolvement and neither its alternative RAT (right anterior thoracotomy) approach. MICS is not new and has been in practice for more than two decades. Even the robot existed for about the same tenure, achieving good results. The mitral repair through right VATS (now Robotic) is an excellent example as it provides a best view, easy access, no sternal split required and very suitable
for redo cases especially where you really do Uniportal bronchovascular sleeve not want to risk your patent LIMA graft. (Photo courtesy of Jianglei) Thoracic surgery in UK has advanced over time and training has become more organized with greater prevalence of thoracic themed trainees. The penetration of VATS for lobectomy has also been quite limited though. The UK’s first VATS lobectomy was done in 1992 in Edinburgh but 19 years later only 13% cardiothoracic trainees to consultant level. of all lobectomies were performed via So the question arises did we actually VATS according to the 2011 Society report. train them or did they get the appropriate This number rose further, but not to my training and if they did why have they not surprise, only 43.9% VATS lobectomy been doing VATS lung resections. There is were accomplished in 2015 according ample evidence and it seems a joke debating to LCCOP 2017 report. for more evidence about the benefits of During all this time we have probably VATS/Robotic lung resections compared trained at least three generations of to traditional approach. A few years ago, questions were raised about the safety and appropriateness of VATS anatomical lung resections and as the evidence for its superiority is there now why are we not raising the question about barring the inferior traditional approach particularly for early stage lung cancer. So what is it that is preventing it? The technology and expertise have existed for the last two decades and have proved itself safe and financially viable. MICS is quite popular both among the patients and trainees. It seems likely Typical Robotic set up it is the culture among the >>
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Doing lobectomy routinely for a <2cm tumor confined to the middle of a segment without any nodal involvement seems a bit harsh. Another question is about peculiar aspect of training, is it really necessary to train the trainees first in traditional and then VATS in later stages of training, I suppose not, it is pointless to complete traditional training first and then step up to the minimal access. In fact it should be the other way around. The evidence from simulation models suggests younger surgeons acquire and adopt the MICS exercises quicker than the experienced surgeons. The international society for minimally invasive cardiothoracic surgery (ISMICS) was formed in May 1997 and been publishing its journal the â€œ Innovationsâ€? for the aspiring surgeons with interest in minimally invasive surgery. A lot of resources are available to
Uniportal Sleeve Lobectomy
cardiothoracic surgical teams. The patients do enquire about keyhole surgery. I remember a younger patient insisting on having mitraclip in 2012, although she was a suitable candidate for mitral valve repair. It is us the experts, who probably are not doing enough to advance in this direction. Similarly, there is also lack of experience in the segmentectomy. In current era when we are heading to lung cancer screening and have excellent follow up program.
have a simulation training that very much mimics the minimally invasive surgery due the use of technology in both. The main advantage of the simulation training is that you are allowed to make mistakes and learn by doing. The reflective simulation exercises show barriers and paths to improvement among trainees. The data also shows that the learning curve and ability to learn robotics initially appears to be shorter and easier than surgeons learning VATS. Gratefully, over 6 thoracic centres in the UK now have access to robot and doing the robotic assisted surgery. Robot will help achieve minimally invasive vascular and bronchial sleeve resections leisurely, which we are currently not performing in the UK via VATS. I hope future of our specialty is bright especially the thoracic surgery at least have picked up some speed now. n
Astronomy: Another thing to do in retirement Jatin Desai, Retired Cardiac Surgeon, Kingâ€™s College Hospital, London
suspect all of us spend our entire professional life learning in our demanding field. With retirement approaching, I prepared by reducing work to only three days a week. This afforded me the opportunity to learn something completely different to cardiac surgery. I had always enjoyed reading about the physical world and had a keen curiosity of the universe since my teens. My interest was further fuelled when my children bought me a small Newtonian telescope for my 60th birthday. On seeing advertisements for courses in astronomy, I applied to join a 2 year part-time certificate course at University College London (UCL). After a brief interview, I was pleased to be admitted to study. Not surprisingly, I found myself to be the
oldest person in the class. The small class of 20-odd people had a wide spectrum of ages and backgrounds – all enthusiasts! The excitement of acquiring a textbook, a scientific calculator and entering the classroom was no less than when I first started medical school. Learning to use the £10 scientific calculator took some doing – what a difference from a slide-rule and Log tables! I would look forward to the once a week evening class where three hours of teaching was imparted in Astronomy and Astrophysics by the excellent faculty at UCL. As with any teaching, homework and extra reading followed. Every three weeks, we would go to our observatory on the outskirts of London. The infectious enthusiasm of our tutor will be remembered forever. He showed us many sights through the old, mechanically-driven refractor scope. The bands of Jupiter, rings of Saturn and many beautifully coloured double stars all seemed to be within touching distance. Fellows would show us the use of computerised telescopes with colour filters – it was fascinating to see the development of faint objects into clear nebulae. On cloudy nights our time will be spent completing a variety of practical exercises like classifying galaxies and stellar spectra. These would be marked and contributed to the final examination marks. Each year required a wellresearched dissertation which would be critically marked. My choice in the first year was Titan (the large methane drenched moon of Saturn) – I barely scrapped through (perhaps I had underestimated the complexity of the subject). I was better with my second dissertation on theories around the existence of extra-terrestrial life. The two years went by far too quickly. I was pleased to pass the finals and gain a certificate. After celebratory drinks, the class
“Retirement has also afforded me the time to visit events like the total solar eclipse, which I viewed from Jackson Hole in Wyoming. It is an experience which I recommend you should have at least once in your life.”
dispersed with some pursuing a higher degree in the subject. On my retirement, my cardiac family at King’s presented me with a beautiful Refracting Telescope. I paired this with a Go-To mount and started to use it from my back garden at home. These electronic mounts make searching for targets easy. On the few clear nights, I brave the cold and set things up but the light pollution in London limits the targets to the moon and the planets. The sights of Jupiter’s moons, Saturn’s rings and the Andromeda Galaxy are aweinspiring. Dark Sky parks are cropping up all over the country. As I find my way around the sky, I plan to visit some of these. Retirement has also afforded me the time to visit events like the total solar eclipse, which I viewed from Jackson Hole in Wyoming. It is an experience which I recommend you should have at least once in your life. There is a total solar eclipse across Chile in 2019, which I am tempted to go to. I also hope to visit some of the biggest and best telescopes, which are built in the Atacama dessert (clear moisture free air), by many countries in the world. Space probes have visited all our planets and have discovered liquid water on the frozen moons of Jupiter and Saturn. This has given us an impetus to the search for life outside earth. Space telescopes have discovered thousands of planets around distant stars, some Earth-like, with the possibility of liquid water. Someday, we may make contact with advanced civilisations but don’t hold your breath quite yet – space is unimaginably vast. I have thoroughly enjoyed learning about astronomy. It is an exciting, dynamic field, which will continue to amaze us. You do not have to retire to take it up but it certainly helps to fill the void left by surgery. n
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Minor VATS procedures on spontaneous ventilation anaesthesia: A novel technique
Syed Qadri, Consultant Thoracic Surgeon, Castle Hill Hospital, Hull
horacic surgery has been evolving progressively over the last decades. There has been continuous improvement in technology and technique from open thoracic surgery to minimal invasive surgery such as video assisted thoracic surgery (VATS) and robotic surgery. The ventilation and anaesthetic management has also evolved over this time. Majority of thoracic surgery is performed with single lung ventilation. However recently thoracic surgery has also been performed with newer anaesthetic management utilising non-tracheal intubation and awake patients. All these development have demonstrated improvement in short- and long term patient outcomes. Thoracoscopic surgery without tracheal intubation is an emerging technique in which patients breath spontaneously during the procedures. Single lung ventilation, double lumen intubation and paralysing agents are not required. Studies have shown rapid recovery, better pain control and lower post op morbidity. Various technique have been described in the literature. We recently adopted this new novel technique using the Laryngeal Mask Airway for Video Assisted Thoracic Surgery (VATS) in procedures such as bullectomy & pleurectomy, pleural biopsy, lung biopsy, drainage of empyema, decortication and wedge excisions. Anaesthetic technique involves intravenous propofol and 100mg of suxamethonium for quick bronchoscopy and the use of a Laryngeal Mask Airway (LMA) (Figure 1) and maintain anaesthesia with inhalation agents. For analgesia paracetamol and titrating dose of
fentanyl is used. Usual monitoring of ECG, non-invasive blood pressure, O2 saturation, end tidal CO2. Surgical technique is the same as in full anaesthesia with one lung ventilation. For surgical exposure surgical pneumothorax is created following port insertion (Figure 2). This allows the lung to collapse to produce adequate surgical exposure (Figure 3). The exposure is identical if not better than single lung ventilation. We have performed more than 40 cases and have not encountered any difficulties in performing the procedures. In fact we find the exposure is improved as compared to single lung ventilation especially in patients with emphysematous lungs. We observed maintenance of oxygen saturation greater than 95% in all patients. End tidal volume was very low during whole procedure. Patients were comfortable and stable during procedures. They recovered from the anaesthesia very quickly after procedure without any anaesthetic or respiratory complication. This is noticeably different from patients with endotracheal intubation who wake up disorientated, drowsy and coughing to expel secretions with increased
pain. We observed that these patients who had surgery on LMA woke up very quickly and were oriented and did not have coughing episodes after surgery, therefore their early post op pain was significantly lower with improved recovery. In conclusion, we found that standard surgical procedures can be performed easily without any Figure 2 difficulty. There was no extra complications in the perioperative period and their post op recovery was unremarkable. To date we have not faced any situation where we had to convert spontaneous ventilation to full anaesthesia. We do not notice any delay in routine discharge or any new post op complication other than what is normally observed. As we do not use double lumen tubes and paralysing agents there is probably a financial benefit of this technique. It also saves on anaesthetic time and it has allowed us to add extra minor procedures on the list. Straight forward VATS procedures can be performed using this technique which is safe and economical with rapid post op recovery. However further evaluation is required. n
Aortic Dissection Awareness Day UK 2018 Chrissie Bannister, Patient Lead, Nursing & AHP Committee
his yearsâ€™ Aortic Dissection Awareness Day UK was held on the 19th September, this corresponded with events held internationally to highlight the issues surrounding Aortic Dissection. Each year, national patient association Aortic Dissection Awareness (UK & Ireland) awards the honour of hosting its annual flagship event to a centre which, in the eyes of patients, is doing excellent work in the field of Aortic Dissection. This year the honour went to Barts Health NHS Trust, in recognition of the excellence of the Barts Aortic MDT. In the magnificent surroundings of The Great Hall at Barts, a group of 160 patients, family members, clinicians and AHPs participated in a day of
presentation and discussion about improving the care and treatment of Aortic Dissection in the UK. Over 40 SCTS members attended, including the President, Mr. Richard Page and the immediate past-President, Mr. Graham Cooper, in his new role as Medical Advisor to the patient association. At the meeting, Richard Page was introduced by the Chair of Aortic Dissection Awareness (UK & Ireland) Mr. Gareth Owens, who is a Barts patient and an AD survivor. Mr. Owens commented on the particularly strong relationship that exists between SCTS and the national patient association. He said that this has created a powerhouse for driving change and improving care and outcomes for AD patients across the UK.
In his keynote address, Richard shared his insights on the likely challenges of implementing the forthcoming NHS service specification for Thoracic Aortic Dissection. SCTS member Mr. Mark Field had presented the work being created on the new service specification and described it as a once-in-a-lifetime opportunity to raise UK standards in the care and treatment of Aortic Dissection. The service specification will be one of the first and most significant deliverables from the collaboration between clinicians and Aortic Dissection patients in which SCTS is involved and is likely to affect every cardiac surgery unit in the UK. Another highlight of the day came when Mr. Owens invited the Barts Aortic MDT >>
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onto the stage for a live re-enactment of the surgery they had performed in 2016/17 to repair his complex Type B Aortic Dissection. SCTS member Prof. Rakesh Uppal led the team that saved Mr. Owens life, but he was operating, so Prof. Aung Oo kindly stoodin for him. Together with his Vascular Surgery colleagues Mr. Paul Flora and Mr. Sandip Sarkar, Prof. Oo demonstrated how in two extensive open surgeries the
team had replaced most of Mr. Owens’ descending thoracic aorta, abdominal aorta and iliac arteries with Dacron grafts, which were manufactured by the event Gold Sponsor, TerumoAortic. Commenting at the end of a highly-successful day at Barts, Mr. Owens said ‘For me, the Barts Aortic MDT represents the benchmark for the standard of care that I want every AD patient in the UK to be able to receive. We must end the unwarranted regional variation in care and outcomes that currently exists. The remarkable progress that our patient-led campaign has made over the last two years would not have been possible without
the full support of SCTS. I am incredibly encouraged to know that the Society, its leadership and membership are committed to realising our shared vision of improved care and outcomes for AD patients across the UK. Together we will make it happen.’ Looking ahead, the Aortic Dissection Awareness Day UK 2019 will be held on 19th September at the University of Leicester and will be hosted by Prof. Gavin Murphy and his team, when the theme of the day will be ‘AD Research & Innovation’. n
SCTS Links with Heart Valve Voice Chrissie Bannister, Patient Lead, Nursing & AHP Committee
The European Heart Valve Disease Awareness Day
he first European Heart Valve Disease Awareness Day was held on the 8th September at ExCel in London, and both Helen Munday and I attended from the SCTS Nursing & AHP Committee. With the support of EuroPCR, the day was a joint venture planned by patient organisations from France, Spain, Italy, Ireland, the Netherlands and the UK, all of whom are dedicated to spreading the word about the need for the timely diagnosis and treatment of heart valve disease. Heart valve disease affects over 10 million people over the age of 65 throughout Europe, and while significant improvement has been achieved in public awareness of
cardiovascular disease, the same cannot be said for heart valve disease. The day was started by an introduction from the Chairman of Heart Valve Voice, Chris Young from Guy’s & St. Thomas’s NHS Foundation Trust who welcomed attendees. He went on to introduce Wil Woan, CEO of Heart Valve Voice, to explain the background of the European Heart Valve Disease Awareness Day and Bernard Prendergast, PCR Director to begin proceedings. We were delighted to see patients, their family members and clinicians coming together to hear about the latest valve technology, the changing landscape of valve disease treatment and how patients can
access the most effective treatment for their condition. Patient ambassadors shared their experiences and talked about the challenges they faced accessing services and the impact of successful treatment on their energy levels and zest for life. In addition, Wil from Heart Valve Voice was able to reveal some new resources that would be able to help patients understand more about their heart valve disease. These included a document entitled ‘A European Heart Valve Disease Partnership: The Power of Positive Ageing’ and a book written by 12 year old Michael Woan, whose family had been touched by heart valve disease, ‘My Grandad’s Heart Valve Disease Story’ which
is available from Heart Valve Voice. Their thanks went to Michael for the story and also to Sally Brown, artist and designer, for her lovely illustrations. There was the opportunity to network with other clinicians, and also patients and their carers which allowed for interesting discussions. Wil summed up the event by saying, “By raising awareness of this disease we can highlight the need for timely detection and intervention in the UK as well as in countries across Europe.” On the day Heart Valve Voice also held a Tweet Chat for those who couldn’t attend the event in London. The tweet chat involved Twitter users from all over participating in a Tweet
discussion, allowing users to ask questions, share insight and contribute their experiences from the comfort of their own home or wherever they might be. Following the hashtag #heartvalveday, we were able to share facts, figures, resources and answered queries with the help of the Heart Valve Voice team, expert clinicians and patient ambassadors. Whilst the day was full of learning opportunities; one that was particularly exciting was the introduction of a new webinar series. The first of the series discussed the role of primary care in the detection and diagnosis of valve disease. The CPD approved webinar was hosted by Dr Chris Arden, GP and GPSI Cardiology and Editor for PCCJ. If you would like more information please get in touch at email@example.com and to find out more about our webinar series: https://webinarsforgps.com/heart-valvevoice-webinars n
Heart Valve Voice – National Photography Competition
fter almost a year in the making, the winners of the Heart Valve Voice Patient Portraits: A New You photography competition have been announced in the Houses of Parliament in October 2018. Everyone who attended the recent exhibition for the finalists for the Patient Portraits: A New You photography competition were very impressed with the high quality of entries but no one was more pleased and excited with the results of the competition than Heart Valve Voice Chairman Chris Young, Consultant Cardiothoracic Surgeon at St Thomas’ Hospital. In an exhibition hosted by heart valve disease survivor and MP Steve McCabe at the Houses of Parliament the photos were revealed and the winners announced. Participating photographers, their model patients, clinicians and family members
were on hand to peruse the photographic documentaries and celebrate the amazing work accomplished over this past year. Judge, Chrissie Banister said “I was taken aback by how successful all of the photographers were at depicting their patient’s lives after heart valve disease treatment. The compelling images told the story of how patients subjects enjoyed their new found quality of life and the joy they experienced doing the activities they loved.” One image in particular really stood out for Chris Young, as it really captured the
pure essence of what it is like to overcome heart valve disease. The image was shot by our overall winner Eric Etchart and depicts his patient Alan Tancred as he descends onto the dance floor (his favourite pastime) confidently and defiantly. “This image to me is what we’re all about here at Heart Valve Voice and the message that we’re trying to get across that a diagnosis of heart valve disease doesn’t have to mean a death sentence,” says Chris. “With the right treatment at the right time patients can return to their lives as good as, if not better, than before their diagnosis. In this photo I see Alan turning his back on a life where valve disease was slowing him down and walking towards a healthy future.” The photo competition was a great success and everyone, the photographers, patient models and judges enjoyed the experience. We hope to continue the photo competition as an annual event so please keep an eye on the Heart Valve Voice website for further announcements. www.heartvalvevoice.com
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Thoracic Surgery - Swiss Style
An aerial photo of the University Hospital Zurich campus overlooking the city and great lake (courtesy of University Hospital Zurich)
A Visit to the University Hospital Zurich Gerard J Fitzmaurice, Clinical Fellow, ST8, Liverpool Heart & Chest Hospital, UK
he Department of Thoracic Surgery at the University Hospital in Zurich is nestled in the heart of the city, close to the main university, and overlooking the great lake. Professor Weder leads this internationally renowned quaternary referral centre that specialises in the management of complex thoracic malignancies, lung volume reduction surgery, and lung transplantation. As the major thoracic surgical department in Switzerland and one of only two lung transplantation centres serving the Swiss population, it also provides a comprehensive ECLS service. In addition they have a wellestablished robotic thoracic surgical program
with dual-consoles and use the well-known Da Vinci Xi system. My visit started on a warm Monday morning in July with the daily surgical meeting at 7.45 am sharp. The dynamics are in contrast to Ireland and the UK, where all of the surgeons and trainees line up in order of seniority and await Prof Wederâ€™s prompt arrival. A handover of cases from the weekend and the patients in ICU are discussed with a review of their imaging, before a ward round of ICU. Thereafter the team splits into the various assigned duties. One of the striking differences between Zurich and home was the amount of staff,
both surgeons and support staff. Indeed, even the wards seemed to have high nursing numbers by our own standards. Theatre was efficient and ran like clockwork, unsurprising in a country renowned for time keeping. There was also a large compliment of anaesthetic staff and it was admirable how the anaesthetists and theatre healthcare assistants positioned the patients perfectly in the anaesthetic room after induction, enabling quick transfer by virtue of a fixed operating table base with changeable operating tables. The case mix was varied and extremely interesting. As expected from a quarternary referral centre, there was a regular flow of
“As expected from the first world centre to perform a thorascopic lung volume reduction surgery (LVRS), the vast majority of cases were performed thorascopically and there were a significant number of LVRS cases.” more complex empyema’s from outside centres. At my stage of training I am particularly interested in gaining further experience in more complex clinical cases. Consequently I was grateful to have the opportunity to discuss and see first hand Prof Weder’s documented technique for managing post-pneumonectomy emyema’s, with and without a bronchopleural fistula1. The results were excellent and provide an additional option in my management armamentarium. The elective cases included robotic-assisted and VATS anatomical lung resections, metastectomies, and management of mesothelioma including extended pleurectomy / decortication. An interesting element of this surgery was the diaphragmatic resection with preservation of the peritoneal integrity, use of a Gortex membrane to reconstruct the diaphragm, and placement of a Pleur-X indwelling drain in addition to the standard chest drains to enable longer term management of the expected prolonged airleak without the need for conventional long-term drainage. I have a keen interest in roboticassisted thoracic surgery and this visit presented an ideal opportunity to develop an understanding of the various issues with running the program. The unit has access to the da Vinci Xi robot one day per week and the dual console provides the opportunity for teaching. This is currently an evolving and expanding area of thoracic surgical practice in both Ireland and the UK with applications primarily in anatomical lung resections, perhaps most notably with the likely increase in segmentectomies. The advantages with resection of mediastinal masses are undoubted. As expected from the first world centre to perform a thorascopic lung volume reduction surgery (LVRS), the vast majority of cases were performed thorascopically
and there were a significant number of LVRS cases. It was very interesting to gain an understanding of Prof Weder’s concept around target areas, quantity of lung parenchyma in terms of volume rather than quantity, and surgical technique to try to create a domed or curved resection margin. I was also very interested in the general approach to post-operative air-leaks which was in contrast to the “ride-it-out” approach at home – these were not tolerated for long and there was a prompt return to theatre for cases with ongoing leaks. During my visit I also had the opportunity to visit the research laboratory that is conveniently located directly under the thoracic surgery department. A wellresourced facility with very friendly and dedicated staff, I saw an experiment involving the placement of ischaemic porcine lungs on EVLP (Ex-vivo lung perfusion) before implantation into a donor pig. I remained on call during my time in Zurich for a lung transplantation retrieval or implantation, and as it happened there was a re-do double lung transplant towards the end of my stay. A 46-year-old lady with Cystic Fibrosis and previous double lung transplantation 10 years
ago, complicated 6 years later with a right upper lobectomy for NSCLC, re-presented on LTOT with poor PFTs. The case proceeded on ECMO assist via a clamp-shell incision and a difficult right-sided explant ensued. However, after a long night and an unusual intra-operative complication that was likely related to ECMO use, the case concluded successfully. Logistically, Zurich is well served by major airlines. The administrative staff at the department (Michael Linggi and Denise Hagg) were a pleasure to deal with and coordinated my visit in conjunction with Prof Opitz-Schmitt. This was a self- funded visit that I organised following previous discussions with Prof Opitz- Schmitt regarding a difficult case referral. During my stay, Alessia was exceptional in looking after any daily issues. I elected to stay in the hospital accommodation as it was nearby (a 5-minute walk to the department) and more reasonably priced. The general cost of living in Zurich is expensive and the room in Ballystrasse 45 was exceptional by home standards. Overall, I cannot compliment the surgical staff in Zurich highly enough. They were extremely welcoming, engaging, friendly and keen to teach, and were very kind in translating the many case discussions from German to English for my benefit. Prof Weder leads a dedicated team and I am very grateful for having had the opportunity to learn a number of techniques and ‘pearls-ofwisdom’ that I can incorporate into my own practice as well as having the opportunity to form new friendships. n 1) Schneiter D, Grodzki T, Lardinois D, Kestenholz PB, Wojcik J, Kubisa B, Pierog J, Weder W. Accelerated treatment of postpneumonectomy empyema: a binational long-‐term study. J Thorac Cardiovasc Surg 2008; 136(1): 179 – 85 University Hospital Zurich foyer (courtesy of University Hospital Zurich)
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“Every day is my birthday” Born 8th October 1945, Frank Hames is believed to be the longest surviving by-pass patient in the world (apparently)...
hen I left school in 1960, I was a super fit, keen sportsman, a member of the T.A. and looking forward to qualifying as an HNC certified engineer. Unfortunately, following an accident at work in 1964, I suffered an injury to my knee incurring several operations which curtailed my ambitions. I then followed advice seeking work as a medical laboratory technician. In 1974 I was advised that a position for a mortuary technician was available at the National Heart Hospital in London, and despite concerns regarding my disability, I proved that was capable of performing the duties required. I had found my niche taking the opportunity to enroll and excel in a number of courses As stated, other than a double laminectomy operation due to damaging the spine by way of my postural gait, I was super fit and used by the National Heart Hospital as a normal control for ECG, Echo and bloods. As by-pass surgery was still a comparatively new procedure in those days, there was unfortunately a fairly high mortality rate. At Post Mortem of the failed cases, after examination by the pathologist, I would inject both the native coronary arteries and the grafts with a radio opaque medium and X-Ray them accordingly for examination by the surgeons before returning the heart to the body. I had just finished such a procedure and returned to the Histology Lab when
I was aware that something was going wrong with my own heart and the next thing I remember is waking up in the Coronary Care Unit in my own hospital and being informed that I had suffered a Myocardial Infarction. I was informed that I would be having an angiogram the following morning. I was 31 years old, had a young family, never had any symptoms and no family history of heart disease. To say I was shocked was an understatement! Following the angiogram Donald Ross came up to the CCU to inform me that by-pass surgery was the only option and surgery would be performed two days before Christmas in 1976. Recovery was slow, but I returned to work after about six weeks and needless to say, the first Post Mortem I was involved in was on a patient with whom I had become friendly during my stay in the National Heart which was a trifle disconcerting. Although I wasn’t in any pain from the wounds, I was suffering a lot of chest pain and following several combinations of medication, it was eventually decided that surgery was once again the only option. I bounced back quite easily this time. Other than a few episodes of heart failure, infection of the wound in the leg and arrythmia, things were manageable. In 1978 I was offered the position of Higher Senior Technician comprising a lot of forensic work at Wexham Park Hospital which meant I would be involved in more varied cases. My condition once again deteriorated and following several unpleasant episodes
requiring admission to hospital, a decision to explore the possibility of a heart transplant was put forward. I was going downhill rapidly and following discussions with Alan Wolpowitz, Donald Ross and Magdi Yacoub regarding the prognosis following transplantation, things were so bad that a third by-pass operation had to be attempted, or I was unlikely to survive. Once again, I bounced back but, unfortunately, because of the amount of time I had spent in hospital, a decision was made to retire me on medical grounds. Fortunately, I had a lot of contacts in the Forensic and Funeral fields and was offered a position as an embalmer with the company appointed as the Royal Family Undertakers. I took the decision to work for them initially on a freelance basis whilst still being involved with my Forensic work. This allowed me to work with Home Office Pathologists such as Ian West, Kevin Lee, others on national disasters such as Kings Cross, Seer Green, Marchioness and several murders. Once again things went downhill. I was experiencing regular episodes of AF culminating in a couple of TIAs in 1986. Several attempts to rectify the symptoms with medication failed and I was informed I would be on Warfarin for life. Eventually I decided to purchase a funeral business as a freelance embalmer. The business grew rapidly but once again fate took it’s inevitable hand. With my own work load increasing beyond belief, something had to give. I was once again
“The next thing I remember is waking up in The Coronary Care Unit in my own hospital and being informed that I had suffered a Myocardial Infarction... I was 31 years old, had a young family, never had any symptoms and no family history of heart disease. To say I was shocked was an understatement!” referred to Kim Fox who managed to control the symptoms for a while but there was further deterioration. Following further diagnostics, I was referred to John Pepper to consider further by-pass surgery. Unfortunately, surgery was cancelled several times and despite several letters and phone calls, nothing appeared to be happening. Eventually the fourth by-pass operation involving Internal Mammary Artery grafts was performed at the Brompton Hospital in 1992. Despite everyone’s trepidations and fears, it proved to be the easiest of the four procedures. I returned to work ten days after the operation and employed a driver to ferry me between appointments until I was fit enough to drive myself. Things went well until the late nineties when breathing problems, AF and Angina became troublesome once more. I was referred to Adrian Banning at the John Radcliffe Oxford Heart Centre who discovered on examination that not only was I in persistent AF, I had Mitral Valve Regurgitation. The condition was monitored for a couple of years but gradually deteriorated despite several attempts at modifying the medication. Adrian Banning referred me back to John Pepper at the Brompton to consider a mitral valve transplant as it was felt I would not survive further surgery. It was decided to refer me to the Hammersmith Hospital under the care of Mike Bellamy for consideration for the
research programme of mitral valve repair to still be here and on borrowed time. But using clips. Should things go wrong during at this moment, I have neither the time or this procedure, I was assured a full cardiac inclination to depart this beautiful world team were on standby to attempt a valve and shall continue to treat every day as my transplant. The Mitral Valve clips were birthday and perhaps help others to come inserted in 2009 and immediately improved to terms with their condition, and not be my breathing, but not my pitting oedema. frightened to seek help when required Following a lengthy stay in the John form the wonderful people out there who Radcliffe due to heart failure and AF, a are skilled in their own particular field of decision was made to apply to NICE for medicine and there when we need them. n consideration of the fitting of an CRTD. This was approved and the defibrillator was fitted in late 2009. Things went relatively well but my kidneys began to fail. I was diagnosed with CRD and renal anemia. Eventually I Congratulations to those mentioned below: was started on self-administered EPO injections and other than Executive Committee: occasional blood transfusions and Mubarak (Mobi) Chaudhry – Elected Trustee iron infusions, the kidney is not Carin Van Doorn – Elected Trustee too bad. I have had to have three Adult Cardiac Committee: ablations including AV node, Chris Satur multiple cardio-versions and a Stephen Billing spell of living with an external Shakil Farid pacemaker and a life vest which had to be removed following an Thoracic Committee: admission for heart failure after Steve Woolley two days of freedom. I am now on Kandadai Rammohan my third defibrillator and things Babu Naidu are not too .bad at the moment. I obviously am very closely Congenital Cardiac Committee: monitored and have since been Rafael Guerrero diagnosed with Tricuspid Valve Andrew (Chuck) McLean Regurgitation which is not a real Andrew Parry problem at this moment. I am however aware that I am fortunate
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The Cardiac Surgical Site Infection (SSI) Network Meeting Christina Bannister, Patient Lead – Nursing & AHP Committee
ith my role as patient lead on the Nursing & AHP committee I attended the Bi-Annual Cardiac SSI Network Meeting. The London-based meetings offer roundtable discussions of adult and paediatric cardiac SSI, and presentations are a mix of case-studies, innovation, trends and SSI surveillance topics. The Cardiac SSI Network Aims are: To create, through collaboration, a central online resource focused on cardiac SSI reduction and dedicated to sharing frontline examples of improving patient experience, safety and outcomes; l
To promote cardiac services as a leading discipline for innovation and spread of initiatives to reduce SSI; l
To share learning from frontline examples, encouraging efficient and effective surveillance in SSI reduction; l
To develop a multidisciplinary network and collaborative approach for adult and paediatric cardiac surgical and cardiology invasive devices to reduce the incidence of infection. l
The group was set up in 2013 with Melissa Rochon, Royal Brompton & Harefield NHS Foundation Trust; Philippa Clark, Royal Papworth Hospital NHS Foundation Trust and Martin Still, Brighton & Sussex University Hospitals NHS Trust and has developed over the years to include nurses and AHP’s from both adult and paediatric backgrounds from across UK centres. Members of the group have presented at the SCTS annual meeting and have won, on differing occasions, both the best presentation award (Preliminary Findings: Targeting CABG patients at high risk of
surgical site infection in 2015) and the best poster award (Does the Photo at Discharge (PaD) Reduce Readmissions for Surgical Site Infections? Learning From Two Large Cardiothoracic Centres in 2016). In addition to presenting at the SCTS annual meeting, members have presented at EACTS and also a myriad of infection prevention conferences across the UK. The co-founders have been Awarded Best Abstract, Wounds UK Excellence Award, 2017 for their paper entitled ‘That Doesn’t Need Another Swab!’: Protecting Surgical Wounds From Routine and Ritualised MC&S Sampling; and a Patient Safety Award 2017 for Best Public Product /Innovation – the BHIS bra, support wear for females following cardiac surgery as well as a Patient Safety Award 2017 and OneTogether gold medal 2017 for the Photo at Discharge. The SSI Network website includes videos for patients and professionals, which can be requested to be placed on individual Trust’s websites. In 2018, NICE endorsed the
video series, which is also used in the patient section of the SCTS/ BUPA website. There are national surveys, and both adult CABG and paediatric cardiac SSI rates; and useful links to other websites. There is an online forum where members can pose queries to others as well as projects to reduce SSI, such as University Hospitals Bristol’s work to reduce SSI with negative pressure wound therapy pathway, or Guy’s and St Thomas’ multidisciplinary team approach to reducing and maintaining low rates. The Cardiac SSI Network actively supports the SCTS CIRN SSI project and is sponsoring SCTS Nursing & AHP memberships for five network members to take part. The next Cardiac SSI meeting was hosted by St Bartholomew’s Hospital in December. It was a great opportunity for sharing projects, networking as well as looking towards further innovations and working together in 2019. n
Andrew Thomas Forsyth 5th June 1945 – 23rd November 2017 Uday Trivedi
ndy was born in East Melbourne into a medical family. His father was a respiratory physician and his mother a nursing sister. He was the eldest of four children and the only son. In his youth, he was a keen sportsman and had to be dissuaded from becoming a professional Australian Rules Football player. He qualified from Austin Hospital Medical School (Melbourne) in 1970, having been in that institution’s first intake of medical students. He began his early surgical training in Melbourne and it was here that he married his first wife with whom he had two children. He trained first in general surgery and then as a cardiac surgical registrar at St. Vincent’s Hospital and the Royal Children’s Hospital, Melbourne. In 1979 he and his family moved to England to continue his specialist training (having told his mother he would only be gone for 6 months!). His first appointment was at the Royal Brompton Hospital as a senior house officer. During this time, he taught his seniors a few surgical tricks and for a short period ran his own lists. Within six months he was made a registrar and over the next two years he worked at Brompton, Harefield and the National Heart Hospitals. In 1982 he was appointed to King’s College Hospital as a consultant where he committed himself to his two professional passions – arterial grafting and data
collection. He had a strong belief in the long-term patency of arterial conduits and this was reflected in his practice. In addition to using both internal thoracic arteries, he also routinely used the gastroepiploic artery and radial arteries. He was not the only Australian to hold these views, but he was the first cardiac surgeon in England to perform total arterial revascularisation for his patients and he encouraged his colleagues and trainees to do the same. From a trainee’s perspective, King’s became the place to go to learn arterial grafting. Andy’s interest in data collection stemmed from his view that no surgeon should operate on patients and not know the long-term outcome. With the help of his son, who was a teenager at the time, he developed the first comprehensive cardiac surgical database in 1988 and by 1990 this dataset had been incorporated into the newly available PATS software. It was this dataset which was used to form and develop the first national dataset for our speciality In 1999 he opened the Sussex Cardiac Centre in Brighton. Many years of planning had gone into this and it wasn’t viewed favourably by everyone. However, he stuck with his view of providing a local service for the people of Sussex. He moved down to Sussex with Ruth (whom he married in 1989), appointed the staff and performed the first operation in June 1999.
From 1999 till his retirement, Andy oversaw the maturation of the Sussex Cardiac Centre into a functional tertiary centre and an early adopter of many new innovations in adult cardiac surgery. He created a sense of belonging for everyone who worked with him and close co-operation between surgeons and cardiologists which continues to this day. He was an excellent trainer and many surgeons from all over the world trained under him. He provided both technical and pastoral mentorship and gave juniors the confidence to make their own decisions. Following his retirement in 2006 he continued to work in the unit ensuring that the database was maintained accurately with full clinical oversight. He remained a visible figure throughout the unit and keen to keep abreast of everything and everyone in the unit. Outside work he was a keen sailor, and along with Ruth he sailed his boat ‘Bye-Pass’ at every opportunity he could. He never lost his enthusiasm for sport and delighted in Australian victories. He always felt a close affinity to Scotland and he had started planning a move to Fife. He and Ruth bought a house in Belbo Craigs, near St. Andrews and it was here that he spent his final months surrounded by his family. Andy is survived by his children and two grandchildren. He died from metastatic renal carcinoma whilst looking out at the view that he had always wanted. n
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Set by Samer Nashef
Spare pen, round container ( 6)
Hand is extremely painful when involved in a break (8)
Protest the conclusion of county court order (6)
Joint for 18 in meat casserole (8)
12/3 John “hot stuff” Major finally embraced in play (8) 13
County in real trouble needs money invested (10) Chef finally cooked spinach dish as traditional fare (4,3,5)
18 Worry about red nails stirring lust (6,6) 21 Accent for artery (10) 22
This artistic skill you acquire at the end (4)
Indeed, if an objection is backed, it must be genuine (4,4)
Stretched out, a thousand dance topless (6)
Hunger means you start making money (8)
Sticker sample (6)
Appropriate way up in department store (8)
Please email solutions by 31/03/19 to:
Not being passive as victim is abused (8)
firstname.lastname@example.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE
See 12 Across
One who’s covered treatment of poorly child having
taken ecstasy (12)
Cobbler tools part of shoe for a special function (4,6)
Owing a little money in international assistance (6)
One in three’s poor as an alternative (6)
Temptation took place here in PM’s backyard (6,2,4)
Jazz and a cake for the street urchin (10)
The first successful solution received will win either a bottle of champagne or fine olive oil. Congratulations to Jonathan Hyde for winning the August 2018 bulletin crossword competition (right) for which he received a bottle of champagne.
Correction: The August 2018 edition of the bulletin included an obituary for Andy Forsyth with Roger Franks cited as author. In fact, the author of this piece was Uday Trivedi and apologies are offered for this error. Please find the article reprinted on page 72 with the correct author.
Barking mad pilot said “go to hell” and you look
forward to the trip (8)
Big beast, if he is drawn to light (8)
With rough coverage from, say, BBC broadcast (6)
Brainboxes with firsts in cardiology, radiology &
anatomy (not in astrophysics) (6)
Bias from the foremost of show gardens (4)
Correction: The August 2018 edition of the bulletin included an article titled “Measuring outcomes in Congenital Heart Disease”. The article had a misspelling of the author name - credited as Marisa Gambarini. Apologies for the misspelling, it should be Marisa Gasparini.
BICARBONÂŽ AORTIC VALVES
Less is more SAFER WITH LESS ANTICOAGULATION Bicarbon Aortic valves are the only mechanical prostheses in the market backed by an indipendent randomized clinical trial which has demonstrated the safety and feasibility of a lower INR* regimen of 1.5 to 2.5 without the addition of aspirin, in low-risk patients** undergoing isolated aortic valve implantation. * Reduced INR applicable starting soon after aortic valve replacement. Stable control of the INR as per clinical practice should be performed ** Low INR not applicable to patients undergoing multiple valve replacement or at high risk of thromboembolic events (e.g. atrial fibrillation, history of cardiac thromboembolism,etc.).
TRIFECTA™ GT VALVE CLEVELAND CLINIC STUDY:
HEMODYNAMICS DETERMINE VALVE DURABILITY
• Increased PPM and higher gradients at implantation linked to valve deterioration and explant, especially in younger patients • To maximize durability, optimize hemodynamics
“Our data suggest that strategies aimed at minimizing early postoperative gradients, such as use of valves with better effective orifice area…may be warranted…” – Johnston et al.1
1. Johnston DR, Soltesz EG, Vakil N, et al. Long-term durability of bioprosthetic aortic valves: implications from 12,569 implants. Ann Thorac Surg. 2015 Abbott Vascular International BVBA Park Lane, Culliganlaan 2b, 1831 Diegem, Belgium Products 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), at eifu.abbottvascular.com or at manuals.sjm.com for more detailed information on Indications, Contraindications, Warnings, Precautions and Adverse Events. Photo(s) on file at Abbott. Information contained herein is for distribution for Europe, Middle East and Africa ONLY. Please check the regulatory status of the device before distribution in areas where CE marking is not the regulation in force. For more information, visit our website at www.abbott.com All products herein are trademarks of the Abbott Group of Companies. © 2018 Abbott. All Rights Reserved. 9-EH-3-7744-01 03-2018