Society for Cardiothoracic Surgery in Great Britain and Ireland
Justice must be blind to race, colour, religion and species
Heart Surgery PSPâ€™s Could you be guilty of Gross Cadaveric simulation â€“ top 10 priorities p28 Negligence Manslaughter? p36 the way of the future? p48
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In this issue... 5 8 11
Society for Cardiothoracic Surgery in Great Britain and Ireland
From the Editor Indu Deglurkar
From the President Richard Page Behind the scenes of the SCTS Narain Moorjani
Nursing and Allied Health Professional update Helen Munday
84th Annual SCTS meeting and Ionescu University, ICC Wales
17 SAC report Rajesh Shah 33rd EACTS Meeting, Nurses & 20 Allied Health Professionals Day
Thoracic surgery audit update Doug West
23 New Consultant Appointments SCTS Education report 24 Sri Rathinam 26
SCTS Education tutors’ report
Carol Tan, Sunil K Bhudia
SCTS AHP Education portfolio Tara Bartley Bhuvana Krishnamoorthy
Aortic Dissection Awareness Day 40 UK 2019 in pictures
Openness, honesty and intellectual 42 responsibility Antony Walker The all-female cardiac surgery team 44 Joy Edlin The SCTS Grant Writing 45 Workshop Marius Roman
Thiel Cadavers for Training in NEW Minimally Invasive Surgical Aortic Valve Replacement (SAVR) Techniques Fraser W H Sutherland
SAS doctors and clinical fellow satisfaction with Cardiothoracic training and career progression in the UK
Anas Boulemden, Ahmed Abbas
Reflections on moving a hospital
David P Jenkins
The challenges for cardiac surgeons in the treatment of infective endocarditis in Persons Who Inject Drugs David O’Regan
I am a medical student interested 62 in cardiothoracic surgery.
When should I start preparing?
Jeremy Chan Amer Harky
SCTS-Ionescu nursing and allied health professional award 2019
The SCTS Education podcast 46 Caroline Toolan
Exploring innovative 64 approaches to Enhanced
WSCTS Meeting, Sofia, Bulgaria
Recovery Programmes (ERP)
Michelle Gibb, Jayne Sharman, Hayley Pike, Rebecca Boyles, Rebecca Halpin
Identifying Heart Surgery PSP’s 28 top 10 priorities Gavin Murphy
Cadaveric simulation - the way of 48 the future? Aleksandra Bartnik
New Cardiothoracic Curriculum: 29 A trainee’s perspective
SCTS-Ionescu 2020 Applications 66 for fellowships
6th International SCTS Student Engagement Day - November 2019
Cindy Cleto, Tom Eadington, Aman Coonar
SCTS: The Beginning
Could you be guilty of Gross Negligence Manslaughter (GNM)?
Society for Cardiothoracic Surgery in Great Britain and Ireland
SCTS, 5th Floor, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PE T: 020 7869 6893 E: email@example.com W: www.scts.org
Society for Cardiothoracic Surgery in Great Britain and Ireland Mentorship Scheme
My fellowship at Prince of 68 Wales Hospital, Hong Kong
Mahmoud Loubani Shyam Kolvekar
Post op Follow up after Lung Resection for Primary Lung Cancer: A SCTS National Survey Syed Qadri
Lung Transplantation: A very thoracic specialty ignored completely by UK Thoracic surgeons Muhammad Asghar Nawaz
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Cardiothoracic Interdisciplinary 69 Research Network (CIRN)
Luke J. Rogers, Ricky Vaja
Obituary: Edward (Ted) Thomas 71 Brackenbury Maziar Khorsandi
Letters to the Editor
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From the Editor Indu Deglurkar, Publishing Secretary, SCTS
“Justice must be blind to race, colour, religion and species.”
et another insightful year draws to a close. There is plenty to look back and reflect on the past with humility and tirelessly prepare for new beginnings and challenges. Self reflection is a great way to improve our emotional intelligence, confidence and decision making. In the President’s report, Richard Page discusses the new methodology of reporting results and the various activities of the SCTS. His glorious journey in attaining the highest office in the SCTS began when he was an elected trustee 20032006, led the Thoracic Audit from 2006-2014, was President Elect 201618 and has served as the President for the last two years. In addition, he has been an Examiner and assessor for the JCIE exam board from 2003-2016 and has been on the SAC since 2015. He passes the baton of responsibility and leadership to Simon Kendall in March 2020. I am sure the entire membership will join me in thanking Richard for leading us with such dedication, dignity and strengthening the Society significantly
and welcoming Simon Kendall, the incoming President and Rajesh Shah as the President Elect of SCTS. Members may have noticed that the cover page generally reflects the leading, thought provoking article in the Bulletin and every cover page has a story behind it. As per 2017 data, 288,521 Doctors were registered with the GMC. There were 8,546 complaints against Doctors Fitness to Practice (majority against BME Doctors) leading to 76 suspensions and 62 erasures from the register. In the last ten years, there have been 12 prosecutions for Gross Negligence & Manslaughter.
safety and improvement. Whilst accepting that it needed a “period of reflection”, an independent group chaired by Mr Leslie Hamilton reviewed the whole process that occurs after an unexpected death extensively and have made 29 recommendations. As always, we have excellent articles from the membership as Narain Moorjani de-mystifies the SCTS working groups, Duncan Steele explains the new curriculum and run through training of seven years starting in 2020. History is fascinating and Graham Cooper delves into the beginnings of the Society in 1933. The Mentorship Scheme Implementation Plan by the SCTS is a particularly commendable undertaking and we look forward to this. We are deeply humbled and would like to share the “high praise” that we have received from the innovator, scientist and educator Mr Marian Ionescu about “The Beautiful Bulletins.” Without a shadow of doubt, it is due to the contribution from the members of the Society. We have introduced a new Letters to the Editor section and encourage submissions to this as well as to the Candid Column. We have been inundated with the number of articles submitted but please do remember that scientific papers are not accepted for publication in the Bulletin. As always, your ideas to improve the Bulletin are very welcome. Happy Holidays & have a great New Year. Look forward to seeing you all at ICC Wales. n
“The NHS is an overstretched, under resourced, highly complex Institution and service delivery is a major challenge.”
The NHS is an overstretched, under resourced, highly complex Institution and service delivery is a major challenge. Serious or catastrophic harm is usually due to a culmination of several weaknesses and failure across systems, processes, equipment, resources, organisational culture and human error. The unprecedented outrage expressed by the medical profession over the handling of the Bawa-Garba case, which resulted in the verdict of gross negligence and manslaughter (GNM) and the appeal of the GMC for erasure of registration, has shaken the very roots of our foundation. Defensive medicine and fear of Could you be guilty of Gross Negligence Manslaughter (Page 36) punishment is toxic to both
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From the President Richard Page
s always there is lots happening within the SCTS. The latest annual round of publication of outcomes for patients undergoing cardiac and thoracic surgery within the UK and Ireland show that our services remain world-class. For adult cardiac surgery carried out between 2015 and 2018, all surgeons and Units are performing to a high standard and there were no outliers. Although the returns of data from Units to NICOR were completed on schedule, publication was significantly delayed due to the need for a comprehensive and detailed review of the methodology used
wisdom and common sense in negotiating this very complex and difficult area. NICOR (as with all NHS departments) continues to be beset by poor funding which limits its functionality, to the frustration of SCTS members who I know spend many hours inputting accurate clinical data which forms the basis for clinical audit projects such as the cardiovascular ones managed by NICOR. The SCTS continues to work hard to find flexible ways of working with the NICOR team to enable the data (which SCTS members have collected and therefore feel is very much ours!) to be used for the maximum benefit of patients.
â€œAortic Networks for dealing with acute and chronic aortic problems are developing. This will particularly benefit patients with acute aortic dissection, and should improve timely access to life-saving treatments.â€? for the detection of outliers. This was eventually completed in June 2019 and members will be aware that the newer Forrest Plots have replaced the more familiar Funnel Plots which have been in use for many years. Although I know that many will find the new methodology difficult to follow and perhaps not as helpful, the SCTS has been closely involved throughout the whole process and I am confident that the new methodology is indeed an improvement and is more sustainable going forward. I am particularly grateful to Uday Trivedi (who has recently taken over from David Jenkins as SCTS adult cardiac audit lead) for his
In September 2019, the newly constituted SCTS Board of Representatives (BORS) met at the College. In addition to many new members attending, each representative (of which there are over 60 throughout the UK and Ireland, when considering separate cardiac, thoracic and congenital services) provided a report on their Unitâ€™s activities which provided very rich evidence of a highly functional and energetic speciality and which we can all be proud of. There was much quality improvement work to commend and the presentations given at the meeting were of very high quality. I urge all SCTS members to engage with the BORS process via their
SCTS BORS representatives. During my term as President the opportunity to hear directly from colleagues as to what rewards and concerns them is the best feedback the SCTS can get about what is happening in our speciality, and allows the SCTS team to focus on what is most important to members. SCTS Educational activities continue to thrive. The organisation of courses and the management of the numerous SCTS-Ionescu Fellowships are run by the skilled and energetic team of Sri Rathinam, Carol Tan, Sunil Bhudia, Letty Mitchell and Emma Ferris. One should not underestimate the amount of work that this takes. But the end result is an internationally unprecedented portfolio of educational activities of the highest quality. I would be grateful if all colleagues could give the team as much help as possible especially by responding in a timely manner to their necessarily frequent e-mails. The budget for the courses (for which numerous consultant surgeon trainers provide their time free of charge) is tight, and I know that the most frustrating thing for the team is when consultants and trainees fail to acknowledge communications. The sub-speciality of thoracic aortic surgery has evolved over recent years with clear benefits for patients. Aortic Networks for dealing with acute and chronic aortic problems are developing. This will particularly benefit patients with acute aortic dissection, and should improve timely access to life-saving treatments. I hope that these Networks will prevent the terrible scenarios where hospitals receiving patients with aortic emergencies find it impossible to persuade tertiary cardiac centres to accept their duty of care, and who on >>
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the 10 bulletin
occasions have refused to arrange for a prompt transfer for non-clinical reasons. Nevertheless, much remains to be done to ensure that services are configured to provide the maximum benefit for patients. The UK Aortic Surgical Forum is the group which along with the SCTS can provide clinical leadership here and I urge all cardiac surgeons with any interest in aortic surgery to engage with the Forum. Significant credit should also go to the Aortic Dissection Awareness Group, a patient led organisation which has demonstrated, in a very short time, that it has the power and the energy to cut through the inertia and bureaucracy which can hamper changes in services. On the opposite side of our speciality general thoracic surgery goes from strength to strength. The UK VIOLET trail comparing VATS and open lobectomy for lung cancer has closed and the results are being reported, with clear benefits in favour of VATS surgery. This, along with the development of UK lung cancer screening programmes, means that the rapid expansion of thoracic surgery which has occurred over the last decade is set to continue for the foreseeable future. The separation of cardiac and thoracic services is now much more clearly defined and has benefited patients hugely. The saddest part of my duties as President is to be informed about colleagues in difficulty, especially newly appointed consultants. These surgeons have had the benefit of a top-class training and education and as such it is so disappointing to hear about their problems. These are complex and varied but the common theme is lack of proper support for them in their first few years of practice. The step-up from trainee to consultant is now the steepest learning curve in any surgeonâ€™s career and as such it needs careful handling. The Deaneries and other formal Educational organisations, including the cardiothoracic SAC, tend to assume their job is complete when a Certificate of Completion of Training is awarded, which is quite understandable given the challenges of training. The success or otherwise of newly-appointed consultants depends largely on the interactions with his/her clinical and non-clinical colleagues working in the same Unit. It is self-evident to those who have gone through the process that it takes many years to develop the required clinical and nonclinical skills for a successful surgical practice. This applies to all surgeons starting out on
â€œAt the March 2020 Annual Meeting we will be running our first SCTS Mentorship course and I invite all colleagues who are interested in being a mentor to attend.â€? their career as a consultant, regardless of their talents and qualities. Working in the NHS is very much a marathon rather than a sprint and the most successful surgeons are the long-distance experts. Nevertheless, without a good start, it can take many years to get back into what should be considered to be a journey rather than a race. It is clear that the SCTS can provide leadership in this difficult but very important area. At the March 2020 Annual Meeting we will be running our first SCTS Mentorship course and I invite all colleagues who are interested in being a mentor to attend. Our ambition is for all newly appointed consultant cardiothoracic surgeons to have an appropriately trained SCTS mentor allocated to them, to assist and advise them as necessary. Hopefully this will enable difficulties to be dealt with before they get out of hand, rather than being a potentially life-long problem for our colleagues to deal with. As President I attend numerous meetings with surgeons in specialities other than our own. On the majority of occasions I feel significant pride, bordering on smugness as to how well our speciality performs and I am pleased to share with you a piece of data which stood out recently. There is an NHS England
standard which states that patients admitted as emergencies should be reviewed by a consultant within 14 hours. Top of the list of all medical specialties with a score of 95.2% was intensive care (not surprisingly when you think about it), but I was delighted to see that cardiothoracic surgery was second with a score of 90.5%. This is testament to the hard work carried out by our colleagues around the country, of which we can all be proud of and which will be very reassuring for our patients. This will be my last Bulletin report as President and I am delighted to be replaced by Simon Kendall who will take over from me at the annual meeting in March 2020. Simon has been a pillar of support to me in my relatively short but rewarding journey on which I have had the honour to travel as your SCTS President and I know he will make an excellent leader for our speciality. He will have the support of a fantastic Executive and Administrative team, but most of all the vibrant, energetic and the hugely talented community of all those working in cardiothoracic surgery in the UK and Ireland. My best wishes to you all for the journey going forward. There is no better one to take than cardiothoracic surgery. n
Behind the scenes of the SCTS Narain Moorjani, Honorary Secretary
n the last in my series on the workings of the SCTS, this article aims to give members a better understanding on the infrastructure of the Society and how the SCTS functions. The Society has a number of aims, including continuously improving the quality of healthcare delivered for patients undergoing cardiothoracic surgery; supporting the education and professional development of cardiothoracic surgical practitioners; ensuring that regulation imposed on the practice of cardiothoracic surgery is fit for purpose; providing information and guidance on the practice of cardiothoracic surgery; and representing the specialty at a national and international level. In order to deliver these aims, the SCTS is organised into a number of subcommittees, with specific responsibilities. The sub-committees report in to the SCTS Executive Committee, which is ultimately accountable for the actions and strategic direction of the Society:
The main aim of the SCTS Executive is to provide leadership for the specialty of cardiothoracic surgery and to oversee the activities of the Society through its subcommittees, with ultimate aim of improving the quality of healthcare delivered for patients undergoing cardiothoracic surgery in Great Britain and Ireland. The Executive interacts and collaborates with a number of national bodies including the Department of Health (DoH), National Institute of Health and Clinical Excellence (NICE), General Medical Council (GMC) and Royal Colleges of Surgeons (RCS) to ensure that national policies pertaining to cardiothoracic surgery are appropriate for the specialty.
There are 11 full Members of the SCTS charity that sit on the Executive, including the President, President Elect, Honorary Secretary, Honorary Treasurer, Meeting Secretary and 6 Elected Trustees. In addition, others members are co-opted onto the Executive to ensure that there is a broad representation of the specialty, including the co-chairs of the sub-committees, chair of the Cardiothoracic Surgery Specialty Advisory Committee (SAC), chair of the Intercollegiate Cardiothoracic Surgery Exam Board, Lay Representative, Trainee Representative and Perfusion Representative. The Executive meets at least 4 times a year in person and presents its activities and pressing issues to the membership through the Annual Business Meeting and the Board of Representatives Meeting, where it is open to scrutiny and members have the opportunity to ask questions.
Adult Cardiac, Thoracic and Congenital Cardiac Surgery Sub-committees
The main aim of the 3 sub-specialty sub-committees is to provide a leadership role and to advise the SCTS membership regarding all aspects of the conduct and practice of its sub-specialty within Great Britain and Ireland. Examples include developing and disseminating examples of best practice and quality improvement projects, updating the SCTS website with contemporary guidelines, important recent publications and guidance for the introduction of new technology, and reviewing job descriptions for consultant appointments. Each of the sub-committees is also developing a video library of advanced operative techniques to provide quality assured demonstration of operations and procedures. To ensure that the SCTS is kept fully abreast of all the changes in the sub-
specialty, each sub-committee liaises with their respective Commissioning Groups, Service Specification Review Groups and other relevant national bodies, such as the British Cardiac Society (BCS), British Thoracic Society (BTS) and British Congenital Cardiac Association (BCCA).
The main aim of the audit sub-committee is to oversee cardiothoracic surgical data collection, analysis and presentation, and to provide advice on the strategic direction the SCTS should take in monitoring cardiothoracic surgical outcomes. This includes exploring the opportunities to extend the range of outcome measures analysed and developing academic aspects of outcomes analysis in cardiothoracic surgery. To achieve this, the audit sub-committee works in close collaboration with the National Institute for Cardiovascular Outcomes Research (NICOR), National Lung Cancer Audit (NLCA) Executive, Healthcare Quality Improvement Partnership (HQIP) and other external bodies related to cardiothoracic surgical audit. The sub-committee also produces the â€˜Blue Bookâ€™ series of outcome data analysis and maintain the audit section of the SCTS website updated with contemporary information and resources, including outcome data. In line with this, they have also developed an individual and unit outlier management programme, which includes reviewing the methodology of detecting outliers, identifying lessons learnt in dealing with previous outliers and a policy for contacting outliers.
The main aim of the education subcommittee is to develop and promote an objectively managed programme of continuing professional development for SCTS members and to provide advice on the strategic direction the SCTS should >>
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“The Society represents a professional body run by cardiothoracic surgical practitioners working together principally to support its members to continually improve the quality care delivered to patients undergoing cardiothoracic surgery.” take to support and promote cardiothoracic surgical training and education. Examples include designing and delivering an education and training programme for all SCTS members; developing strategies to increase the teaching and training skills of SCTS members (faculty development); developing a portfolio of education and training fellowships; conducting evaluation of the quality of internal and external training courses (accreditation); and securing funding for the delivery of the educational programmes through negotiations with industry and other external bodies. In addition, the sub-committee is responsible for maintaining the education section of the SCTS website, updated with contemporary information and educational resources for all SCTS members to access. The Education sub-committee also works very closely with the Cardiothoracic Surgery Specialty Advisory Committee (SAC) to improve and quality assure cardiothoracic surgical training.
The main aim of the research subcommittee is to promote research opportunities for all SCTS members, and to provide advice on the strategic direction the SCTS should take to support cardiothoracic surgical research. Examples include developing and supporting a network to deliver nationally coordinated cardiothoracic surgical research trials; working in close conjunction with the research department of the Royal College of Surgeons; developing strategies to increase the research skills of SCTS members; and maintaining the research section of the SCTS website updated with contemporary information and resources. The research sub-committee also organises the SCTS national cardiothoracic surgical research meeting,
which provides an opportunity for members to present and discuss their current research projects, and secure funding for the delivery of the research programmes and fellowships through negotiations with industry and other external bodies.
The main aim of the communications sub-committee is to maximise interactions between the SCTS Executive with its membership, external stakeholders and the general public. Examples include maintaining an up-to-date, informative and professional website with appropriate content; defining and implementing the Society’s strategic approach to social media; producing and distributing the SCTS Bulletin publication twice a year; producing and promoting high quality reference information (videos and written information) regarding all aspects of cardiothoracic surgery for both patients and healthcare professionals; liaising with patient groups to ensure that the SCTS provides information in an optimal format for the general public to access; promoting and advertising important cardiothoracic surgery events, including professional meetings, conferences and educational courses; and interacting with industry to optimise the support and sponsorship of SCTS-led educational, research and audit projects.
Nursing and Allied Health Professionals Sub-committee
The main aim of the nursing and allied health professionals’ sub-committee is to support all non-medical practitioners involved in the care of patients undergoing cardiothoracic surgery. Examples include designing and delivering an education and training
programme for all nurses and allied health professionals; developing a portfolio of education and training fellowships; developing and supporting a network of nurses and allied health professionals to deliver nationally coordinated cardiothoracic surgical research trials and developing strategies to increase the research skills of its practitioners. The sub-committee is also responsible for maintaining the Nursing and Allied Health Professionals section of the SCTS website updated with contemporary information and educational resources. In addition, there is the Meetings Sub-committee, which is primarily responsible for organising, delivering and financing the SCTS Annual Meeting, and the Professional Standards SubCommittee, which deals with non-clinical matters related to the specialty. Moving forward, we are in the process of setting up a Charitable Missions Working Group, with the aim to share knowledge from those who already have vast experience in this field and also to provide a platform for those keen in getting involved in or developing such a venture. As well as the SCTS Executive and Sub-committees, the SCTS Administrative staff (Senior Administrator, Finance Officer and Educational Administrators) are integral to ensure the smooth running of the Society and its activities. In summary, the Society represents a professional body run by cardiothoracic surgical practitioners working together principally to support its members to continually improve the quality care delivered to patients undergoing cardiothoracic surgery and the SCTS is eternally grateful to all who contribute to this process. n
the 14 bulletin
Nursing and Allied Health Professional update Helen Munday, SCTS Nursing and AHP Representative
t’s hard to believe that another six months have gone by and the next Bulletin is due. By the time this issue lands on your doorstep, we will have had a general election, we will know who the next Prime Minister is and we will see if the NHS remains the government’s top domestic priority. Let’s hope we can all look forward to some stability and investment for this fabulous institution that is our national health service. Despite the political shenanigans of the last year, there is much to feel positive about as we reflect on the latter part of 2019 and move into the new year. The Royal College of Surgeons of Edinburgh (RCSEd) and the Federation of Surgical Specialty Association (FSSA) continue to show their support for surgical care practitioners (SCP) with a letter sent earlier in the summer to the Secretary of State for Health and Social Care, calling for statutory regulation with common education and training pathways – something that SCPs have long been asking for. The pressure on the government is mounting for this to happen and I am hopeful that we will see this resolved in 2020. The President of the Association of Cardiothoracic Surgical Care Practitioners, Dr Bhuvana Krishnamoorthy, has been pivotal in canvassing her colleagues and keeping this matter high on the agenda. The first annual meeting for cardiothoracic SCPs was held on 24th November 2019 at the Abbott Medical Teaching Facility in Solihull; more about that in the next issue. The 17th September is a date which from this year, it is hoped, will become synonymous in healthcare with World Patient Safety Day after the World Health Assembly endorsed its introduction. The idea of this global campaign is to create awareness of patient safety and encourage a global approach to making healthcare safer.
Social media provided a great platform for Trusts to share their work and ideas and I’m sure there is much we will learn from each other as this initiative gathers pace. Allied Health Professionals (AHPs) celebrated their second National AHP Day on 14th October. There are a staggering 14 different roles under the AHP umbrella, with AHPs making up the second largest healthcare workforce. AHPs are integral to multi-disciplinary team working and make a significant contribution to care delivery. We have had some fantastic presentations from cardiothoracic AHPs at the annual meeting over the years, and it is really encouraging to see growing membership to the SCTS from AHPs. Speaking of the annual meeting, preparations are well under way for Wales 2020 and planning of the CT Forum is happening as I write, under the watchful eye of Daisy Sandeman. Daisy and the meeting team have already made several trips to the ICC Wales venue set amongst glorious Welsh woodland I’m told. It sounds spectacular and a fantastic choice for our next meeting. I am very grateful to Daisy for all her hard work in putting the Forum together and for providing the following update: “So to Cardiff, 21st March – 24th March 2020…… rather than the proverbial kicking the meeting off with a football tournament, we are clearing the winter cobwebs with a 5km run on Saturday 21st March, at 4p.m. The Society will donate £10 for every participating runner and all the proceeds will go to the local charity ‘Welsh Hearts’. So you can walk it, jog it or beat your personal best …... it’s all for fun and a great cause!! Sunday is the SCTS-Ionescu University day organised by Tara Bartley and Bhuvana Krishnamoorthy, offering a variety of hands on skills stations and
wetlab areas where delegates can interact and practice a host of procedures. This informative, educational day is open to all, but nurses and allied health professionals are our target audience. This year, for the first time, we will also be running a research workshop to run concurrently during the university day. This is being facilitated by Professor Julie Sanders and will be planned around ideas generated from the SCTS National Research meeting, which was held in Leicester in November 2019. The two day CT Forum begins on Monday and we have some inspirational invited speakers who will be sharing some of their work and observations with us on the following topics: • Changing Faces - Nursing and AHP roles in the modern NHS • Communication challenges - Media blessing or Curse? • Post operative Delirium We also look forward to hearing from the SCTS-Ionescu Fellowship award winners about their travels and experiences and of course hearing from colleagues who have been successful in having their abstracts accepted for presentation. The annual dinner will be held at The Exchange Hotel which is a historic venue in Cardiff and the theme this year is – The Great Gatsby! Naturally we could not be in Wales without some singing, so we are promised a Welsh Choir at some stage during the meeting!”
Research Nursing and Allied Health Professional Research Group (NARG) As mentioned above, in response to feedback from the annual meeting last year, there will be a research workshop during >>
Gatsby themed evening. Ticket includes Welcome Drink, 3 Course Meal, Entertainment and Transport 7pm - 1am Tickets ÂŁ65.00 each Dress code: Black Tie or 1920s Gatsby Tickets can be purchased online when registering for the SCTS Annual Meeting Location The Exchange Hotel The Exchange Building Mount Stuart Square Cardiff CF10 5FQ
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the university day on the Sunday, rather than trying to fit it into the main meeting. Last year, delegates felt disadvantaged by having competing sessions timetabled so we hope this approach will be more favourable. All associate members of the SCTS are invited to join the NARG, led by Professor Julie Sanders (SCTS Nursing & AHP Research Lead). Its purpose is to support the development of nursing and AHP-led research, share expertise and highlight research and funding opportunities. There is a dedicated webpage (https://scts.org. narg/) for SCTS members to access a research support directory and an emerging resource library. Cardiothoracic Interdisciplinary Research Network (CIRN) This research network was set up last year by the SCTS Research Sub-Committee and is led by Professor Julie Sanders, Luke Rogers and Ricky Vaja (RCS Associate Surgical
Specialty Leads). The CIRN aims to have a member in each cardiothoracic surgical unit in the UK, with a remit to deliver a portfolio of multi-centre clinical trials, the first of which is to focus on surgical site infections. Findings from the initial survey to identify variation in practice will be presented at the annual meeting with a discussion about the next stage of the project. Work is ongoing with the West Midlands Research Collaborative to finalise Associate PI status for nurses and AHPs (and junior doctors) on CIRN trials. 3rd SCTS National Research Meeting: Glenfield Hospital Leicester, LE3 9QP This meeting took place on 2nd November 2019, on the cusp of the deadline for Bulletin submissions, so there will be more about this event in the next issue. Outstanding Royal Papworth Hospital Finally, I would just like to add my heartfelt
congratulations to friends and colleagues at Royal Papworth Hospital for their clean sweep “outstanding CQC report”. This was a phenomenal achievement, especially coming so soon after the move to the new hospital. I very much hope that we will hear more about the move and their CQC report, possibly at the annual meeting, as there is already a lot of interest! You’ve set the bar high Papworth!! n For more details about any of the above, or for more information about the SCTS, please do not hesitate to contact me, details below. Helen Munday Matron - CT Surgery & Respiratory Medicine Barts Health NHS Trust Direct Line: 0203 465 6503 Mobile (Work): 07810 655 358 Email: firstname.lastname@example.org
84th Annual SCTS Meeting and Ionescu University, ICC Wales Maninder Kalkat, SCTS Organising Committee
he 84th Annual SCTS and CT Forum meeting will be held at ICC Wales from 22nd to 24th March, 2020. The ICC Wales is a new and exciting convention centre located at the famous Celtic Manor resort. The rooms are spacious, with magnificent views of nature outside through large glass walls and the venue is well connected by road, rail and air. As in the past, Sunday will host the SCTS-Ionescu University, CT forum Wetlab and Students’ Engagement events. The main meeting, scheduled for Monday and Tuesday, will include joint plenary and individual sessions with themes covering new techniques, updates and controversies in Cardiothoracic surgery. The programme committee is in the process of allocating various lectures to the experienced and learned faculty from all over the world. This meeting will give an excellent opportunity to interact
with these experts, get educated and further share experiences. The conference dinner is always a sell out and the Great Gatsby themed event at the historical Exchange Hotel in Cardiff at the 2020 meeting will provide a memorable evening of entertainment and fun. The sprawling lush green surroundings of Celtic Manor Resort motivated us to organise the first SCTS 5K charity run on Saturday, 21st March starting at 16:00; a pair of trainers is all that will be required for participation, limited to first 50 entries. We welcome any suggestions and ideas from members to make our meeting
a great educational and professional development event. Look out for the registration process which opened on 1st December 2019 and don’t miss the early bird rates. And book accommodation now. We look forward to seeing you and members of your wider team at the ICC Wales in March 2020. n
SAC report Rajesh Shah, SAC Chair Cardiothoracic Surgery
n December 2019, I will finish my 3-year term as chair of the SAC. I am grateful for the opportunity to serve, and have to say this is one of the best jobs I have done. I had the support of a fantastic team of SAC colleagues / trainee representatives and as I prepare to demit office, I wish to highlight what the team have achieved in the last 3 years. This was made possible by the support, energy, drive and enthusiasm of my SAC colleagues, programme directors, trainee reps, support of SCTS / JCST, trainees and trainers for which I am very grateful.
Achievements from 2016-19 with key colleagues who have led / contributed: l
Curriculum change: The GMC has approved the new curriculum which will go live in August 2020: Andrew Goodwin; Sion Barnard; Tim Jones; Steve Clark; Narain Moorjani; David Jenkins; JCST team; SAC team Development of strategy to address challenges of the new curriculum: Jonathan Hyde; Mike Lewis; Ehab Bishay; Ravi De Silva; Duncan Steele; Sri Rathinam; David Jenkins; Elizabeth Belcher
National Trainee Committee: Ahmed Al-Adhami; Jacob Chacko
Annual specialty reports / review of GMC / JCST surveys / QA reports: David Barron; Sarah Murray (Lay Representative)
SAC Review of ROI: Sion Barnard 2016/17 National selection 2017-19: Jonathan Hyde; Steve Tsui; Paul Sadler; Wessex deanery; programme directorâ€™s; SCTS members Measuring success of Congenital
Training Programme: David Barron l
Quality assurance report for National selection 2018-19: Pat Forsyth; Jonathan Hyde; Steve Tsui; Peter Hockey Quality assurance of Transplant fellowships including fellowship survey: Steve Clark
Review of ST1 Pilot: Marjan Jahangiri; Sarah Murray
SAC / SCTS Impact of Training on Quality of consultants: David Jenkins
Review of CCT guidelines including research: David Barron; Marjan Jahangiri
SCTS / SAC support system to address bullying: Richard Page
Influencing HEE on NTN numbers: Steve Tsui; Peter Hockey
Contributing to Credentialing Consultation: SAC team
Several members of SAC contributed to standard setting, question writing, FRCS (C/Th), international cardiothoracic exam
Review of success at consultant post by programme of the CCT holders in the last 10 years
Successful evaluation of CESR applications
Developing CCT check list: Sri Rathinam
SAC / SCTS Wire Skills survey: Sunil Ohri
Review of JCST Survey questions: Alan Soo
SAC / SCTS Workforce standards for units: Prakash Punjabi
Review of Exam pass rate / Exam structure for new curriculum: Mike Lewis
Stage specific operative skills requirement: Ehab Bishay
Measuring success of SAC / SCTS Education Curriculum aligned courses: Narain Moorjani; Sri Rathinam
Delivered operational aspects: Appointing leads. Vice chair, appraisal, LM reports, CESR
Measuring Success of Peri CCT transplant fellowship: Steve Clarke
SAC / SCTS Workforce Document: Prakash Punjabi; SAC team; SCTS Executive
Impact of training on Outcomes in Thoracic surgery SAC / SCTS project: Sri Rathinam; Doug West
Simulation survey: Sri Rathinam
Review of operative experience of CCT holders: Sunil Bhudia
HEE Review of North West Training Programme: Steve Tsui
Submission of Congenital Curriculum: Tim Jones
As one can see from the achievements above, the SAC team have been exceptional in their commitment to serve the training system. Whilst there are continued challenges to the implementation of the new curriculum, I am optimistic, positive and certain these can be delivered by the new chair Marjan Jahangiri with the support from the excellent SAC team. I wish to thank all SAC colleagues, Richard Page, SCTS executive, JCST administration, Gareth Griffiths JCST chair, Jon Lund ISCP director, Paul Sadler, and the trainee reps (Ahmad, Jacob, Abdul and Duncan) for their support, help and guidance in doing my job. n
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33rd EACTS Meeting, Nurses & Allied Health Professionals Day, Lisbon 5th October 2019 Tara Bartley, SCTS Allied Health Professional Education Lead
isbon is an amazing city and provided a fitting backdrop to the 33rd EACTS meeting. The Nursing and Allied Health Professionals day was both enjoyable and thought provoking, with lots of interaction from the delegates. We were privileged to have a significant number of abstract submissions and some excellent plenary presentations. Dr. Cibelli dazzled us with patient videos showcasing the true success of Loco-regional techniques. Having explained the technique and pathophysiology, we saw a number of patients reporting that they were pain free. An International, multidisciplinary team looked at the impact of an ERAS programme to improve patient tolerance of surgery. The session covered the key
components of a successful ERAS Cardiac Program, utilising a multidisciplinary team to implement evidence-based aspects of the ERAS Cardiac guidelines to standardise best practice. There was an engaging roundtable discussion with nurses, anesthesiologists, intensivists, and surgeons. Colleagues from Australia provided a Lung Ultrasound workshop that explored the benefit of Ultrasound in reducing exposure to radiology and early identifications of complications such as sternal instability, pneumothorax and pleural effusions. The practical session enabled delegates to put the skills discussed into action. Our final plenary presentation was given by two nurses who are part of a multidisciplinary team working with colleagues in Ghana to start a program of Cardiac Surgery. They shared the highlights and the struggles faced when new working practices are introduced without all the human and financial resources in place. We were delighted to receive an increased number of abstract submissions that provided a stimulating variety of subjects incorporating
â€œWe were privileged to have a significant number of abstract submissions and some excellent plenary presentations.â€? patient anxiety, perceptions of pain, service developments to improve the patient experience, risk stratification, reducing the risk of bleeding and fluid management. Best paper was awarded to Mr. Nigel Evans, a Trainee Advanced Practitioner from the UK. Mr. Evans presented Establishing A Patient Pathways For Those Without Support At Home On Discharge. Thank you to Getinge for their generous prize and support. The day was well attended and enabled delegates to network and share their experiences. The wider meeting offered a diverse program which was also of interest to our delegates. Next years meeting will be in Barcelona, so we would encourage colleagues to submit their work for presentation and to join us to celebrate our achievements. n
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Thoracic surgery audit update Doug West, Thoracic Audit Lead and Audit Committee Chair
embers are likely to notice some changes this year, as initiatives from the Society and elsewhere come online. Preparations for a third Blue Book in cardiac surgery continue, with the background data now received from the analytic team at NICOR. Publication is planned for the first half of 2020, and we hope to be able to share insights from this project at the annual meeting in Cardiff. Links to the NICOR NCAP 2019 report are now available at www.scts.org.
Moving forwards, we are developing guidance on the definition of operative urgency in cardiac surgery to support clinicians, which should standardise definitions across units. The response to the survey was excellent and certainly showed the variation in interpretation of operative urgency between surgeons. The survey results were presented to the Board of Representatives in September 2019 and the comments/feedback were collated. On the back of this a draft document has been circulated to the membership for comment. Within this document is a link for the members to view the survey results for themselves.
for this audit please contact the Society or Professor Jahangiri directly.
In thoracic surgery, the LCCOP report is scheduled for release at BTOG 2020, simultaneous with the main National Lung Cancer Audit and the Mesothelioma UK Audit. This year will see the addition of specific resection rates for early stage (I-II) fit patients (performance status 0-2), which should be a better assessment of surgical services than overall resection rates. We have just made the first call for this yearâ€™s SCTS returns data in thoracic surgery. This project is being led by KS
â€œMoving forwards, we are developing guidance on the definition of operative urgency in cardiac surgery to support clinicians, which should standardise definitions across units.â€?
Dual consultant allocation is now recognised in the adult cardiac database, we have developed guidance on which operations should be recorded as dual consultant cases. This has already happened in other specialities, for example vascular surgery, and should support high quality operative care in technically complex surgery.
Professor Jahangiri is conducting an audit on surgical aortic valve outcomes to help inform NICE, the public and other health organisations. All units have been invited to participate in submitting this data for her audit, which will provide us with the most up-to-date National outcomes and can be used as a comparator when making decisions for TAVI vs. SAVR. The audit will not have any patient or surgeon identifiable data and is effectively data that has already been submitted ot NICOR. If anyone has any questions relating to submitting data
Rammohan. This year we are asking for some more detail on your interventional bronchoscopy practice. Please get your data in early so that we can show you some useful data at the forum and at the annual meeting.
In congenital, because of the introduction of GDPR, NICOR has made changes in the reporting of the National Congenital Heart Disease Audit. As NCHDA reports on an increasing number of procedures (currently 83) and there has been an
on-going reduction in 30-day mortality, reporting has been on 3 year rolling data, with mortality reported at centre level and depicted in funnel plots. However, as a result of GDPR, HQIP has stated that low numbers of deaths cannot be specified, as it may be possible that patients will be identified. Therefore in the centre specific outcomes, ‘<3’ is now used in cases where there have been either one or two deaths. It has not been possible to produce funnel plots. These changes went ahead despite objections by professional societies, NICOR, and patient representatives, who felt that the new reporting was a step back from transparency and accuracy. Importantly, to date no complaints have been received from parents about identification in mortality reporting. These changes do not apply to data reported at national level.
Several national clinical audits, including LCCOP/NLCA and NICOR, are in the process of recommissioning, where bids are invited from potential other
providers. The Society will seek to engage productively with any successful provider to maximise the benefit to patients and to effectively represent our members. We have recently made our formal response to NHS England’s National Clinical Improvement or NCIP Programme. This project will give clinicians access to their own activity, comorbidity and outcome data through a dashboard, with the option to “click through” and identify individual patients. Properly implemented, this will support effective local quality improvement, morbidity and mortality reviews and appraisal. We are broadly supportive, but in some areas such as congenital surgery we have raised concerns, while in other areas such as urgent thoracic surgery we have advocated for more reporting. We believe that team work between surgeons and with the wider team leads to better results and a better working environment. We will continue to advocate for innovations which support team working. Lastly, you may have noticed that parts of our website SCTS.org are in need of a refresh. Narain Moorjani has recently led a review of the website. A new commercial provider has been identified,
“We believe that team work between surgeons and with the wider team leads to better results and a better working environment.” and we are reviewing the content that will form the new site. Expect updated and more usable audit and QI pages soon. If you have ideas or reflections to offer on any part of our work in audit and QI please do get in touch, either with me or with the SCTS subspecialty audit leads Carin Van Dorn in congenital and Uday Trivedi in adult cardiac. Email: email@example.com n
New Consultant Appointments - September 2019 to January 2020 Name
Northern General Hospital, Sheffield
Liverpool Heart & Chest Hospital
Golden Jubilee National Hospital, Glasgow
University Hospital of Wales
Bristol Royal Hospital for Sick Children
Other Appointments Name
St. George’s Hospital, London
Locum Consultant Adult Cardiac
The Royal Sussex County Hospital, Brighton
Locum Consultant Cardiac
Freeman Hospital, Newcastle
Locum Consultant Cardiac & Transplant
New Cross Hospital, Wolverhampton
Locum Consultant Thoracic
St George’s Hospital, London
Locum Consultant Thoracic
Blackpool Victoria Hospital
Locum Consultant Thoracic
Liverpool Heart & Chest Hospital
Locum Consultant Thoracic
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SCTS Education report January 2020 Sri Rathinam, SCTS Education Secretary
CTS Education takes pride in the fact the first cohort of trainees have completed the whole portfolio of courses from the boot camp to the professionalism course, spanning 6 years. When we set out on this venture there were raised eyebrows, question marks and scepticism. I think we have achieved a great milestone in the history of SCTS. The concept we have adopted has reflected what I was taught as an aspiring surgeon years ago. I was advised by my trainer if you want to succeed as a surgeon respect the three ‘T’s: Tissue, Time and Team. SCTS Education has used novel innovative ideas to offer the trainees the various ‘Tissue’ for their simulated learning, plastic, animal wet labs and live animal operating. We have offered in to correlate with their training ‘Time’ a course offered to reflect needs as per curriculum progression, as well as timed appropriately to avoid conflicts with other training opportunities. We emphasise the importance of working in a ‘Team’ both in the operating environment, resuscitative environment (CALS), non-technical areas (NOTTS) and professional development. We hope that inculcating these values in our trainees will offer better outcomes to our patients. The Education Team as always have had an exciting, eventful and evolving six months in delivering the targets we aimed for tackling the challenges on our path. Every section lead has delivered success and I need to acknowledge and thank them for their perseverance and performance. The administrators, Letty Mitchell and Emma Ferris, have worked relentlessly to run all the courses very efficiently. To make their lives and yours easier we have split their responsibilities to
Emma coordinating all the NTN, Non NTN & Consultant Courses and Letty overseeing the AHP courses, fellowships and Operative video prizes. They are the nerve centre of SCTS Education, so please respond to their request and emails promptly. A big thank you to both of them!
SCTS-Ionescu Collaboration We have another year of fruitful collaboration with Mr Ionescu and the SCTS membership has immensely benefitted. Mr Marian Ionescu has been generous with his contributions to the society for educational activities over the years. This year he has supported part of the SCTS Education portfolio and allowed us to award another round of exceptional winter fellowships. The SCTS-Ionescu Additional Exceptional Fellowships for 2019 had a great response and the awardees were: SCTS-Ionescu Consultant Fellowship Team fellowships: Ms Donna Eaton, Mater Miseriecordae University Hospital, Dublin to the
Shanghai Pulmonary Unit. Uniportal VATS lobectomy and Thoracic Surgery in spontaneous breathing patients. Mr Uday Dandekar, University Hospitals of Coventry and Warwickshire to Prof Ozaki in Toho University Tokyo. Aortic valvular repair techniques using autologous pericardium (Ozaki technique). Mr Omar Nawaytou, Liverpool Heart and Chest Hospital to Prof I El Hamamsy in Montreal Heart Institute. Ross procedure to complement the Liverpool Thoracic aortic services and to benefit both adult and adult congenital patients. SCTS-Ionescu NTN fellowship: Ms Elaine Teh, South West Training Programme to visit Imperial Medical school and St Bartholomew hospital (Mr Sasha Stamenkovic) to focus on Surgical innovation and Robotic thoracic surgery. Mr Amir Sepehripour, London post CCT Fellow in Barts Heart centre to train with Prof El Khoury in St Luc Belgium to focus on mitral surgery with emphasis on mini mitral programme and robotic mitral surgery.
“The Education Team as always have had an exciting, eventful and evolving six months in delivering the targets we aimed for tackling the challenges on our path.”
SCTS-Ionescu Non NTN fellowship: Mr Rohit Govindaraj, Golden Jubilee National Hospital Glasgow to visit the Shangai Pulmonary Hospitals to immerse in minimally invasive lung resections (uniportal) and lung cancer pathways.
The second SCTS Team Human Factors course took place at Harefield Hospital
Mr Mohammed El Saegh, St Bart’s Hospital London to train with Prof G El Khoury’s unit in St Luc Belgium to focus on aortic surgery. SCTS-Ionescu Nursing and Allied Health Professional Fellowship: Dr Bhuvana Bibleraaj, University Hospitals of South Manchester to attend the Surgeons as Educators Training course as well as visit local units in Atlanta & to gain knowledge on local practice of SCPs particularly focusing on minimally invasive vein harvest. SCTS-Ionescu Medical students Fellowship: Tom Eadington, Manchester University Fortis Hospital Mumbai, to gain clinical immersion in cardiac surgery including paediatric cardiac surgery and transplant. Jean-Luc Duval, King’s College London Eric Williams Cardiac Centre in Trinidad (Dr Natasha Rehaman-Ganga) to focus on cardiothoracic surgery and peri operative care Arian Arjomandi Rad, Imperial College Medical School Hammersmith Hospital (Professor Prakash Punjabi) with a focus on cardiac surgery. We are delighted to invite applications for SCTS-Ionescu Fellowship awards for 2020 with a closing date of 15th January 2020.
SCTS Education podcasts Caroline Toolan, an ST8 in Northwest, has introduced a novel concept of audio podcasts of the interviews based on the chapters from SCTS Perspectives books. This is available free to the membership.
SCTS Educational Events Consultant Education: The second SCTS Team Human Factors was held in the Harefield Hospital.
Just like last year, there was phenomenal interest when we invited teams to apply to the course. The team training day focuses on team working, interaction and better cohesive performance. The impressive impact was two of the four units have taken on board the value of the course and have expanded it to other specialities in their local units. Further to the success of our last year’s Consultant education event, we are hoping to have the third 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 “Mentoring in clinical practice”. NTN Portfolio: The courses have run smoothly in 2019 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. 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. Non NTN portfolio: The Non NTN members will have the Residential course, day course on professionalism and a cadaveric based course in 2020. SCTS has surveyed the Non NTNs and will focus on their learning requirements and development.
Medical Students: The University of Liverpool and Manchester teams hosted the medical students cardiothoracic careers day in November 2019. As always a big thank you to Aman Coonar, who led this event especially during his challenging personal circumstances; to deliver 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. 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. The first SCP conference is set to happen on the 24th November under the auspices of SCTS. The new addition to 2020 are the Innovations in surgery course aiming to showcase the recent advances and their impact on AHPs. 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. We once again thank our course directors, faculty, industry and our benefactors in making these educational opportunities a reality. I wish you all a prosperous 2020. n
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SCTS Education tutors’ report Carol Tan, SCTS Thoracic Tutor Sunil K Bhudia, SCTS Cardiac Tutor
s we reflect on the last 12 months, we are delighted to report that we have had a successful year of delivering all twelve NTN courses for SCTS Education, as well as our second SCTS-Ionescu Human Factors Course. This would not have been possible without the commitment of course directors and faculty, many of whom have been involved for several years. We cannot express our gratitude enough, particularly as we are aware of the time and commitment required, not only for attending the courses, but also pre-course preparation and organisation. Feedback from trainees has generally remained positive, but we have and will continue to look at ways of improving the courses through feedback from course directors, faculty and trainees. This includes logistical arrangements, content of course equipment and materials required for simulation training, as well as invitation of new faculty members and course directors to give those who have been teaching for many years a break, and to bring in fresh ideas for the courses. Ashorne Hill, a training facility in Leamington Spa, Warwickshire, has been the venue for many of the courses (both NTN and non-NTN) in 2019. With in-house provision of bed and full board, as well as training facilities including accommodating our need for wet-lab simulation training, it has meant that we can focus on education in a cost-efficient way. Given the positive feedback from trainees and trainers with the facilities and support from in-house staff, we have negotiated another great deal for our courses in 2020. We look forward to a continued successful partnership with Ashorne Hill in years to come.
Apart from the ST5B course, dates for all other NTN courses in 2020 have been confirmed and already published on the SCTS Education website. Emma Ferris and Letty Mitchell who have been invaluable as our administrative staff, work tirelessly to ensure the smooth running of not only the NTN courses, but also courses for nurses and AHPs, SAS doctors and other non-NTN doctors. With hundreds of trainees/delegates as well as faculty and course directors to
contact over the course of each year, we urge those who have been contacted to respond to their emails and confirm attendance as well as accommodation and other logistical arrangement as soon as possible so that these can be finalized ahead of time. We cannot stress enough how important this is as it helps to keep running cost down. For anyone who thinks they should have been contacted for a course but have not been, please ensure SCTS Education has your up to date email address
SCTS Education NTN Courses in 2020 Intermediate Viva Course (ST5A) 13th – 14th January 2020, Ashorne Hill, Leamington Spa Cardiothoracic Surgery Sub-Specialty Course (ST6A and ST6B) 5th – 7th February 2020, Johnson and Johnson Institute, Hamburg Revision and Viva Course for FRCS(CTh) (ST7A) 2nd – 5th March 2020, Ashorne Hill, Leamington Spa Operative Cardiothoracic Course (ST3B) 10th – 11th March 2020, Johnson and Johnson Institute, Hamburg Cardiothoracic Surgery Pre-Consultant Course (ST8A) 8th – 10th June 2020, Johnson and Johnson Institute, Hamburg Core Thoracic Surgery Course (ST4B) 15th – 17th June 2020, Ashorne Hill, Leamington Spa Introduction to Specialty Training in Cardiothoracic Surgery Course (ST3A) 7th – 9th September 2020, Ashorne Hill, Leamington Spa Clinical Examination Course for FRCS(CTh) (ST7B) 26th September 2020, Royal Papworth Hospital, Cambridge Core Cardiac Surgery Course (ST4A) 23rd – 25th November 2020, Ashorne Hill, Leamington Spa Professional Development Course (ST8B) 7th – 8th December 2020, Ashorne Hill, Leamington Spa Non-Operative Technical Skills for Surgeons (NOTSS) Course (ST5B) TBC, Advanced Patient Simulation Centre, St George’s Medical School, London
and any other contact details, but also please check your junk mailbox. As the curriculum for Cardiothoracic Surgical training will be changing to a 7-year run-through training programme, we will be looking at revising the current portfolio of 12 courses to fit into the new 7-year programme. Further information will be provided in due course. We are also looking into providing assessment of
progress alongside the training programme. With support from Mr Marian Ionescu and positive review in 2018, we ran the second Multidisciplinary Simulation Course, now known as the SCTS-Ionescu Human Factors Course in September 2019, with input from a very capable Harefield Hospital faculty. Through a shortlisting process, a team from Nottingham led by Mr Selvaraj Shanmuganathan, and
one from Newcastle, led by Ms Karen Booth, were selected to attend. Both teams engaged and interacted well during the course and positive feedback was received. The Newcastle team are now planning on arranging in-house Human Factors training for the rest of their team members. We will be planning another course later this year, and invitations for application to attend will be sent out in due course. n
SCTS AHP Education portfolio Tara Bartley & Bhuvana Krishnamoorthy, SCTS Allied Health Professional Education Leads
SCTS Annual meeting CT Forum This yearâ€™s annual meeting saw another successful University wet lab for nurses and allied health professionals (AHPs). We were also delighted to welcome a number of our surgical colleagues and extended an invitation to the A level students, who joined us for an hour of the morning and afternoon session. This was very well received with positive feedback. We will run this excellent MDT day again at our 2020 meeting in March to be held in Wales. Our working relationship with Wet lab limited, Abbott, Ethicon, Medtronic, Karl Storz, Chest drain is excellent, and we would like to thank them for their continued support to deliver high quality hands-on teaching.
Cardiothoracic surgical training courses Our nursing and AHP portfolio consists of a variety of educational courses throughout the year, most of which were held at Abbott teaching centre in Solihull. The Surgical Skills Cardiothoracic course was attended by 65 delegates and the Core Surgical skills course attendance was 72 delegates over three days. We have started our 1st CT Surgical Care Practitioner annual conference with a collaboration between ACTSCP/ SCTS which was conducted on 24th November 2019. The session was filled with hands on practices of robotic,
ECMO, SSI symposium, Latest technologies cardiothoracic surgery. The feedback for all our courses was excellent with the mean of 4.5. Delegates felt that all courses were conducted to a pedagogical theory with practical sessions. The sessions were interactive and group sessions were welcomed by the delegates who mentioned that they were able to benchmark their practices with their national colleagues. We are looking forward to recruiting new course trainers; if you are interested please do not hesitate to contact Bhuvana or Tara via the SCTS office. n
Notable events in 2019
Plans for 2020
AHP Education courses
SCTS Advanced Cardiothoracic Course, January 2020
The SCP Revision course, 27th and 28th January 2019
Surgical skills course, January 2020
Surgical Skills course for SCP, 15th February 2019
Revision course, March/April 2020
SCTS University Wetlabs, 10th March 2019 SCTS Non-Medical Prescribing one day course, 13th April 2019 SCTS Core Skills three-day course, 14th, 15th and 16th September 2019 Theatre surgical course, 28th September 2019 ACTSCP/SCTS annual conference, 24th November 2019 SCTS Educational input at EACTS October 2019
SCTS University Wet lab CT forum, March 2020 New CT surgery Innovations course, April/May 2020 Core surgical skills course, July 2020 Theatre course, September 2020 ACTSCP annual conference, November 2020
the 28 bulletin
Identifying Heart Surgery PSP’s top 10 priorities Professor Gavin Murphy, British Heart Foundation Professor of Cardiac Surgery, University of Leicester
n 2015 the British Heart Foundation and the Society for Cardiothoracic Surgery in Great Britain and Ireland identified an unmet need for high quality clinical research in cardiac surgery. As part of a wider strategy to address this, it was suggested that the British Heart Foundation (amongst other research funders) would welcome an agreed set of national research priorities, developed through a process of consultation and stakeholder engagement. In response, members of the Society came together to define the Top 10 priorities for UK cardiac surgery research. The team worked with the James Lind Alliance, a non-profit making initiative that brings patients, carers and clinicians together in Priority Setting Partnerships to identify and prioritise research questions in specific areas of medicine. Funded by Heart Research UK, the James Lind Alliance Adult Cardiac Surgery Priority Setting Partnership brought together patients, carers, nurses, doctors, pharmacists, and organisations such as the Leicester Centre for Black and Minority Ethnic Health. With an independent chairperson appointed by the James Lind Alliance, the team used a Delphi approach to identify the top research priorities. The modified Delphi process consisted of a number of surveys. The Initial Survey was launched at the annual meeting of the Society for
Cardiothoracic Surgeons in the UK and Ireland (SCTS) in March 2018. The Initial Survey was available both online and in paper format. Digital dissemination proved to be particularly effective, as it was a method of reaching participants with whom the Project Team had no direct contact with. However, due to the demographic, it was necessary to produce paper surveys for
research themes they wished to explore – simply because they had previously received an excellent standard of care – or they felt under-qualified to volunteer a question. In total, however, 629 participants, including those from clinical networks across Australia, New Zealand, North America and Europe, contributed 1080 research questions. The interim period between the Initial and Second Surveys allowed for analysis of the survey results and systematic reviews of existing evidence that potentially addressed these research questions. Expert members of the Project Team who performed this work were Dr Riccardo Abbasciano (Clinical Research Fellow), Ms Florence Lai (Senior Statistician), Dr Clare Gillies (Lecturer in Medical Statistics and Evidence Synthesis), and Selina Lock (Library Research Services Consultant). Their work removed any questions from the submission pool that had previously or were currently being addressed by research, thereby preventing replication, which would be wasteful of resources and effort. Duplicate submissions to the Initial Survey were combined into ‘umbrella questions’ which formed the final 49 questions available for votes in the Second Survey. The Second Survey launched at the SCTS Annual Meeting, in March 2019. The Second Survey requested that respondents selected their Top 10 priorities from a longlist
“The role of the Heart Surgery PSP was to identify what was most important to those affected by cardiac surgery, and to provide a set of priorities for the research agenda which could be translated into future clinical trials.” those participants that did not have online access. This, of course, was an important consideration because the whole project was premised on inclusivity. Obtaining a representative sample in the Initial Survey was challenging. Conventionally, a survey asks questions whereby participants provide answers – whether responses be tick-in-the-box, multiple choice or qualitative. However, the preliminary stage of a PSP requests that participants propose the questions they wish to see addressed by research – in other words, the participants needed to ask questions rather than provide answers. In turn, several individuals in the patient/ carer demographic did not feel they had
of 49 questions. This was easier than the Initial Survey, in that the Heart Surgery PSP project team were able to target the network of contacts established for Initial Survey respondents (in comparison to starting from scratch the previous year). The Second Survey was open for four months, between March 2019 and June 2019 and received votes from 493 participants. Upon closure of the Second Survey, the Top 21 questions were identified after taking into consideration the top priorities of patients, carers and healthcare professionals, thus ensuring equal influence across the different stakeholder groups. These 21 questions were then available for the final priority setting exercise – which would take place as workshop, including patients, cares and healthcare professional – to establish the Top 10 research priorities. The final workshop took place at Leicestershire County Cricket Ground, at Grace Road, in Leicester. Every effort was taken to ensure equal numbers of the three stakeholder groups were present for a
balanced system of prioritisation. Delegates were also selected from across the UK to prevent any accusation of geographical bias. They were then designated to one of the three working groups. With the help of a JLA Facilitator, the groups then began the ranking of the final 21 questions. At the end of the morning session, each group’s ranking was entered into an Excel spreadsheet to produce the first aggregate ordered list. Following this, three new groups were formed to create a fresh perspective of the ranked questions in the combined list. By the end of the session, each group had ranked the summative list of questions as per their group’s agreed priorities. The three groups were then united in the plenary phase of the workshop, allowing all delegates an equal opportunity to contribute and voice their reasoning (for and against) for a particular priority to appear in the final ranking. The Top 10 questions for cardiac research, which were agreed by general consensus of all delegates, or by majority votes where consensus was not present.
The role of the Heart Surgery PSP was to identify what was most important to those affected by cardiac surgery, and to provide a set of priorities for the research agenda which could be translated into future clinical trials. It is important to recognise that the prioritisation process is just the beginning, and that transparent results are shared effectively to potential funders and researchers. The project team are currently working closely with members of the Steering Group to ensure fruitful dissemination of the results. An official launch of the Top 10 Priorities is scheduled for Monday 11 November, 2019. View our Top 10 priorities at: http://www.jla.nihr.ac.uk/prioritysetting-partnerships/heart-surgery/ downloads/Heart-Surgery-PSP-Top10-priorities.pdf Follow us on twitter: @HeartSurgeryPSP For further information: www.le.ac.uk/ heart-surgery-psp n
New Cardiothoracic Curriculum A trainee’s perspective on challenges and opportunities Duncan Steele, Senior Cardiothoracic Trainee Representative
T1 trainees starting in 2020 will train for seven years, instead of eight, to gain certification of completion of training (CCT). This year will effectively be taken away from early training and experience towards the end of the training pathway will remain almost identical. This exciting change will bring on a subtle revolution of cardiothoracic training to improve the experience National Training Number (NTN) trainees have. The perfect storm of too few consultant positions and too many graduates from the
training programme fills the minds of current NTNs with trepidation. On top of this, the proportion of consultant appointments from the UK training system has decreased significantly over a generation, which some say, reflect difficulties in the current programme. Many would argue that trainees are already struggling for case numbers and shortening training will only worsen the quality of training over the programme. This change, however, is an opportunity to refocus efforts and circumvent wasted time, which causes so
much frustration for trainees. Many of us have periods where caseloads are plentiful only to be followed by a drought for 6 months due to an inappropriate trainee : trainer allocation. It is also important to remember our colleagues in the US whom, post general surgery residency, train in cardiothoracic surgeons in just two years. The attrition of the long formal training in the UK has been cited as a key factor in burn out and dissatisfaction. Many instead would prefer a more direct, shorter path to consultancy. >>
the 30 bulletin
‘The new pathway picture’ It is clear after spending five minutes talking with any surgical trainee, they have all had periods of treading water, where learning stagnated and professional development limped along. It is also abundantly clear that each trainee has their own needs and we must avoid treating all trainees the same. The same goes for trainers, who develop themselves in their role as the mentors and guides for the next generation. The key is nurturing trainee enthusiasm and drive by avoiding these futile periods of stagnation. The absolute number of cardiothoracic trainees is reducing and the competition for trainees being allocated to deaneries and departments is increasing. The supply:demand ratio is increasingly in favour of trainees, meaning only trainers that cultivate their trainees will continue to have NTNs. No longer will it be ok for a trainer to take their trainee through just a handful of major cases in a registrar year. This will directly result in fewer and shorter periods of treading water. Furthermore, training programme directors (TPDs) will be acutely aware that with one fewer year to train an NTN these periods of stagnation are not just to be avoided, but a catastrophe for all involved. So what does this mean for you as an NTN, trainer or TPD. The list below, in my opinion, must be seen as essential to ensure high quality training: 1. Proactive evaluation of trainee: trainer compatibility.
“Aiming to complete training in seven years rather than eight means those embarking on this pathway can achieve excellence with a year fewer of mandatory training.” 2. Every 3 or 6 months trainees should evaluate progress and raise concerns with their trainer and TPD quickly to find solution. 3. Objective goal setting at the start of each rotation for each aspect of professional development including setting goals for number of cases performed and assisted. 4. Trainees making the most of all training opportunities available to them in their departments with the support of their supervisors and TPD. 5. Proactive evaluation of rota/on call design to ensure it matches trainee’s requirements. This change is clearly significant and because of this, trainees will be followed closely to ensure progress is proportionally accelerated in the early years. Bumbling on is no longer an option, if it ever were
before. The actual risks of embarking on such a project are limited as all trainees will benefit from a refocusing of trainee allocations and training environment. Moreover, through more robust ARCP evaluations, trainee difficulties can be dealt with straight away improving focus and alleviating frustration. Aiming to complete training in seven years rather than eight means those embarking on this pathway can achieve excellence with a year fewer of mandatory training. With a surgeon’s career duration finite, this change in itself allows more time for other activities such as research or sub specialty fellowships before, during or after NTN years. For some starting next year, seven years may be too short. However with improved efficiency and more proactive training, there is no reason why they won’t achieve excellence in this streamlined timeline. n
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the 32 bulletin
6th International SCTS Student Engagement Day: 9th November 2019 Cindy Cleto, Medical Student Tom Eadington, Medical Student Aman Coonar, Consultant Thoracic Surgeon
he Manchester and Liverpool University team, led by Tom Eadington, Cindy Cleto, Mr Michael Shackloth and Mr Kandadai Rammohan worked hard to organise and host the 6th International SCTS Student Engagement day, held at the Liverpool University campus. Over 100 medical students and sixth formers attended the meeting. The day started with a range of engaging talks on a variety of cardiothoracic subspecialties, including paediatric and congenital surgery, the use of robotics in cardiothoracic surgery and heart and lung transplantation. We were privileged to have the SCTS president, Mr Richard Page, chairing the session. There was lots of audience participation throughout the morning with healthy discussion between students and consultants between the lectures. For the medical students, the afternoon comprised of 5 different practical skills stations, including basic and advanced suturing and knot-tying, VATS skills, chest drain insertion, and advice on cardiothoracic training and the application process. These
allowed students to develop and hone key practical skills, and gain valuable feedback on their performance. The sixth form students had talks from Liverpool consultants about how to get into medical school, including useful tips on extracurricular activities, personal statements and the interview process. This was then followed by interview stations, designed to give an insight into what medical school entrance interviews would be like and build the students confidence and allow them to practice common questions they will be asked. The day ended with a social event that allowed for networking and guidance. Overall the day was a great success. Students left feeling welcomed to the specialty of cardiothoracic surgery and more knowledgeable about what it involves. n Lead Medical Students Tom Eadington and Cindy Cleto Lead Consultants - Mr Michael Shackloth and Mr Kandadai Rammohan Head of SCTS Students - Mr Aman Coonar
The organisers (l-r): Kandadai Rammohan, Aman Coonar, Cindy Cleto, Michael Shackloth, Tom Eadington
Chair - Mr Richard Page Speakers - Mr Manoj Purohit, Mr Mark Field, Mr Paul Modi, Mr Manoj Kuduvali, Mr Steven Woolley, Mr Ioannis Dimarakis, Mr Ansha Garg, Miss Debbie Harrington and Miss Gill Hardman Workshop Faculty - Mr Julius AsanteSiaw, Mr Richard Page, Mr Kandadai Rammohan, Miss Gill Hardman, Mr Matt Smith, Miss June Yi-Ling Low, Dr Jeesoo Choi, Dr Vinci Naruka, Mr Samail Shahjahan, Dr Maria Nizami and Dr Beverly E MacCarthy-Ofosu Organising Committee - Leah Argus, Georgia Elizabeth Bailey, Graeme Burt, Constantina Tilia Michaelides, Ozhin Karadakhy and Aikaterini Eleftheriadou
Kandadai Rammohan teaching VATS skills to medical students
Gill Hardman teaching advanced suturing skills to medical students
Matt Smith teaching medical students how to insert chest drains
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the 34 bulletin
SCTS: The Beginning Graham Cooper, immediate past President, SCTS
t the beginning of the 20th Century surgeons began to specialise in a particular form of surgery. This development of specialisation was accelerated by the First World War [Riberio]. In 1918 the British Orthopaedic Association was formed and in 1926 the Society of British Neurosurgeons was founded by two surgeons who practised exclusively as neurosurgeons. Despite its rather limited scope at this time developments in thoracic surgery were rapid and it increasingly became an area of specialisation [Abbey Smith]. In this era of development, on 19th September 1931, Bryce1 wrote to Morriston Davies2 ‘Since the day when I enjoyed your hospitality at Ruthin I have thought more and more of the idea of forming some sort of little surgical club or society for people interested in Thoracic Surgery.’ Later he writes ‘Do you think the London men would be interested in such a project?’ Presumably the response from Morriston Davies was positive because on 2/11/31 Bryce wrote to Roberts3 at 26 Harley Street, London, raising the idea of a thoracic surgery club. In May 1932 the Association of Surgeons annual meeting was held in London. Evidently Bryce and Roberts met there and talked further because on 19th April 1933 Bryce writes again to Roberts
asking if he is coming to the Association of Surgeons meeting in Manchester in 1933 where he has arranged a dinner to ‘renew the discussion about the formation of a society of thoracic surgeons.’ The dinner took place on Friday 5th May 1933 at the Midland Hotel in Manchester. Present were Bryce, Morriston Davies, Tudor Edwards4, Price Thomas5 and Moir6. We have no record of this meeting beyond the menu however subsequent correspondence indicates that the formation of ‘The Thoracic Surgeon’s Club’ was agreed. In deference to seniority, Morriston Davies was to be President, Roberts and Tudor Edwards Vice-Presidents and Bryce Secretary. The intention was to limit membership to 20 to 25 and to hold an annual meeting in October or November alternating between a venue at home and one abroad. In June 1933 Bryce writes a series of letters to those surgeons known to have an interest in thoracic surgery seeking their support for the club. All replies are very supportive including the ‘London men’ who all write from a Harley Street address. Nelson7, in his reply of 9th June 1933, from 26 Harley Street, suggests that an Association would be more appropriate than a club. At some point before the first Annual Meeting the name became The
“...I have thought more and more of the idea of forming some sort of little surgical club or society for people interested in Thoracic Surgery.” Alexander Graham Bryce writing to Morriston Davies in 1931
Society of Thoracic Surgeons of Great Britain and Ireland. The first annual Meeting was held on Saturday 11th November 1933 at The Royal Brompton Hospital (Figure 1). A Business Meeting was held in the morning, Morriston Davies was confirmed as President, Roberts and Tudor Edwards as Vice-Presidents and Bryce as Secretary. The members of the committee were Anderson, Hunter, Moir, Morison and Romanis. The constitution and an annual subscription of half a guinea8 were agreed. In the afternoon operations were performed by Roberts and Tudor Edwards. Dinner was held at the Langham Hotel. The second committee meeting was held on the London to Folkstone train on Sunday 11th November 1934. The committee were travelling to the second Annual Meeting in Davos-Platz, Switzerland.
Acknowledgements I am grateful to Isabelle Ferner for access to the SCTS archive and The Royal College of Surgeons of England, Library for access to their archive. n
References 1) Alexander Graham Bryce 1890-1968. Thoracic surgeon at Manchester Royal Infirmary became interested in thoracic surgery in 1929 and was the driving force behind the foundation of SCTS. He was Secretary 1933 to 1946, VicePresident 1947 to 1949 and President 1950 to 1951. 2) Hugh Morriston Davies 1879-1965. Specialised in thoracic surgery from 1908 whilst working in London, he pioneered many important developments and was developed an international reputation. In 1916 he cut his right hand whilst
operating on an empyema. The subsequent infection in his hand and forearm left his hand effectively useless. Considering his surgical career to be over he purchased a sanatorium in North Wales, however recognising that many of his patients required surgery he taught himself to operate left handed and resumed surgery in 1921. 3) James Ernest Helme Roberts 1881-1948. Thoracic surgeon in London who helped develop thoracic surgery after the First World War. 4) Arthur Tudor Edwards 1890–1946. Thoracic surgeon in London, who like Morriston Davies and Roberts was a pioneer of the specialty in the twenties. 5) Sir Clement Price Thomas 1893-1973. Thoracic surgeon in London trained by Tudor Edwards. On Sunday 23rd September 1951 he performed a left pneumonectomy on King George VI at Buckingham Palace. It may be apocryphal but it is said that after removing the lung, Price Thomas left his assistants to close and went to speak to the waiting Royal Family. Princess Elizabeth, now her Majesty Queen Elizabeth, asked if she could see her father to which Price Thomas replied that they were just finishing the operation. Princess Elizabeth replied asking why Price Thomas was not in the operating theatre then. Price Thomas replied ‘Ma’am, I haven’t closed a chest in 25 years and I am not going to start again with the King of England.’ 6) Percival John Moir 1893-1980. Professor of Surgery at Leeds. Is best known as a general surgeon but must have has a thoracic surgical interest at this stage of his career. 7) Henry Philbrick Nelson 1902-1936. Born in New Zealand he was educated in England and trained in London. He died from streptococcal septicaemia contracted after he cut himself whilst operating. 8) Half a guinea, ten shillings and six pence equivalent to about twenty five pounds today. Ribeiro B, Chaplin S, Peel A, Treasure T, Leopard P, Jackson B. Surgery in the United Kingdom, Arch Surg 2001;136:1076 – 1081. Abbey Smith R. The development of lung surgery in the United Kingdom. Thorax 1982;37:161 – 168.
“The first annual Meeting of The Society of Thoracic Surgeons of Great Britain and Ireland was held on Saturday 11th November 1933.” Figure 1: The signing in book for SCTS’ first Annual Meeting
the 36 bulletin
Your patient dies Could you be guilty of Gross Negligence Manslaughter (GNM)? T
he 25th January 2018 was a landmark date for the medical profession (except in Scotland which has a separate legal system and does not have an offence of GNM). You might not have appreciated the significance at the time but on that day the Divisional Court allowed the General Medical Council’s (GMC) appeal and Dr Bawa-Garba’s name was erased from the Register1.
The background was that a 6-yearold boy tragically died (as a result of sepsis related to a chest infection) and she (a trainee in paediatrics) was subsequently convicted of gross negligence manslaughter (GNM). The fact that she was known as a good doctor (in the top 1/3 of her cohort of trainees) and had been working in very difficult circumstances with little support (the Trust investigation identified
multiple issues), generated widespread concern amongst doctors – some even described it as a “toxic fear”. All doctors could identify with her. That she had been working for over 4 years between his death and the criminal trial, with no concerns about her fitness to practise added to the feeling of perceived injustice. Real anger was directed at the GMC. An editorial in The Lancet on 14th April called for the resignation of both the Chair
Leslie Hamilton of Council and the Registrar/CEO.2 At their Annual Representative meeting in June, the British Medical Association (BMA) passed a vote of no confidence in the GMC. Although probably remembered best by doctors for his response to the junior doctors’ strike, Jeremy Hunt’s (Secretary of State) focus had always been on improving patient safety. He recognised that this case would make doctors less willing to be open about errors and this would have a negative impact on patient safety. He asked Professor Sir Norman Williams (past President of the RCSE) to conduct a rapid policy review (NHS in England) around GNM – published in June 2018.3 The GMC recognised that real harm had been done to their relationship with the profession – they asked Dame Clare Marx (immediate past President of RCSE) to conduct a wide-ranging review (the GMC covers all 4 countries) looking at the whole spectrum of investigations which might occur after an unexpected death ranging from the Trust investigation, the Inquest, a police investigation and the CPS (Crown Prosecution Service). Dame Clare had been President of the College when the conviction of David Sellu4, a Colo-rectal surgeon, prompted a petition of concern, resulting in a debate at Council5. She established a working group of eleven - six doctors (including a trainee), three legal and two patient and family representatives. I was one of the doctors. When Dame Clare was later appointed as the
incoming Chair of the GMC, I was asked to take over as Chair. Although applying the definition of GNM is challenging even for senior criminal Barristers, our terms of reference (ToR) excluded us from calling for a change in the law. GNM is a criminal offence defined by case law. The leading case until recently was that of Adomako.6 Lord Mackay stated that whether a crime had been committed was a decision for the jury and the judgement set out a definition of gross negligence (“so bad as to be criminal”).7 The judgement in David Sellu’s successful appeal against conviction (after he had served his sentence)8 added clarification – the doctor’s conduct must have been “truly exceptionally bad”. It is important to maintain perspective. Prosecutions for GNM are exceptionally rare. An independent analysis of CPS files over 12 years for our Review identified 192 cases investigated by the police – an average of 16 per year. With over 250,000 doctors with a licence to practise on the GMC register, the chance of an individual doctor being investigated is extremely small. Nonetheless, the psychological threat is real and may impact on decision making. Our report was published on 6th June 2019 9. You will be forgiven for not spotting it – it was released (not intentionally!) on the day of D Day remembrances, Donald Trump’s visit to London and the Conservative Party began their leadership contest. Although the national press did not show much interest, it was covered in the BMJ and The Lancet. I was keen to keep it short (77 pages) in the hope it would be read and to limit the number of recommendations (29) so they might have an impact. It was commissioned by the GMC so implementation of the recommendations will be up to them. Essentially the call is for a “just culture” in healthcare in which errors by staff will be acknowledged (to err is human)
“With over 250,000 doctors with a licence to practise on the GMC register, the chance of an individual doctor being investigated is extremely small. Nonetheless, the psychological threat is real and may impact on decision making.”
and the emphasis placed on “learn not blame”. That is widely accepted as the best way to improve patient safety. Sir Liam Donaldson summed up the issues in a recent editorial in the BMJ10 “In Harm’s Way”: “Nor do the public or the media seem too horrified by the lamentable failure of the NHS to learn from the past… investigations invariably show these (patient safety) events are caused by a combination of individual failings, systemic weaknesses, and environmental factors…Regulations, legal frameworks, and most statutory inquiries have so far failed to understand the difficulties for conscientious health professionals of keeping patients safe in a flawed and overloaded system.” n 1) https://www.bailii.org/ew/cases/ EWHC/Admin/2018/76.html 2) https://www.thelancet.com/journals/ lancet/article/PIIS0140-6736(18)30838-9/ fulltext 3) https://assets.publishing.service. gov.uk/government/uploads/system/ uploads/attachment_data/file/717946/ Williams_Report.pdf 4) He was asked to see a patient in a private hospital who developed abdominal pain 6 days after elective knee surgery. As a result of multiple factors, there was a delay in getting him to theatre and he died of sepsis related to perforated diverticular disease 2 days later. David was convicted of GNM and served 15 months (half his sentence) in prison. Subsequently, he was successful in his appeal against conviction following a campaign led by Jenny Vaughan. 5) https://publishing.rcseng.ac.uk/doi/ pdf/10.1308/rcsbull.2018.207 6) R v Adomako  UKHL 6 7) The essence of the matter…is whether having regard to the risk of death involved, the conduct of the defendant was so bad in all the circumstances as to amount in their judgment to a criminal act.” 8) https://www.davidsellu.com/ copy-of-home 9) https://www.gmc-uk.org/-/media/ documents/independent-review-ofgross-negligence-manslaughter-andculpable-homicide---final-report_pd78716610.pdf 10) BMJ 2019; 365:I2037
the 40 bulletin
Aortic Dissection Awareness Day UK 2019 in pictures Christina Bannister, Patient Lead - Nursing & AHP Committee
CTS President Richard Page and immediate past President Graham Cooper both attended Aortic Dissection Awareness Day UK 2019, which this year was hosted by Chair of the SCTS Research Committee Prof. Gavin Murphy and his team at the BHF Cardiovascular Sciences Research Centre at the University of Leicester. The event took the form of a Delphi conference, where 160 patients, relatives, clinicians and academics worked together to design a trial that will produce the evidence to support the UK becoming the first country in the world to introduce a targeted national screening programme for AD risk. Professional photographer Paul McKie of www.enjoytheimage.com was on hand to capture this very special day. At the end of the day, Gareth Owens and Catherine Fowler of Aortic Dissection Awareness UK & Ireland announced that the honour of hosting next yearâ€™s event, on Thursday 17th September 2020, has been awarded to the Bristol Aortic Service, in recognition of the great service provided to patients by the ED, Radiology, Cardiology, Cardiac Surgery and Vascular Surgery teams working closely in partnership across the University Hospitals Bristol and the North Bristol NHS Trusts and their strong commitment to Aortic service improvement. n
Over 160 patients, relatives, clinicians and academics attended this unique engagement event in Leicester and worked together on tackling the national challenge of Aortic Dissection
The event was hosted by Prof. Gavin Murphy, BHF Chair of Cardiac Surgery at the University of Leicester and Chair of the SCTS Research Committee At the event, Aortic Dissection Awareness UK & Ireland launched their new patient leaflet, produced in partnership with Liverpool Heart & Chest Hospital and endorsed by SCTS and the British Cardiovascular Society. The leaflet is available free to download, print and give to patients with a diagnosis of aortic disease and you can find it here: www.bcs.com/documents/ Caring_for_your_Aorta_Leaflet.pdf
Immediate past President of SCTS, Mr Graham Cooper, met with guest speaker, Hollywood actress Amy Yasbeck, whose husband John Ritter died of a misdiagnosed Aortic Dissection
Prof. Gavin Murphy welcomed SCTS President Mr Richard Page as a member of the distinguished Faculty
The event was generously sponsored by Terumo Aortic. There were more of their Dacron aortic grafts walking around the room inside patients than there were on the display table! International guest speakers Ms Amy Yasbeck and Prof. Dianna Milewicz, President George H.W. Bush Chair of Cardiovascular Medicine at the University of Texas Health Science Center in Houston, networked with Aortic Dissection patients and took the â€˜Think Aortaâ€™ campaign message with them back to the USA
Mandy Hawker, whose life was saved by SCTS member Mr Uday Trivedi in 2016, told her inspiring story of surviving a Type A Aortic Dissection, recovering from a spinal cord injury and going back to paddle-boarding. The visibly-moved audience gave her a standing ovation
the 42 bulletin
Openness, honesty and intellectual responsibility Antony Walker
oronary artery bypass surgery is the bread-and-butter procedure for cardiac surgeons. The academic dough for the bread has been perfectly baked in the randomised, controlled ovens of clinical evidence. The original landmark SYNTAX trial findings were published in the New England Journal of Medicine in 20091 and defined coronary revascularisation practices for a decade; “CABG remains the standard of care for patients with three-vessel or left main coronary artery disease”. Lower rates of adverse outcomes (ie. MACCE) at one year following revascularisation ensured that the bread remained on the side plate of surgical revascularisation at five-year follow-up;2 “CABG should remain the standard of care for patients with complex lesions.” The only fly in the butter – higher stroke rates in the CABG group at one-year follow-up – had well and truly flown away by five-years; suggesting the stroke risk to be procedural. The on-going stroke risk was no different between treatments, despite significant differences in
cardiovascular risk factors discussed below. Paris, 2019 saw the European Society of Cardiology congress attempt to force the baguette of bad science on to the dining table of coronary revascularisation; SYNTAX at 10 years: bypass vs PCI still a toss-up overall.3 The dough for the original SYNTAX study simply had insufficient preservatives to last ten years. Ischaemic heart disease is a chronic condition. Follow-up at twelve months is likely to reflect technical aspects or failings of the index procedure. Conversely outcomes at five and ten-years, in a trial not designed for this duration are more likely due to subject risk factors and the management of these risk factors during the follow-up period. Differences between the two original study groups should raise concerns regarding the interpretations of results at ten-year followup. Original authors stated, “patients in the two groups were well balanced with regard to most of the baseline demographic and clinical characteristics”.1 In reality, the ingredients were like comparing artisanal single-batch sourdough to Warburtons (other brands are available) thick sliced white. CABG patients
were more likely to have high Triglycerides (38.7 vs 32.3%, >150mg/dl, p=0.007) and lower levels of HDL cholesterol (52.5 vs 46.2%, <40mg/dl for males and <50mg/ dl for females, p=0.01).1 There was also a trend towards surgical patients being smokers at the time of their index procedure (22% vs 18.5%, p=0.06).1 These differences in cardiovascular risk profiles raise questions regarding the validity of any longer-term analysis and conclusions. Because the study was not designed for longer term follow-up, differences also existed in the pharmacological management of risk factors. Surgical patients were significantly less likely to receive aspirin or other antiplatelet agents at all follow-up points to one-year post procedure (p<0.001). 1, 3 Surgical patients were less likely to be prescribed statins (74.5 vs 86.7%, p<0.001), ACE inhibitors (44.6 vs 55.1%, p<0.001) or angiotensin IIreceptor antagonists (7 vs 13.3%, p<0.001).1 The surgical population had a higher cardiovascular disease risk factor profile that was not as rigorously managed during the study period.
Bakers sell bread. Every baker will be biased to the benefits of their own particular loaf and the methods used to produce it. So, with surgeons and cardiologists. At ten-year follow-up the SYNTAX authors describe their findings as being “in contrast to that of the FREEDOM trial – the most definitive trial of CABG versus PCI in patients with diabetes”.1 FREEDOM was a “loaf” designed to last five years by an independent baker with no vested interest or ulterior motive (National Heart, Lung and Blood institute)4. SYNTAX is not at odds with FREEDOM because CABG continues to show “non-inferiority” despite unfavourable cardiovascular risk factor profiles and inadequate management of these risk factors. To continue the baking theme, “noninferiority” is perhaps akin to “best-of-both” or “50/50”. The terminology is increasingly used but disguises true scientific meaning, enhances a potentially inferior product and in this case simply and fundamentally wrong. An appropriate non-inferiority margin must be defined pre-trial, before recruitment. Nowhere in the original published documentation (or indeed methodology of publications arising from this study) is mention made of “noninferiority” nor is a non-inferiority margin calculated or defined. Fake news, spin doctoring and false advertising are rife and aided by the global attention that comes from recent advances in communication. We have a great product that the nation should love because it does what it says on the tin (or in this case, the bread bag). Journal editors and reviewers have a responsibility to ensure authors are held to account for their work and the reported outcomes. Misreporting or misrepresentation of findings as illustrated in this case can only
Figure 1: Important limitations of the PARTNER III trial harm patients. The authors identify the usefulness of a multil sAVR and TAVI groups fundamentally different disciplinary, heart-team (26.4% requiring concomitant procedures, 7.9% in TAVI) approach for decision l One-year follow-up insufficient to change guidelines making in coronary (sutureless sAVR for example has follow-up to 11 years) revascularisation; l Non-Blinded individual clinicians within these teams l Highly favourable TAVI candidates must have confidence (extrapolation to “real-world” not possible) in the literature on l 50 patients did not undergo index procedure which they base their opinion and decisions. SAVR = surgical aortic valve replacement We are seeing TAVI = transcatheter aortic valve implantation similar bad science in other bread-and -butter procedures of cardiac surgery. Partner III reported favourable oneyear outcomes of a single TAVI prosthesis in 1) Patrick W. Serruys et al for the SYNTAX low surgical risk patients.5 Again, this industry investigators. Percutaneous coronary sponsored trial has many failings (Figure 1) intervention versus coronary artery bypass and the headlines and interpretations have grafting for severe coronary artery disease. had far reaching consequences; including the N Eng J Med 2009; 360: 961-972 expansion of the indications for TAVI to low risk patients.6 2) Prof Friedrich W Mohr et al. Coronary Understandably Master Bakers artery bypass graft surgery versus have raised concerns; authorship has percutaneous intervention in patients with been withdrawn from international,7 three-vessel disease and left main coronary multicentre publications and concerns disease: 5-year follow-up of the randomised, relating to unreleased and mis-represented clinical SYNTAX trial. The Lancet 2013. data highlighted. It was stated during 381; 9867: 629-638 a presentation at the recent European Association for Cardio-Thoracic Surgery 3) https://www.medpagetoday.com/ annual meeting that “withheld clinical meetingcoverage/esc/81944 data, has impaired the ability of the medical community at large to fully 4) Farkouh M E et al. Strategies for evaluate the impact of TAVI on specific multivessel revascularisation in patients with patient populations”. diabetes. N Eng J Med Dec 2012: 367:2375 As with the traffic light packaging of our 2384 bread-and-butter, researchers have a duty to be open about their work; from the original idea 5) Michael J Mack et al. Transcatheter through the hypothesis to the aortic-valve replacement with a balloonpublished outcomes. expandable valve in low-risk patients. N Eng All well performed J Med May 2019; 380: 1695-1705 and accurately reported research has the potential to 6) https://www.fda.gov/news-events/ be useful even if the findings press-announcements/fda-expandsdo not satisfy the original indication-several-transcatheterquestion, concept or sponsors heart-valves-patients-low-risk-deathmotivation. As intellectuals or-major we have a duty to highlight failings and to raise questions; 7) https://www.tctmd.com/news/ questions that on occasion former-excel-investigator-allegesthe authors’ may not have trial-manipulation-promptingconsidered or more worryingly, vehement-denials deliberately ignored. n
“Journal editors and reviewers have a responsibility to ensure authors are held to account for their work and the reported outcomes.”
the 44 bulletin
The all-female cardiac surgery team Joy Edlin, ST6 Cardiothoracic Surgery, Health Education England, London
n 21st October 2019 Jessica Meir and Christina Koch became the first women to complete an all-female spacewalk. Ahead of the historic event, Koch said: “In the end, I do think it’s important, and I think it’s important because of the historical nature of what we’re doing. In the past women haven’t always been at the table. It’s wonderful to be contributing to the space program at a time when all contributions are being accepted, when everyone has a role. That can lead in turn to increased chance for success. There are a lot of people who derive motivation from inspiring stories of people who look like them, and I think it’s an important story to tell.”1 As Koch is alluding to, a mixed gender workforce is thought to have a positive impact on productivity and outcomes. Some have even gone so far as to hypothesise that with more women in the financial sector, or with more female thinking, the financial crisis in 2008 could have been avoided or at least been a lot less severe.2 In May this year the International Labour Organisation (ILO) published the results of its survey of 13,000 companies in 70 countries worldwide, ‘Women in Business and Management. The business case for change.’ The report concludes that “gender diversity is a smart business strategy” as most companies that replied to the survey reported that gender diversity helped improve business outcomes in terms of both profitability and productivity. The ILO also states that increasing the female workforce boosts gross domestic product at a national level.3 In business, the female way of thinking is often described as deriving from the right side of the brain and includes traits such as altruism, consensus, being people-orientated, emotionally engaged, open and co-operative. It is
easy to see how these traits are relevant in any work place, certainly in medicine and most definitely in the multi-disciplinary environment of the operating theatre. In contrast, male behaviour is often described as associated with taking risk and acting before thinking.4 Realistically this is not the case for all men and may even describe only a small percentage of them and even some women. Moreover, the commonalities in management style between men and women are more numerous and even though some differences exist, they “do not provide a basis for sexual stereotyping.”4 During the last 12 months, Bart’s Heart Centre in London had seven female cardiac surgery registrars in a team of 24 registrars; almost one third women. On a couple of occasions, we found ourselves being part of an all-female theatre team (surgeons, anaesthetists, perfusionists and nurses). Allfemale surgical teams may have previously operated at Bart’s and other units, but this was the first time I was part of one. Often, I have been the only female in a cardiac surgery team and I have grown accustomed to working in a male-dominated specialty. For too long, the world of cardiothoracic surgery (CTS) has been dominated by men and has had a sexist reputation. To work with an all-female team was a milestone in my training and shows the progress the speciality has made in becoming more inclusive. Presently, one fifth of surgeons in England are female.5 In the UK, this number is 12.9%, an increase from 3% in 1991.6 This positive number is also reflected in our specialty. The Society for Cardiothoracic Surgery (SCTS) currently counts 20 female consultants to its membership. Perhaps more all-female cardiac and thoracic surgery teams will be more commonplace in the future. More importantly, having a better balance between the number of male and female team members in all disciplines should
improve outcomes by benefiting from the best traits of both genders, as shown in the business world. To any aspiring female cardiothoracic surgeon: “Go for it”. n
References 1) Dunbar B. Friday’s All-Woman Spacewalk: The Basics. NASA, 17th October 2019. Available on URL: https://www.nasa.gov/ feature/fridays-all-woman-spacewalkthe-basics Accessed on 30th October 2019. 2) Paton N. More senior women needed, now. Management.Issues, 6th January 2009. Available on URL: https://www. management-issues.com/news/5381/ more-senior-women-needed-now/ Accessed on 30st October 2019. 3) Women in Business and Management. The business case for change. Report published by the Internal Labour Organisation, May 2019. Web PDF: 9789221331681[ISBN]. Available from URL: https://www.ilo.org/global/ publications/books/WCMS_700953/ lang--en/index.htm Accessed on 30th October 2019. 4) Sexton DL, Bowman-Upton N. Female and male entrepreneurs: Psychological characteristics and their role in genderrelated discrimination. Journal of Business Venturing, 1990;5:29-36. 5) Moberly T. A fifth of surgeons in England are female. BMJ 2018;363:k4530. 6) Statistics. Women in Surgery. Royal College of Surgeons, England. Available on URL: https://www.rcseng.ac.uk/ careers-in-surgery/women-in-surgery/ statistics/ Accessed on 30th October 2019.
The SCTS Grant Writing Workshop Marius Roman, MD (Cantab), NIHR Academic Clinical Lecturer in Cardiac Surgery ST4 Cardiothoracic Surgery
he SCTS Academic and Research Committee, following feedback received from the current academic trainees, has proposed and supported the organisation of a grant-writing workshop dedicated to Cardiothoracic Surgery trainees and fellows. This year, the inaugural workshop was hosted in the BHF Cardiovascular Research Centre in Leicester, on 14th September 2019. The workshop was attended by 14 participants. The overarching aim of the workshop was to increase the number of successful grant applications led by trainees. The workshop was structured around practical sessions, in which successful grants were critically appraised by small team working groups (4-5 members). All the participants were familiarised with the academic trainee pathway, and gained insight into how to successfully secure a competitive grant. (Figure 1)
Professor Gavin Murphy led the workshop and presented his experience, and discussed the key indicators for becoming a successful academic trainee. Additionally, everyone gained an insight on what reviewer panels consider a strong candidate. It highlighted that the principal marker of academic potential is the ability to generate funding that supports independent research. Key MRC skills were reviewed and consideration was given to integration in the wider research team. It was emphasised that these key skills are developed and honed through research fellowships. Emphasis was placed on how to deal with failures and guidance on successful strategies when preparing a grant application. The key elements of a competitive grant were detailed and included: 1) testing a hypothesis; 2) focusing on excellence; 3) providing evidence of preliminary work; 4) working as part of
an interdisciplinary team; 5) working in the correct setting; 6) targeting the traineesâ€™ aspirations to the stage of your career; 7) tailoring the grant to the requirements of the funding call; 8) making sure that all of the required data fields are addressed in the application; 9) making sure that the final formatting is perfect (typos, wrong font size, and punctuation may lead to immediate rejection by some reviewers); 10) justifying all costs carefully. This event was a great opportunity to network with colleagues within our speciality with an interest in research. Feedback showed an increase in likelihood that the attendees will apply for a grant from 10% to 40% (very likely to apply). The organising team were highly praised for the professional and meticulous organisation of this event. The excellent feedback received will aid to further improve the quality of future meetings. n
Figure 1. Source: https://www.spcr.nihr.ac.uk/files/trainees/tcc-nihr-career-development-opportunities-presentation.pdf
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The SCTS Education Podcast Caroline Toolan, ST8 Cardiothoracic Surgery
nspiration for the SCTS Education Podcast came from my many journeys up and down the M6 motorway. Striving to find a way to boost exam preparation and avoid motorway fatigue I discovered some cardiothoracic surgery themed podcasts, my M6 woes were over! However, these podcasts were chiefly from the USA and I thought it was high time the UK stepped into the frame.
Podcast Facts & Figures
Podcasts are audio programmes distributed over the internet and have their origins in the combined enthusiasm of Adam Curry, a MTV video jockey and coding skills of Dave Winer, a software developer.1 In 2000 they developed code that enabled internet radio broadcasts to be downloaded as MP3 files to iPods. This set the stage for people to independently produce and distribute their own media. Recognition by tech companies followed which led to the creation of dedicated libraries of podcasts in software such as iTunes. The use of the term “podcasting” is widely attributed to journalist Ben Hammersley in his Guardian article “Audible Revolution” in 2004 and “Podcast” became the New Oxford American Dictionary’s word of the year in 2005.1, 2 The popularity of podcasts shows no signs of abating weekly UK listeners increasing from 3.2 million to 5.9 million between 2013-2018.3 Podcasts are largely free to access and have the advantage that they can be downloaded and listened to anytime, anywhere. They are distributed through many online providers including iTunes, Google Play, Spotify and Stitcher. Intermediary podcast “hosting” sites provide audio file storage and simultaneous distribution across many platforms. In addition, hosting sites provide statistics on
number of downloads per episode, timing and geographical location- fingers-crossed for some international listeners!
So how do you go about making a podcast? Well, like many before me, I reached out to the expertise of YouTube. Many videos, a laptop and a microphone later I was ready to roll: lights, microphone, action! However, a podcast is nothing without interesting content. Following approval in principle of my ideas from the SCTS Education subcommittee, I set out to make some episodes. Cindy Cleto, SCTS medical student representative and Simon Xu, a fellow Cardiothoracic Surgery trainee, very kindly agreed to be my first podcast participants. Cindy collected questions from medical students asking what they would like to ask Cardiothoracic trainees; Simon and I answered them to the best of our ability! This episode was a lot of fun to make and produced some excellent content which I hope will be valuable to anyone thinking of applying to the specialty. Subsequently, using the SCTS produced book “Perspectives in Cardiothoracic Surgery Volume IV” as a base, I recorded interviews with contributors from the book, such as Dr Anoop Haridass and Prof Torsten Doenst, to delve deeper into the subject matter of their chapters. In the most recent episode, inspired by Mr Ahmed Abdulsalam, the Aortic Fellow at Liverpool Heart and Chest Hospital, we focused on the challenges of being a left-hander in surgery. We explored the experience of not just surgeons but the wider team including surgical care practionners and scrub nurses. As a
right-hander myself, I think this particular Podcast should be compulsory listening for all but especially those with an interest in training as it provides an excellent insight into the practical struggles that left-handed trainees face. The purpose of the SCTS Education Podcast is to produce content that is informative but also enjoyable. I would encourage anyone to get in contact with their suggestions for future episodes so we can build a fantastic resource for our members and anyone else interested in cardiothoracic surgery. Please send any suggestions or feedback to firstname.lastname@example.org Happy listening and I look forward to hearing your suggestions! n The SCTS Education Podcast is available on iTunes (use the Podcast app if you have an iPhone) and the Podbean website. Soon it will be available via Spotify and Google Play. Link: SCTSEducationpodcast. podbean.com
Other interesting listens (aka my M6 playlist!) l
TSRA podcast: Clinical case discussions from the other side of the Atlantic
Circulation on the Run: has a great theme tune, worth a listen alone!
Surgical Hot Topics: Produced by the Society of Thoracic Surgeons; policy, career and clinical discussion
References 1) Restivo, G. 2019. One Fine Play. [Online] [Accessed 26 October 2019]. Available from: https://www.onefineplay.com/ latest/2019/8/2/a-brief-history-ofpodcasting 2) Hammersley, B. 2004. Audible Revolution. [Online][Accessed 26 October 2019]. Available from: https://www. theguardian.com/media/2004/feb/12/ broadcasting.digitalmedia 3) Ofcom. 2018. Podcast listening booms in the UK. [Online][Accessed 26 October 2019]. Available from: https://www. ofcom.org.uk/about-ofcom/latest/ media/media-releases/2018/ukpodcast-listening-booms
The WSCTS Meeting Sofia, Bulgaria
Professor Vipin Zamvar, Consultant Cardiothoracic Surgeon, Edinburgh
n average, surgeons in the UK attend between three and four professional meetings a year. These are great for networking, meeting colleagues from the past, keeping up to date with the latest advances in the field, and making new friends. Our national SCTS meeting is of course the first choice for all of us; the annual EACTS meeting, the biggest meeting in the world, is also on our radars. May I introduce you to the annual WSCTS meetings? The World Society of Cardiovascular and Thoracic Surgeons is an international society that is a broad church of cardiac, vascular, and thoracic surgeons. Rather than being a society for surgery, we are a society for surgeons. (A fine but important difference). I first came in contact with WSCTS in 2012, when I attended the Vancouver meeting. I bid for Edinburgh to host the 2015 meeting. The Edinburgh bid was successful, and we hosted the WSCTS meeting in Edinburgh in 2015. Many UK surgeons who attended the meeting will remember it fondly. (Bill Walker received the lifetime achievement award from the WSCTS for his contributions to Thoracic Surgery). This year the WSCTS meeting was held in Sofia, Bulgaria from the 6th to 8th September. Professor Genko Nachev was the chairman, and he organised a fantastic meeting, with some of the best-known surgeons from across the globe as faculty. The meeting was held at the National Palace of Culture in Sofia, and was inaugurated by the Prime Minister of Bulgaria, Mr Boyko Borissov. Coincidentally, 6th September also happened to be the Unification Day of Bulgaria. In 1885, on this day, Eastern Rumelia was united with (Northern) Bulgaria; and the modern country of Bulgaria was formed. This was the culmination of a long struggle on the part of Bulgarians to wrest back Rumelia from the Ottoman Empire.
Against this Figure 1 backdrop, the WSCTS meeting opened with the Prime Minister at the helm. The National Guard of Bulgaria displayed a classical military ceremony which included the playing of drums, and a march-past in the main hall. The Prime Minister spoke briefly about the history of Bulgaria, and how Bulgaria was meeting the challenges of the modern era. We in the UK take the NHS for granted, (different countries have different challenges, and they face them in different ways). The Minister of Health was also present, and he lauded the rapid strides in making healthcare available to all Bulgarians. At the meeting, the Bulgarian government also issued a stamp (Figure 1) to commemorate the WSCTS meeting in Bulgaria. This postage stamp was designed by Viliam Kitanov, and features a surgeon operating. It was a unique privilege for the WSCTS to be honoured by the country in this manner. The release of the stamp, and the grand opening ceremony set the tone for a great meeting. There were a number of guest lectures from leading authorities, which were essentially state of the art reviews of the topics in question. Many young doctors from across the globe (more than 50 countries participated) presented their research and experiences. One of the advantages for all the junior doctors was that their abstracts were published in the Pubmed-indexed the “Journal of Cardiothoracic Surgery”, a useful bonus, as they climb their career ladder.
The social programme was exotic too. The dinner was set in the Nu Boyana film studios. “Khatron ke Khiladi” the Indian version of “Fear Factor” was being shot in Sofia during that time, so there were many Bollywood players in town. At dinner, we heard lovely Bulgarian Gypsy music, and saw some beautiful dancers showing traditional Bulgarian dance. The delegates enthusiastically took part in some of the Bulgarian line dances. The next WSCTS meetings will be held in St Petersburg (17th to 21st September 2020), and Brazil (Sept 2021). I would ask all of you to consider attending these meetings. These are meetings with a difference; wonderful locations, fantastic academic programmes with great learning, and once the sun sets, wonderful social programmes that will always be remembered. In addition, you will make friendships from across the globe. Over the last 7 years, I have met hundreds of surgeons from across at least 60 countries, and many of them I can now call close friends. There is a wonderful world out there, waiting to be explored. It is just like opening Narnia’s wardrobe door. Come join WSCTS and come to St. Petersburg this September. n
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Cadaveric simulation â€“ the way of the future? Aleksandra Bartnik
he role of cadaveric simulation in cardiothoracic training has been growing in significance in recent years with some deaneries incorporating it into their compulsory regional teaching. Several factors have been implicated, including growing interest in simulation as a means of acquiring and improving surgical skills, as well as improved preservation techniques leading to greater realism and physical comfort
of the learners during the courses. As an ST5 trainee in cardiothoracic surgery in the East of England, I have had the opportunity to attend an annual two-day course organised recently by a thoracic consultant Mr Kadlec and taking place at the University of East Anglia (UEA) Cadaveric Laboratory in Norwich. The course is very popular among trainees and faculty alike. In terms of the realism, it is only one step behind the live animal
laboratory in Hamburg, which the national trainees visit three times during their training. When it comes to the benefits for cardiothoracic trainees, it is worth considering where cadaveric simulation lies in the growing body of simulation techniques. An average cardiothoracic trainee would have at some point practiced coronary anastomosis on rubber tubes mimicking blood vessels, used a box
simulator to practice VATS skills and performed a sternotomy and intercostal drain insertion on a pig thorax. These simulation techniques are task specific i.e. they allow the learner to focus on perfecting a certain task by removing the complexities of the environment. What remains unclear is whether performance mastered on these task simulators will be maintained when the learner is put back in a more complex environment. The literature has repeatedly failed to give a clear answer to this question. Cadaveric simulation lies at the higher end of the fidelity spectrum, providing a relatively complex environment but still removing the most important factor in surgical training - the risk to patient. The way the cardiothoracic cadaveric courses are run at UEA addresses several learning needs of the trainees. The first one is performing procedures for the very first time. The junior trainees can familiarise themselves with using the sternal saw to open the chest or practice securely tying off branches of the saphenous vein before attempting one on a patient. On the other end of the spectrum, the senior trainees can perform complex aortic arch replacement or tracheal resections which they would have assisted with but not performed yet. The second learning need involves performing rare procedures. For example, during our courses we practice performing left anterior thoracotomy for emergency access for chest trauma or radial artery harvest which has largely become the forte of the surgical care practitioners. Thirdly, the courses allowed me to “play” with the less familiar instruments such as a Gigli saw to perform clamshell incision or the Octopus stabiliser for off-pump coronary bypass surgery. This is also the place to trial novel and emerging techniques before introducing them in clinical practice, which also turns the faculty into learners. In previous courses, we had
the opportunity to trial out the newest stentless aortic valves and endoscopic vein harvest devices. Personally, having just started my transplant rotation I was able to perform a full harvest of heart and lungs before going on retrievals. Last but not least, cadavers offer the chance to perform anatomical dissection, which many of us would have last done in the first years of medical school. This means we can safely “stick our fingers” in the transverse and oblique pericardial sinuses and see the exact relationship between the phrenic nerve and superior vena cava. High fidelity of cadaveric simulation relates to several aspects. Firstly, thanks to improved preservation techniques, the quality and tactile properties of the tissue closely mimics a living human body. Moreover, the logistics of operating on a whole human body adds
to say that they would like to donate their body for medical education and give written consent. Advertising is not appropriate and therefore most people know about this through word of mouth. Health records are checked in order to exclude potential risk of prion or viral diseases. For people who generously chose to donate, their body will be frozen as soon as possible after death. This dramatically slows down the process of breakdown allowing a maximum of 3-4 months for it to be used. For the UEA cadavers this tends to be a lot sooner. Anecdotally, the cadavers obtained in this way are preferable to those obtained from overseas or using other preservation techniques. Several caveats need to be mentioned when considering cadaveric simulation. The availability of cadavers is limited and therefore it is the moral duty of everyone involved, from course organisers to learners, to make the most of this learning opportunity. Running of the laboratory is costly and therefore funding for the courses has to come from deaneries with help from the industry. Despite best available preservation techniques some of us are less tolerant of the physical discomforts involved. While these aspects prove the point that no simulation is perfect, there is certainly more to be gained than not for the trainees. Cadaveric simulation offers a realistic operating environment suitable for team-based exercises geared to all levels and skills and covering every possible cardiothoracic procedure. Based on the feedback, it can be safely said that trainees value it above any other form of simulation. n
“Cadaveric simulation lies at the higher end of the fidelity spectrum, providing a relatively complex environment but still removing the most important factor in surgical training - the risk to patient.” to the realism. Factors such as patient positioning and manoeuvring around the table come into play. Lastly, the learners come from multi-professional backgrounds including trainee surgeons at all levels, surgical care practitioners and scrub nurses which mimics the theatre environment and potentially translates to improved teamwork outside of the course. I will devote a few words to the process of obtaining cadavers as it is interesting and often somewhat mysterious to the learners*. In the UEA cadaveric laboratory the standard technique is to use fresh frozen cadavers. The donors come from the local population of Norfolk through a carefully ethically-guarded bequethal process compliant with the Human Tissue Act. Individuals contact the UEA laboratory
*This paragraph is based on the interview with Mr Richard Haywood, Clinical Senior Lecturer and Head of Anatomy at the Norwich Medical School in the University of East Anglia which can be found on https://heeoe.hee.nhs.uk/simulation/ cadaveric-simulation
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Society for Cardiothoracic Surgery in Great Britain and Ireland Mentorship Scheme Professor Mahmoud Loubani, Consultant Cardiothoracic Surgeon, Castle Hill Hospital Shyam Kolvekar, Consultant Cardiothoracic Surgeon, Barts Heart Centre
entorship is the activity of giving a younger or less experienced person help and advice over a period of time. The General Medical Council, British Medical Association and Royal College of Surgeons have all advocated the development and provision of mentorship schemes in all organisations. The Society for Cardiothoracic Surgery in Great Britain and Ireland has the moral and professional responsibility to provide mentorship to its members whenever it is required. The era of shortened training and publication of results have introduced a number of challenges to newly appointed Consultants and even established Consultants can run into patches of difficulty. Furthermore, trainee members pose another stream that requires support and nourishment to assist them to achieve their potential and continue to develop and flourish. The terms mentoring and coaching often get used interchangeably, which can be misleading. While similar in their support of someone’s development, they involve very different disciplines in practice. Mentoring consists of a long-term relationship focused on supporting the growth and development of the mentee. The mentor becomes a source of wisdom, teaching, and support, but not someone who observes and advises on specific actions or behavioral changes in daily work. Coaching typically involves a relationship of finite duration, with a focus on strengthening or eliminating specific behaviours in the here and now. Coaches help professionals correct behaviours
that detract from their performance or strengthen those that support stronger performance around a given set of activities. The Mentorship Scheme proposed and agreed by the Executive Committee of the Society is planned to start next year. It will be managed by designated Trustees of the SCTS with oversight provided by the SCTS Executive Committee and administrative support from the administration staff of the Society. It will require the identification of a number of mentors in Cardiac, Thoracic, Congenital and Transplantation of senior standing and the provision of adequate training to provide the required support by the mentors. The scheme is envisaged to have three mentorship streams:
Trainee’s mentorship: The SCTS will collate a list of volunteer mentors and assign trainees to them once appointed through national selection. These are envisaged to remain as a mentor to the trainee throughout their training. The mentor would preferably be in the region of the trainee to facilitate closer contact and also familiarity with regional variations that would affect the training.
Newly appointed Consultants: The challenges faced by a new Consultant are unique but common to all surgeons of other specialities. However, Cardiac Surgeons with individually published results will have more specific problems and pressures. A mentor to help guide a newly appointed Consultant would aid them to
avoid the pitfalls that could affect their career progression and also support them to start developing their surgical practice as well as other areas of a consultant work such as management, leadership, research and education.
Consultants in Difficulty: This group is the most challenging and will require the most care and support. There are two main areas of difficulty, namely surgical competence and outcomes, and interpersonal relationships. Mentorship can be achieved in collaboration with Practitioner Performance Advice Service of NHS Resolution. This service contributes to patient safety by helping to resolve concerns about the professional practice of doctors, dentists and pharmacists. They can design and oversee assessment programmes for Consultants in Difficulty which requires the involvement of mentors. The reskilling or behavioural modification plan can be set between the assigned mentor and the NHS Resolution Advisor and implemented either in the Consultant’s base hospital or at the Mentor’s Hospital with the oversight of Medical directors of both institutions.
Mentorship Scheme Implementation Plan 1) SCTS to send an email to all Consultant members asking for volunteers to be involved as Mentors. 2) Run a Consultants master class focused on Mentorship to coincide with the Annual Meeting in March 2020.
3) Selection of Mentors: i. All Consultants in the UK can be included as mentors for Trainees and newly appointed consultants. ii. Mentors of Consultants in Difficulty required to be: a. Experienced Senior Cardiothoracic surgeon. b. Surgeon willing to give time commitment required either in their base Hospital or in another Hospital and SCTS to support their application for approved leave. c. Part time/retired surgeon with active GMC registration. 4) Training: SCTS Education led by Mr S Rathinam and Mr N Moorjani, have very kindly agreed to assist in organising the Consultants’ Master class of 2020 as a training course for mentorship and have secured the funding for it. This will form the original mentors training package and only consultants who attend this master class or future training can be included on a list of mentors to be held by SCTS. This training will be delivered in conjunction with the Annual Meeting of SCTS initially. n
SCTS Consultant Masterclass - Mentoring in Cardiothoracic Surgery Saturday 21st March 2020 - Celtic Manor Newport Course Directors: Prof M Loubani, Mr S Kolvekar, Mr N Moorjani & Mr S Rathinam 12:30 – 13:00: Registration and coffee
13:00 – 13:30: Lunch
13:30 – 13:40: Introduction
13:40 – 14:20: What is mentoring and proctoring?
14:20 – 15:00: Principles of mentoring and developing mentoring skills
15:00 – 15:20: Mentoring surgical trainees
15:20 – 15:40: Mentoring newly appointed consultants
15:40 – 16:00: Coffee
16:00 – 16:15: Clinical Immersion and Proctoring: Industry perspective
16:15 – 16:30: Clinical Immersion and Proctoring: SCTS perspective
16:30 – 16:50: Mentoring consultants in difficulty
16:50 – 17:20: NHS Resolution Practitioners Advice Service
17:20 – 17:50: Invited Review Mechanism
17:50 – 18:20: Mentoring the Unit in Difficulty
18:20 – 18:30: Summary and close
This is a great opportunity for our profession to look after the future generations of our colleagues and to assist others in times of difficulty. It will be another example of Cardiothoracic Surgery taking the lead in another area of practice and we hope that everybody will join in.
Post op Follow up after Lung Resection for Primary Lung Cancer: A SCTS National Survey Syed Qadri, Consultant Thoracic Surgeon, Castle Hill Hospital
ung resection with curativeintend is a standard modality for resectable lung cancer which improves long term survival comparative to radical chemotherapy and radiotherapy. However, regardless of the size and the stage of cancer, there is always a risk of local and/or distant recurrence despite complete resection. Therefore, these patients have been followed up with chest X-ray for 5-years
most commonly. In last 5-10 years, follow up protocol has been reviewed for the diagnostic tool, duration of follow up in the eye of evidence and who would follow these patients, surgeons or physicians. As there is no proven evidence, various pathways exist in various hospitals and they vary in various follow up pathways stages such as surgeons vs physicians follow up, chest x-ray vs CT scan monitoring, variable duration from 18
months to 5 years. There is no standard, national or uniform pathway for follow up of post-operative thoracic surgical patients. Interestingly there is almost no evidence in literature regarding duration of follow up. There is some evidence that lung cancer recurrence is most commonly found within first 2-3 years after surgery. However, there is no strong evidence like CRT or metanalysis on recurrence and duration of surgical follow up. >>
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Therefore, I decided to conduct a survey with thoracic surgeons of UK and Ireland to find out: l
What is routine practice in various hospitals?
Do surgeons think if post op follow-up needs to be updated?
Is there any consensus on any particular pathway?
What is their suggestion for a uniform national pathway?
The responses demonstrated, interestingly, very variable practice in different hospitals. Only 56% responses show that they have proper departmental protocol for follow up with these patients. 92% responses demonstrated that they follow these patients up for five years while 8% follow up for 18 months. Chest X-ray is still a first choice of investigation for follow up in 72% while either CT scan alone or combination of both is used for follow-up in 28%. Indication of CT scan is very variable. 33% responses show that it is only indicated when there is suspicious of cancer while 14% decides on post op stage of cancer. 28% of people repeats yearly, 20% 6-monthly, 2.8% on every visit and 2.8% on 2-yearly. Regarding discharging patients to respiratory physicians for follow up, though 78% of surgeons referred to physicians but it is due to various reasons such as distances, peripheral hospitals, and patients’ choice. Timings of follow up are variable as well. 22% of surgeons follow these patients themselves. 92% of Physicians follow these patients up for 5 years, 4 years by 3% and 18 months by 5%. Regarding the discussion in MDT, 82% physicians discussed only if there is a suspicion of recurrence of cancer. Nurse-led and telephone-led follow up is a recent development in post op surgical follow up pathway. 44% of responses showed
that they have an organised nurse-led follow up in OPD. However, there are various reasons of not having nurse-led follow up such as physicians’ follow up, surgical follow up, financial restriction etc. Regarding telephone-led follow up, only 22% surgeons do have nurse-led follow up but with variable protocols. I asked question “Should we have a national uniform pathway?” Only 76% surgeons agree to have a single uniform follow up pathway. There are interesting comments regarding a standard pathway for all as below:
does not impact on survival”, “We have data supporting 6 monthly CT for 2 years and then annually - identifies radically treatable new primaries and recurrence in many cases”. In summary, standard departmental protocol is not present in all hospitals. Although there is no strong evidence in literature, 5 years is still a standard duration for post op follow up in majority of hospitals. Despite low yield, Chest X-Ray is still first investigation of choice to find out a recurrence. However, CT chest is getting more popular for using a first choice for recurrence. Studies have shown that recurrence is more common in first 3 years. A study regarding the timing of recurrence published in 2010 showed that 80% of recurrence, both local and distant, develops in first 3 years. This survey shows various timing of CT scan in different practices. Although majority of patients are still followed up for 5 years, there are still different opinions. Nurse-led and telephone-led follow up are in discussion. Nationally the management of lung cancer is very standard under the NICE guidelines. We all have a standard guided pathway for investigations of lung cancer, standard MDT and decision-making meetings, standard lung surgical procedures and techniques, almost standard post op management, almost standard and similar complication rate, standard operative mortality and standard quality analysis of the results of all surgeons. Then why don’t we have a standard post op follow up pathway for all? No doubt it should be evidence based, however, there are no strong evidences in literature about duration of follow up, choice of investigation and responsible person for following these patients. There are some studies that can be used or general consensus among our surgical group that can be produced to develop standard recommendations until we produce strong evidences in the form of randomized control trials. n
“Why don’t we have a standard post op follow up pathway for all? No doubt it should be evidence based, however, there are no strong evidences in literature about duration of follow up, choice of investigation and responsible person for following these patients.” “There should be guidance, but implementation must fit with local population. Patients do not want to travel into central London from outside M25 for follow up”, “National cancer surveillance team should follow up all lung cancer patients with CXR and CT scan at intervals”, “Need better evidence for optimum follow up protocol first”, “There are NICE guidelines. All four trusts have formulated something on that basis”, “needs to be evidence based”, “Guided by evidence - i.e. CXR and not CT. Symptom driven. Nurse led”, “It already is part of discussion in the thoracic sub-committee”, “Needs to be NICE mandated. Disappointing absence of recommendation in draft guidance”, “Should be cancer team follow up with protocolled CT scan”, “Only good RCT evidence is CNS Instead of doctor. I’d prefer CT to CXR”, “A standard based on evidence for frequency and radiology”, “don’t know but happy to follow an evidence based pathway including imaging etc”, “No follow up as probably
Lung Transplantation A very thoracic specialty ignored completely by UK Thoracic surgeons Muhammad Asghar Nawaz, Post-CCT National Transplant Fellow â€“ Manchester Thoracic Robotic Surgery Fellow â€“ SCTS & JCUH Middlesbrough
he number of adult lung transplants performed in the recent period showed a peak of 210 in 2014 but has since gradually fallen. The DCD lung transplantation in the preceding year represented approximately a quarter of the total activity. Although during the last decade, 1723 lung transplants were accomplished in the UK, the partial lung transplant counted none. The number of patients actively waiting for a lung transplant has generally increased year on year and the median waiting time to lung transplant for adult is 326 days. Nationally, within six months of registration, 33% of lung patients had been transplanted and 7% had died. Three years after listing, 60% have been transplanted and 20% had died. On May 2017, the superurgent and urgent lung allocation schemes were introduced for prioritisation. The unadjusted UK post-lung transplant survival for 90 days, 1 year and 5 year is 88.8% vs. 80.8% vs. 56.2% respectively. The department of health is not only keen for increasing the number of lung transplants but also concerned to improve the 5-year survival. How can we achieve this? Well, there are lot of things which NHSBT is going to address, for example, increasing the number of potential donors, making the most of donor organs, increasing retrieval and transplantation of organs, resuscitation of retrieved organs and systems to support organ donation and transplantation. There is also need to improve the transplant capacity and surgical expertise not only to achieve the planned 5% increase by 2020 but also to attain the better long-term survival. Out of six UK cardiothoracic transplant centres, five provide the lung transplant service, all in England. Surprisingly, there are only two thoracic surgeons who participate just for
the lung transplant rota in the entire UK. Their job plan does not include transplant assessments, MDTs or M&Ms. Having said that, the Irish Lung Transplant program, run purely by two thoracic surgeons, has succeeded significantly. Thoracic surgeons are doing a virtuous job for their program. With the change in the cardiothoracic curriculum, more surgeons are trained either as cardiac or thoracic with minimal experience in non-dominant specialty. Although the current team of cardiac surgeons providing the lung transplant service is doing an excellent job, new consultants have relatively less experience in thoracic and the future cardiac consultants will have minimal. There has been no mix practice cardiothoracic consultant surgeon appointment for the last 5 years or so, meaning they do not deal with thoracic conditions on a routine basis. Fear of the future is, with the new cardiothoracic curriculum, the trainees will have up to12 months of non-dominant specialty experience, which means a cardiac transplant surgeon of the future would be expected to do the lung transplant with just one-year thoracic experience? If we wish to improve the lung utilization and push the boundaries then with this existing framework, I am afraid the future of lung transplant is uncertain. But there is a lot that could be done by thoracic surgeons being on board both for the retrieval and transplant programs by their valuable service. Following training, they can boost the retrievals and assess the lungs proficiently. They can also help progress the transplants, both for the explants and implants. This will assist increasing the number of lung transplants overall. I believe lung transplants have a potential, where a lot
can be achieved by pushing the boundaries by the unorthodox thoracic surgeons. This includes, but not limited to, lobar implant, back table lung volume reduction surgery including anatomical (segmentectomy / lobectomy) and non-anatomical (wedge resections) to accommodate the size unmatched lung in a smaller chest cavity. Previous pleurodesis is no more an absolute contraindication but sometimes lung explant could be challenging e.g. previous pleurectomy, thickened pleura due to asbestos exposure etc where a thoracic surgeon would be valuable. They can also help deal with the post-transplant airway problems including rigid and fibreoptic bronchoscopy and airway interventions e.g. dilatations, stents etc. All this experience would vice versa make them better thoracic surgeons, as they would have then performed complex intrapericardial pneumonectomy, familiarity with the ECMO/CPB use and doing bronchovascular sleeve resections. During my fellowship, I have performed a number of the above-mentioned procedures making me a poised confident thoracic surgeon from personal experience. Robotic is the future of thoracic surgery and if we have a lot of experience in bronchovascular anastomosis during transplantation we can easily translate this in our robotic practice to do bronchovascular sleeves for lung oncology. This is my personal feeling while learning robotics and transplants. Being honored with the first of its kind National post-CCT Transplant Fellowship of this peculiar program, I can recommend the thoracic trainees to consider transplant rotation during their training. I would suggest cardiothoracic trainees should have at least 6 months of transplant rotation as part of their training. n
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Thiel Cadavers for Training in NEW Minimally Invasive Surgical Aortic Valve Replacement (SAVR) Techniques Fraser W H Sutherland
ontinued evolution and development of minimally invasive techniques is fundamental to the advancement of modern cardiac surgery. However, safe and widespread adoption of minimally invasive cardiac surgical procedures requires practitioners to undertake extensive training prior to commencing surgery on patients. Models that accurately reflect normal anatomical and physiological conditions of tissues encountered during live surgery are critical to providing effective training simulation for surgeons. Thiel-embalmed cadavers have multiple advantages over other surgical training models and may now be considered the ultimate high-fidelity training model for learning minimally invasive cardiac surgery.
Minimally invasive techniques have revolutionised the surgical treatment mitral valve disease. Mitral valve repair is now routinely performed through a tiny periareolar incision. In experienced hands, these procedures are a joy to watch and the cosmetic results are truly remarkable. These tiny incisions have many advantages beyond cosmesis alone. The much reduced blood loss and diminished postoperative pain associated with the less invasive access facilitates early discharge from hospital and prompt return to normal activities. From a financial perspective, minimally invasive mitral procedures are capable of delivering operational efficiencies and cost savings. Whilst aortic valve surgery is increasingly performed through moderately less invasive incisions (partial sternotomy
or right anterior thoracotomy) there is still much progress still to be made in making these incisions less invasive. Myself and others have demonstrated that a totally endoscopic and/or off-chest approach to aortic valve surgery is feasible. However, realising this goal for patients routinely will require a commitment to acquisition of new skills and suitable training models.
Cardiac Surgery Training Models
Computer based virtual reality simulators and video box devices have been developed for educational training in laparoscopic surgery and seen limited use in training minimally invasive mitral surgery. However, these models generally lack the complex anatomical relationships observed in cardiothoracic surgery and suffer from an absence of tissue feedback which is important in aortic valve surgery. Animal models can provide highfidelity training in relation to tissue handling and accurate replication of conditions encountered in operations on the vasculature. However, the usefulness
Figure 1 Initial skin incision on Thiel cadaver (left panel) and mobilisation of tissues at the thoracic inlet (right panel)
of animal models in aortic valve surgery is curtailed by major dissimilarity in anatomy between animals and humans and the fact that operations on aortic valve are performed on the arrested heart. Many doctors also share our belief that the use of live animals for training in surgical techniques is both unnecessary and unethical. The lack of realistic physiological features in current virtual simulations and inability of animal models to accurately replicate complex human anatomy means that there is currently no substitute for human cadaveric models.
Traditional Cadaveric Preparation
Whilst the various preservation techniques are equally capable of providing models with realistic anatomical relationships, training in minimally invasive aortic valve surgery requires preservation techniques that firstly leave the vasculature patent for proper exposure of the aortic valve and secondly retain some pliability of musculoskeletal tissues so that access conditions can be replicated.
performed remarkably well during training. These surgeons went on to perform First-in-Man cases successfully thus validating the surgical techniques and method of training. The realistic preservation of colour and consistency of tissues enabled accurate simulation of every step of the procedures (Figures 1-3).
Figure 2 Adjustment of CoreVista® Retractor light settings (left panel) and preparation for insertion of the transthoracic aortic clamp (right panel)
We believe that Thielembalmed cadavers present a promising training model for minimally invasive cardiac surgical procedures. The high anatomical accuracy of these models coupled with the preservation of tissue flexibility and low burden of intravascular fixed material particularly favours training in minimally invasive aortic valve procedures. To the extent that accomplishment of certain surgical skills requires motor memory, it is impractical for individuals to practice the same surgical procedure on multiple cadavers so repetitive training in specific surgical manoeuvres may still best be delivered by virtual reality simulators or low fidelity models. Nonetheless, Thiel-embalmed cadavers present the most promising and realistic simulation of living human tissue available at the moment and in the absence of other high-fidelity models provide the most important tool for advancement of surgical training in minimally invasive techniques in general and aortic valve replacement in particular. n
“Thiel cadavers have been used for advanced training in several other surgical specialities, most notably in learning complex intra-abdominal procedures such as laparoscopic colectomy.” Formaldehyde-based tissue fixation is currently the most commonly used method of donor body preservation. Formaldehyde is economical and has potent antiseptic and tissue fixation properties that make it well suited for teaching basic human anatomy and surgical dissection. However, it imparts an extreme rigidity to tissues and, when mixed with blood, causes rapid coagulation. Removal of this material from the aorta is both frustrating and time consuming. Finally, the toxic and unpleasant odour emitted during storage and handling creates an unpleasant environment for training. Fundamentally, however, the lack of tissue flexibility and presence of solid, fixed material inside the aorta limits the suitability of formaldehyde-fixed cadavers for training in novel, minimally invasive, aortic valve surgical techniques.
embalming methods do not release harmful substances into the environment. Thiel cadavers have been used for advanced training in several other surgical specialities, most notably in learning complex intra-abdominal procedures such as laparoscopic colectomy. To date, their use in cardiac surgical training has been very limited. We have used Thiel-embalmed cadavers iteratively to develop a step-by-step guide to performing surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) through a novel transcervical access. Operators were trained to perform SAVR and Direct Aortic TAVI through a short transverse incision in the neck. Thiel-embalmed cadavers
Unique Advantages of ThielEmbalmed Cadavers for Training
In 1992, Thiel presented a novel preservation method which produces soft and pliable cadavers. Despite the considerable cost and time associated with preparation and storage of bodies, Thielembalmed cadavers retain significant joint and tissue pliability rendering such cadavers ideal for training. A small amount of soft intravascular residue is typical but this is easily removed and importantly Thiel
Figure 3 Completion dilatation of Perceval® prosthesis is followed by detailed inspection of the implanted prosthesis on-screen
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SAS doctors and clinical fellow satisfaction with Cardiothoracic training and career progression in the UK Anas Boulemden FRCSEd (CTh), Senior Fellow in Cardiothoracic Surgery Ahmed Abbas, Clinical Fellow
n the UK within cardiothoracic surgery, there are over 250 Specialist doctors and associate specialists (SAS) and clinical fellow doctors who are not enrolled into a national training program, however, their contribution to patient care, service provision and to the progression of the speciality is crucial. Over the past few years, the SCTS started engaging fellows and SAS doctors via courses and scholarships, these sessions were very well received with positive feedback from fellows. This survey questionnaire aims at further exploring the shortcomings in the process, aspirations and views of fellows and SAS doctors vis-a-vis their training and career progression. SAS doctors and clinical fellow doctors in a non-National Training Number (NTN) program will be referred to as fellows.
› 1 OPERATING THEATRE TRAINING
Approximately 40% of respondents either agreed or strongly agreed and 40% disagreed or strongly disagreed.
The survey was powered by SurveyMonkey and was open for about 4 months (July 2019 – October 2019). It consisted of 10 questions encompassing four main domains: operating theatre training, research and teaching, Certificate of eligibility for specialist registration (CESR) application and career progression, and access to professional development. Likert scale was used to rate the respondent answers, ranging from ‘strongly disagree’ to ‘strongly agree’ (1 to 5). The survey was circulated via the SCTS education mailing list and sent to individual emails.
Results There were 91 responses in total (approximately 36% response rate).
unlikely or very unlikely that they would achieve the indicative Cardiothoracic operative number.
I have satisfactory access to teaching opportunities in the operating theatre, in my current placement
I feel confident that I will reach the indicative number of 250 major cardiothoracic operative cases within an average period of 8 - 10 years (at registrar level) Approximately 30% of fellows answered that it was likely or very likely that they would reach 250 major cardiothoracic cases towards the end of their training. However, over 40% stated it was either
Respondents were asked to elaborate on their answers, whereby comments ranged from no chance of achieving the 250 cases, possibly will be achieved to already achieved. Most of the comments alluded to the lack of theatre opportunities with no clear set educational pathway. These are some of the comments: ‘Already reached’, ‘220 cases done’, ‘already on specialist register’, ‘No chance’, ‘very limited theatre opportunities’, ‘Non-NTNs are used for service cover’.
› 2 RESEARCH AND TEACHING Do you have an intercollegiate surgical curriculum programme (ISCP) account?
40% of respondents agreed or strongly agreed with regards to departmental support towards achieving specialist registration through the CESR pathway whilst 30% of respondents disagreed or strongly disagreed.
› 4 PROFESSIONAL DEVELOPMENT AND TRAINING OPPORTUNITIES I am overall satisfied with training opportunities in my current placement
Are you allowed a funded study-leave at least once a year?
› 3 CESR APPLICATION AND CAREER PROGRESSION I applied or plan to apply for the certificate of eligibility for specialist registration (CESR)
Approximately a third of the respondents were satisfied or very satisfied. 40% were dissatisfied or very dissatisfied while 26% were neither satisfied nor dissatisfied.
In your current placement, what percentage of your time do you dedicate to each of these activities?
64% have applied or plan to apply via CESR. It should be noted that some respondents may already hold specialist registration and thus do not need to apply through the CESR route.
I have enough support in my current department to achieve CESR application requirements
The majority of the respondents spent most of their time in the operating theatre and performing clinical duties. There was also evidence of participation in other activities including governance, teaching and managerial tasks. Most respondents had very limited time dedicated to research.
“A high percentage of respondents were dissatisfied across all domains of training and career progression.” >>
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What aspect(s) of training would you like to improve on further in your current placement? (You are allowed up to 3 choices)
Suggestions Department Related A job plan with time allocated for research and academic work Allocate time and fund for SCTS activities Same opportunities as NTNs A bit more hands-on opportunity An arranged program of training in theatre Monitoring step by step the progress of registrars It would be good if the department monitors the number of first operator cases done by non-NTNs’ Career progression shall be part of the job description and contractual obligations Attachment to one consultant per year
It was evident that respondents aspire to have more training opportunities in the operating theatre (81%), followed by a willingness to be involved in research activities (48%) and want a dedicated educational pathway (i.e. through ISCP) (43%). Approximately a third of the respondents would like further support and guidance with their exit exam preparation, as well as with managerial and leadership roles.
Critical appraisal, statistics and publication support SCTS Related I wish the SCTS had a process to monitor progress Dedicated SAS curriculum/requirements by SCTS Leadership courses Managerial course
Are you a member of the SCTS?
Other A training pathway required for clinical fellows even 30% of trainees
Discussion and recommendations
Respondents comments and suggestions Respondents were asked to comment on their current training and provide suggestions on the support they wanted from their department or the SCTS. There were 20 comments in total and all comments are summarised in the tables (below and top right) in the respondents’ own words.
While several fellows were satisfied with their training and career progression, a high percentage of respondents were dissatisfied across all domains of training and career progression. The results of this survey underline important areas for improvement in the training of cardiothoracic fellows, who play a key role in the speciality. Over the last few years, the SCTS have been instrumental in involving and supporting cardiothoracic fellows through Ionescu scholarships, fellowships and two courses a year held regularly at Coventry. Based on the results of this survey and our own experience, the following recommendations can be made: l
Increasing the number of educational courses dedicated to fellows to 4 a year; namely professional, clinical, wet lab, and a FRCS exam preparation courses.
Consider organising dedicated Cardiothoracic CESR courses regularly.
Support from SAC and SCTS to outline a standardised pathway for training and career progression for fellows, which can be translated at department level.
To create an official database of non-NTN fellows across the UK that will help with future communications.
Thank you Difficulty in getting study leave funding for aspirational courses e.g. EACTS It has been a useful move. The SCTS helped me a lot not to feel completely isolated. ISCP should be removed – it’s a waste of time and money Very minimal support Minimal, if any, support from SCTS or trust
Conclusion We showed that there are many areas of improvement in the training and career progression of cardiothoracic fellows (non-NTN’s). It needs a sustained effort to implement changes. n
Reflections on moving a hospital David P Jenkins
n May of 2019, we finally opened the new Royal Papworth hospital in south Cambridge. After 100 years at a small rural village, Papworth Everard, we have moved 15 miles to a purpose built state-ofthe-art hospital on a biomedical campus fit for this century. In writing this, I wanted to share some personal reflections that may be useful to others who make future equivalent transitions. In the last few years, we have coped with multiple additions to our usual workload; a change from paper notes to a brand new electronic medical record, relocation of some administration staff offsite, the loss of some experienced and trusted colleagues, equipping and moving into a brand new building, and finally a full CQC inspection just after the move. All of this has taken
place while continuing the business as usual of healthcare. Due to some unfortunate timing on my part, I have had the dubious privilege of being the clinical director for surgery and transplantation during this time. What is remarkable in retrospect is that it has happened relatively smoothly, and now 6 months since we did the first operation, it feels as if the old hospital is a very distant memory. Another revelation is how quickly staff adapt to the changes, including consultant surgeons thought to be set in their ways. Although we all miss our old comfortable private offices, we have put up with our new hot desking PFI environment better than I anticipated and there is a benefit that we probably see each other more on a daily basis than we did before the move.
Some of the things we learnt were fortuitous, but have proved rather important. As some may know, our original date for relocation was changed twice due to delays with the building, mainly due to the need to change the external cladding. We therefore moved in May. This worked out very well and should be considered in future planning of similar transitions.Staff were able to have Easter holidays before a general leave embargo for a month around the move period. We were running on both sites for a two week period with a transition date when emergencies changed admission from the old to the new site. There was a very positive feel good factor in the long sunny days in the first few months post move, and tired staff had summer holidays to recuperate. The >>
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The old theatres
new surroundings also looked at their best and experiments with new commutes were easier in the summer. Reduction in elective activity was important for surgery. We did the same at the time of the transition to the new electronic medical record. This meant that there were fewer in-patients at key times when staff were busiest with other distractions. For two weeks before the move we did less elective surgery, we ran a few theatres for a week at both sites and emergency admissions transitioned from the old to new site at noon on 1st May, just as we finished the first cardiac surgery case in the new theatres. Coordination with local ambulance services was important and the final in-patients, including some on ICU, were moved in one 12 hour period over the following Saturday. Some on ECMO and mechanical circulatory support were moved a few days earlier. I remain relieved that no patients came to any harm during this exercise, and it is a real testament to the dedication of all the teams that weekend. However, one cannot expect on-calls to be conveniently quieter than usual, and on that first day our cardiology colleagues encountered an extremely busy PPCI service. Reviewing our M&M figures there has been a temporary reduction in surgical activity, but no increase in mortality or morbidity. We built up activity on the new site relatively slowly as almost everything, apart from the cutting and sewing, takes longer in unfamiliar surroundings with new portering and facilities management
part of the PFI deal. Indeed, the operating has been the easiest part. Six months later I don’t think we are yet as efficient as we were on the old site and 3 pump days still take longer without the convenience of anaesthetic rooms. There were concerns about IT and communications, and these proved justifiable. The IT systems worked as well (or poorly, for those who know Lorenzo) as previously, but the changes in bleeps, telephone numbers and systems took longer to get used to, and are still not perfect. We all learnt to rely more on our mobile phones, even when in the hospital. However, there are things I wish we could have done differently. I think
the consultants should have been more involved in the planning stages. I suspect this is a common theme, as the consultants are usually fully committed with job plans devoted to patient care, and others can free diaries more easily to attend the important meetings and get more of a voice in the decision making. Assumptions that electronic patient records mean you can be paper free and need fewer administration staff on site have proved wrong. One has to be vigilant not to lose patients in new booking systems when there is an inevitable turnover of staff. Facilities for staff seem to be less critical than those for patients, and although we are catching up, we probably did not build big enough changing rooms, did not have enough on-call rooms and not enough rest spaces for on-call teams. On the positive side, we have had a very successful move, an ‘outstanding’ CQC rating, the Queen who opened our new building, and we now have > 300 individual rooms for our patients, a larger ICU and six new theatres including hybrid facilities. We see consultant colleagues more frequently than we did on the old site, with its multitude of ad hoc extensions and different buildings. We also have easier access to other specialists at our big neighbour, but this works both ways as I found one day rushing through our underground link tunnel with a tray of instruments to help with an IVC anastomosis problem in a liver transplant patient. Not sure what the next 100 years holds for our new site, but I hope the rate of medical progress continues. n
The hospital’s new theatres
The challenges for cardiac surgeons in the treatment of infective endocarditis in Persons Who Inject Drugs (PWID) David Oâ€™Regan, FRCS, 2Department of Cardiac Surgery, Leeds Hospitals NHS Trust
ersons who inject drugs (PWID) have a 50-fold increased risk of developing infective endocarditis (IE) and their management is frequently challenging for a variety of reasons. The published literature relating to their outcomes paints a confusing picture in terms of whether there is a predominance of right or leftsided valve involvement, the choice of valve prosthesis and of particular concern is the long-term survival of these patients and the rate of recurrence of cardiac infection. We undertook a review of our experience in the management of 92 consecutive patients between 2006-16. Uniquely, we confirmed the causes of death in 90% of cases which has provided important insights into the likelihood of them returning to high-risk behaviour which leaves them vulnerable to life-threatening infection. The data were presented at the SCTS meeting in March and the paper was recently published.1 Of the 92 subjects, two-thirds had left sided-disease and nearly half (47%) required surgery. Unsurprisingly, the commonest indication for surgery was heart failure complicating left-sided disease. The majority of patients received tissue valve replacements, which removed the potential difficulties of monitoring anti-coagulant therapy had a mechanical device been used. Despite a favourable 30-day mortality rate (15%), long-term survival was very poor and disappointingly surgery did not confer prognostic benefit compared to the patients treated medically. For the group as a whole, the 1, 3, 5 and 10 year survival rates were
poses difficult ethical considerations. Perhaps the use of a written patient contract at the time of first operation would define the relevant boundaries and potential considerations of treatment options in the future? A precedent has been set in the UK where a contract is agreed with recipients of a liver transplant for alcoholic liver disease. All patients were seen by the addiction support services whilst in-hospital. It is a sobering reflection that once discharged a large proportion seemed to return to intra-venous drugtaking resulting in a high-rate of bacterial infection, which most commonly was a second bout of infective endocarditis. This suggests that if there was more effective and prolonged support in rehabilitating these patients then this might translate into better life-time expectancy. In the meantime, we hope that our study will be a stimulus to addressing the pressing issues reported and discussed in this report. n
â€œAny patient with refractory heart failure from an infected and severely regurgitant valve is a candidate for surgical treatment but this particular scenario poses difficult ethical considerations.â€? 74%, 63%, 58% and 44%, respectively. Put bluntly, 52 of the 92, or more than half of the patients, were dead 10 years after first presenting with valve infection. Analysis of the causes of death indicated that a return to drug use was common. 29 deaths were due to further infections, which in the majority (23) was a further episode of IE. Drug overdose and suicide accounted for an additional 15 deaths. A particularly difficult patient subset is PWIDs who present with prosthetic valve endocarditis related to continuing drug use. Our data show that this is sadly common. Any patient with refractory heart failure from an infected and severely regurgitant valve is a candidate for surgical treatment but this particular scenario
1) Straw, S., et al., Long-term outcomes are poor in intravenous drug users following infective endocarditis, even after surgery. Clin Infect Dis 2019, https://doi. org/10.1093/cid/ciz869
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I am a medical student interested in cardiothoracic surgery When should I start preparing? Jeremy Chan, Department of Cardiothoracic Surgery, Morriston Hospital, Wales Amer Harky, Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital
ith an application ratio of 8:1 in 2018 for ST1 run through training, Cardiothoracic Surgery National training number enrolment (NTN) remains a competitive speciality. Preparing in advance is, therefore, crucial in order to successfully getting short listed with good scores and obtaining a national training post afterward. We would like to share a few recommendations for medical students who are interested in pursuing a career in cardiothoracic surgery, hoping that it will guide them to prepare in advance for such a promising career. First, getting exposure into the speciality is the most important step. This can be achieved through elective placements or work experience; this can ensure that you made the right choice and really into this career and ready for fair competition among your peers. Currently, exposures to cardiothoracic surgery in most medical schools are limited, therefore prompting to arrange for electives and placements in cardiothoracic surgery is crucial and should be initiated in advance. This can also ensure that you are demonstrating your enthusiasm in cardiothoracic surgery in the application form and give you more scores at time of application. Moreover, having an Intercalated BSc related to cardiothoracic surgery will also demonstrate your interest and build up your knowledge in undertaking research in cardiothoracic surgery. These steps will rather strengthen your position at time of application as majority of ST1 selection criteria and scores are related to undergraduate achievements and therefore, appropriate time utilization is very important.
It is important to optimize your gain from the elective placement. It is advisable to undertake an audit within the unit, not only to understand the process but also to familiarize yourself with the guidelines, data collection and how to interpret the results and plan further intervention, if needed. This can help you answer many questions at time of interview which could be related to quality improvement projects. Additionally, this can allow you to learn the audit process and present your audit in the local departmental or national meetings which will help you gaining more scores on the matrix. Academically, you will need to get involved into different research projects and this can be achieved through seeking help during your elective placement and networking with people who can help you into conducting research and even publications. Our experience with motivated medical students has been very positives, and those who approached us have got publications and presentation at national levels which aided their application. Therefore, make use of your elective placement and try to get publications while collaborating with other team members. The Society of Cardiothoracic Surgery (SCTS) is an important element of gaining insights into cardiothoracic surgery speciality. It is important to have regular works submitted to the Society’s annual meeting; as this will help you build your career and enhance your enthusiasm toward the specialty. Even if you have not got any work to be presented at the SCTS meeting; try to make efforts to attend the meeting as the lectures/workshops will update you with the most updated practice in most of UK, Europe and in the international
fields of cardiothoracic surgery. The Patrick G. Magee Student Prize, limited for medical students’ work only, is rewarded to the best oral presentations, cardiac and thoracic posters. Having a national prize would significantly boost your CV and your application to both core surgical training and cardiothoracic speciality training. The Society for Cardiothoracic Surgery in Great Britain and Ireland also fully supports medical students and sixth form students who are interested or would like to explore the speciality more; therefore, join and seeks advice from the members. The annual student engagement day allows you to meet and listen to talks from various consultants across cardiac, thoracic, transplant and congenital surgeons. There are also several practical/academic stations to develop basic surgical skills and develop your CV. Surgical Skills course for medical students by Royal College of Surgeons is specifically designed for medical students who are interested in surgery. The course aims to develop students’ basic surgical skills. For example, handling surgical equipment, various suturing and knot tying technique. While the Systematic Training in Acute Illness Recognition and Treatment for Surgery aims to allow student to advance their knowledge on managing acutely unwell patients in the surgical ward. In summary, Cardiothoracic Surgery remains a competitive speciality. Preparing in advance is crucial. It remains challenging but highly rewarding. Your first question remains “Do I want to be a cardiothoracic surgeon?” If yes, please join the speciality and enjoy. n
SCTS-Ionescu nursing and allied health professional award 2019 Louise Wyllie, Surgical Care Practitioner (SCP) in Cardiac Theatres
work as a Surgical Care Practitioner (SCP) in Cardiac Theatres at the Trent Cardiac Centre, Nottingham University Hospital Trust, and was fortunate to be awarded the SCTS-Ionescu Nursing and Allied Health Professional award for my application to establish and manage a postsurgical Atrial Fibrillation (AF) ablation follow up clinic, for which I would like to thank the Society and Mr Ionescu. In Nottingham currently we routinely carry out AF ablation surgery as a concomitant procedure through a median sternotomy. Our centre has plans to expand this program in the future. My award application outlined my aim to travel to America and visit units that have already established a comprehensive follow up programme for patients undergoing AFablation surgery, whether this be via MAZE procedure or hybrid AF ablation procedures. My goal was to understand the principles
of their follow up process with the aim of introducing a similar programme for our patients in Nottingham. I spent my first week in Brooklyn New York, at Maimonides Hospital with their AF coordinator Jini Samuel. Brooklyn is a centre which frequently performs hybrid AF ablation. My second week was spent in St Louis, at the Washington University Hospital, with their AF coordinator Laurie Sinn, Consultant Cardiac Surgeon Dr Damiano and his team. At this centre they routinely perform the MAZE procedure through both Median Sternotomy and Mini Thoracotomy. Maimonides, Brooklyn, is a multicentre hospital and I had the opportunity of attending clinics in the hospital with the surgical team and satellite clinics with the Cardiology EP. My time was spent between theatre, clinic and on the ward/intensive care unit reviewing and educating post and preoperative patients. At Washington University Hospital I was integrated into the team and spent my week following all aspects of their service, from research and lab meetings, pre and postoperative clinics and theatre, to time with the data base manager. This gave me an excellent insight into how and what data they collect and store for the purposes of ongoing patient management, research and further development of their service. They had patients in their database who were still attending
annual follow up 15 years after their ablation procedure. Their patient database was a great way of ensuring consistent follow up and accurate data collection, which I believe, in turn, will translate to improved patient care. I had a fantastic experience and was fortunate to spend time in two centres that carry out AF ablation in different ways and learn from both these programmes. One area of interest was the protocol surrounding the stopping of anti-arrhythmic and anti-coagulant drugs and the investigations carried out prior to this. In each centre this was slightly different. The way in which continued follow up and data collection was carried out also differed across the centres, as did their patient demographics, unit size and type of procedures being carried out. Experience of both centres has given me ideas for altering their follow up models to tailor them better to the needs of my local service. I aim to produce a follow up programme which is applicable to UK patients, which can be used by other centres after it has been established at the Trent Cardiac Centre, Nottingham. The welcome, support, information and continued contact I received from my visits have given me a solid foundation to start building our own AF follow up program. So far I have established the initial database, based on that used in St Louis. We have a specific patient information leaflet, a protocol for the stopping of antiarrhythmic and anti-coagulant drugs, and a proforma for patient follow up. This follow up will be carried out in a multifaceted manner at specific time intervals. The aim of the Trent Cardiac Centre is to offer a comprehensive program to treat atrial arrhythmias in order to improve quality of life and reduce the risk of stroke. To achieve this we will work in partnership with our cardiology colleagues to provide optimal care and treatment for this patient population. We are due to start our pilot program in December and hope that by the time you read this we will have seen our first few patients in the new AF ablation follow up clinic. n
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Exploring innovative approaches to Enhanced Recovery Programmes (ERP) Michelle Gibb (Clinical Specialist Physiotherapist); Jayne Sharman (Advanced Nurse Practitioner); Hayley Pike (Thoracic Nurse Specialist); Rebecca Boyles (Research Nurse); Rebecca Halpin (Ward Manager)
RP is an evidenced based approach that helps people recover more swiftly after major surgeries and is implemented with differing approaches at individual centres. The AHP team from Glenfield Hospital, University Hospitals of Leicester, successfully applied for, and Figure 1: Procedures performed at Glenfield in 2019
were awarded the SCTS-Ionescu AHP fellowship. Our aim was to visit other centres across the UK with established ERP, to learn from and improve our current practices. Our unit has 4 Thoracic Surgeons performing in excess of 1,100 cases
per annum (Figure 1) from a large geographical area. We are a busy 25 bedded unit, including 6 High Dependency beds – operating Monday to Friday, (double theatre lists on two days). Currently our ERP consists of Preadmission education in the form of Patient Information Sheets, and a limited preassessment clinic for our complex patients (capacity for 12 patients per week). All of our major lung resections, mesothelioma resection and LVRS patients are supported by the Clinical Specialist Physiotherapist during their inpatient stay. Finally, patients are discharged with a comprehensive discharge booklet highlighting important information to empower them to continue their recovery at home. Once discharged, patients are supported by the Thoracic Nurse Specialists with any post-operative advice/support both virtually by telephone and in our base and peripheral clinics. We have identified areas for improvement within our current practices and sought the opportunity to benchmark against other Thoracic centres. We wanted to explore ideas and strategies already embedded in practice to learn, develop and enhance the ERP for Thoracic patients at the Glenfield hospital. We identified key centres with well-established ERP’s (Heartlands at Birmingham, Guy’s Hospital London, Southampton General Hospital and John Radcliffe in Oxford.) Each centre varied within their practices, but the delivery of ERP was similar. For instance, all centres had pre-assessments clinics which all
elective patients would attend. Patients were admitted to hospital the same day as surgery, facilitated by a dedicated admission lounge, whether it was a multipurpose admission unit or a specific Thoracic admission ward.
Some pre-assessment clinics, patients attended for all pre-operative investigations the same day. There was anaesthetic presence in majority of these clinics, with one centre having a one stop clinic where patients were seen by a Surgeon, Anaesthetist, clerked and investigations performed. Carbohydrate loading was utilised at two of the centres. Scheduling for theatre was normally performed by the consultant, yet one centre had designated case managers to ensure breech dates were adhered to.
Centres found pre-habilitation difficult to access/establish within the ERP and all reported that this was a future service development. The difficulty with prehabilitation was multifaceted; most stated that exercise classes were limited by staffing pressures and available space to hold classes. However, different methods by way of patient information leaflets and education were utilised, often referring to General practitioners for more specific needs.
Post-operative care varied between units. Paravertebral infusions were the main post-operative analgesia. Many centres had no High Dependency beds on the ward but utilised Intensive Care Unit if required. Patients often returned to the wards with no arterial lines or intravenous infusions. Digital drains were attached in theatre which were changed to ambulatory bags post op day one, to facilitate mobilisation and patientsâ€™ home with a drain in situ. Staffing levels were high on wards to facilitate flow. One centre had designated staff for ERP who followed the ward round removing/changing drains, to enhance early discharge. Specialist nurses or physiotherapists provided a discharge talk. Patients on day of discharge went to the discharge lounge with drains in situ, many centres provided no hospital transport. Electronic prescribing was evident in all centres.
In keeping with the ERP early mobility was highly recommended to patients, however none of the centres yet achieved day 0 mobilisation. One centre did have patients sat out in the evening of their operation. One centre had a designated gym on the ward and the majority of patients attended. Patients were all encouraged to get dressed post operatively on day one.
All patients had their first appointment post operatively with the operating consultant. Some centres then referred lung resections back to the respiratory team for follow up. One centre had structured CT Scan based ANP follow up clinic with telemedicine. There was no TNS in follow up clinics.
Research varied between each centre. Some had a designated thoracic research team which consisted of nurses, research assistants and data managers, giving opportunities for patients to be co-enrolled into multiple studies. Whilst other centres had research nurses linked to individual studies. In one centre, research assistants worked closely within the theatre which ensured research was embedded in clinical practice. One similarity across the majority of centres was the practice of screening and recruiting patients to studies, at the point of pre-assessment capturing patients from wider geographical areas. This gave the patients the opportunity to take part without having to make additional travel arrangements. Figure 3: Glenfield Thoracic Team strengths
Figure 2: Staffing of centres
Levels of nursing staffing and specialist roles differed throughout (Figure 2). The number of ANPâ€™s varied between sites as did their responsibilities. Nurse led clinics were run at different centres by Registered Nurses/ ANPâ€™s. The number of physiotherapists varied with some centres having a plethora of physiotherapists and some having to share one with cardiac surgery. Our fellowship enriched our understanding of various practice to make changes in our practice. It has also allowed us to evaluate our strengths (Figure 3). It also offered us the opportunity to share our best practice with the other units. It reinforced our confidence and credibility of achieving a higher throughput of complex cases load with increasing activity with the same bed base in the last decade due to our pathway and team work. We are in the process of developing a Quality Improvement Plan with key strategies and achievable goals in order to continually provide the optimal experience and care for our patients. The team would like to thank the SCTS and Mr Ionescu for supporting our fellowship to allow us to visit centres and the centres for providing us with their time and hospitality, we are very grateful. n
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Applications for fellowships
he Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) is pleased to invite applications for the Annual Fellowships for 2020 sponsored by Mr Marian Ionescu. The broad range of the Fellowships allows all SCTS members to benefit - Consultants, all grades of Trainees, Nurses, Allied Health Professionals and Medical Students. Mr Ionescu has supported the SCTS with his donations to the society for educational activities for many years. As a surgeon, educator and trainer Mr Ionescu has seen the value of helping in the development of trainees, consultants and the teams in which work. In view of the great success of last year’s additional fellowship round and Mr Ionescu’s continued support we are privileged to announce the following fellowships for the wider cardiothoracic multidisciplinary community. The Marian and Christina Ionescu Travelling Fellowship for a consultant: 1 award, £10,000 Eligible applicants include Consultant Cardiothoracic Surgeons currently working in Great Britain & Ireland in all sub-specialties, including adult cardiac surgery, thoracic surgery, congenital cardiac surgery and transplantation surgery. The fellowship is awarded to support a visit to a cardiothoracic surgery centre, which may be in the UK, Ireland or elsewhere in the world. SCTS-Ionescu Consultant Team Fellowships: 2 awards, £15,000 each Eligible applicants include all members of the multi professional team which should include a Consultant Cardiothoracic Surgeon currently working in Great Britain & Ireland in all sub-specialties, including adult cardiac surgery, thoracic surgery, congenital cardiac surgery and transplantation surgery. The fellowship is awarded to support a visit of a team to a cardiothoracic surgery centre, which may be in the UK, Ireland or elsewhere in the world.
SCTS-Ionescu NTN Trainee Travelling Fellowship: 1 award, £10,000 Eligible applicants include nationallyappointed cardiothoracic surgical trainees in Great Britain & Ireland, who have not yet secured a consultant post. The fellowship is awarded to support a visit to a cardiothoracic surgery centre, which may be in the UK, Ireland or elsewhere in the world. It is designed to enhance the experience of the applicant in preparation for a career as a Consultant Cardiothoracic Surgeon. SCTS-Ionescu Non-NTN Surgical Fellowships: 2 awards, £10,000 each Eligible applicants will be cardiothoracic surgical trainees currently without a National Training Number. Examples would be clinical fellows, specialty doctors, associate specialists and staff grade doctors, currently working within cardiothoracic surgery in Great Britain & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world, although applications will be considered for other educational opportunities to enhance the experience of the applicant in furthering their career in cardiothoracic surgery. The applicant should be able to describe how their Fellowship will enhance the specialty of cardiothoracic surgery and the wider NHS. SCTS-Ionescu Non-NTN small travel awards: 1 award, £5,000 each Eligible applicants will be cardiothoracic surgical trainees currently without a National Training Number. Examples would be clinical fellows, specialty doctors, associate specialists and staff grade doctors, currently working within cardiothoracic surgery in Great Britain & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world to enhance the experience of the applicant in furthering their career in cardiothoracic surgery.
SCTS-Ionescu Nursing & Allied Health Professional Fellowships: 2 awards, £5,000 each Eligible applicants include Cardiothoracic Nurses, Advanced Nurse Practitioners, Surgical Care Practitioners, Physician Assistants, Physiotherapists, Pharmacists and Perfusionists, currently working within Cardiothoracic Surgery in Great Britain & Ireland and professionally registered with the NMC or HCPC. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world, or other educational opportunities which enhance the experience of the applicant to further their career in cardiothoracic surgery. SCTS-Ionescu Medical Student Fellowships: 2 awards, £500 each Eligible applicants include medical students at a University in the UK & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre which may be in the UK, Ireland or elsewhere in the world. It is designed to enhance the educational experience of an aspiring cardiothoracic surgeon. It is likely that the successful applicant will have already shown an interest in cardiothoracic surgery, identified a UK consultant mentor and will be seeking an immersive experience during an elective typically at least 4 weeks in duration. n
Deadline for applications: 15th January 2020 Details of the applications can be found at www.sctsed.org Please email the SCTS Education department on email@example.com with any queries.
So you can seal pulmonary veins and arteries — up to and including 7 mm in diameter — with confidence1–6 Comparing the LigaSure™ Maryland jaw thoracic sealer/divider to our original LigaSure™ Maryland jaw device
Compared to systemic vasculature, pulmonary vessels are:
PHYSIOLOGICALLY DIFFERENT Significantly lower blood pressure7
Thinner, less muscular, and more elastic walls8,9
Based on preclinical test results, we narrowed the specifications of two proprietary jaw parameters for the LigaSure™ Maryland jaw thoracic device. These changes significantly improve the reliability of pulmonary sealing performance compared to the original LigaSure™ Maryland device (See Figure 1).11 Figure 1. The Maryland jaw thoracic device delivers statistically significant higher burst pressures on pulmonary veins and arteries than the original Maryland device (p < 0.05; n ≥ 304 per group).11
Burst Pressure (mmHg)
DIFFERENT. BECAUSE IT HAS TO BE.
EVIDENCE-BASED TECHNOLOGY. PROVEN PERFORMANCE.11
Burst Pressures of Pulmonary Vessels Burst pressure for individual seal
90 0 Original LigaSure™ Maryland Jaw Device
LigaSure™ Maryland Jaw Thoracic Device
INHERENTLY COMPLEX Vascular morphology and elasticity of pulmonary arteries varies throughout the pulmonary system10
Pulmonary veins have more collagen content than pulmonary arteries9
These variations highlighted the need to evaluate our devices differently, which led to design changes to our LigaSure™ Maryland jaw thoracic device.11
of seals have burst pressures that don’t meet the LigaSure™ technology performance standard on pulmonary vasculature11
normal pulmonary systolic blood pressure (30 mmHg)7
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My fellowship at Prince of Wales Hospital, Hong Kong Ashok Narayana MBBS, M.S, D.N.B, M.R.C.S, F.R.C.S(CTh), Cardiac Surgery
was in my final year of my Cardiothoracic NTN rotation when I scouted for fellowship options to consolidate my competencies in Complex Aortic Surgeries. I designed a timeline, shortlisted my options and met a few overseas trainers. Finally, I chose the Prince of Wales Hospital in Hong Kong. The next task was to get the funding for the fellowship for which I knocked on the doors of the SCTS Education. The application procedure for the SCTS Education Ethicon fellowship was very streamlined. A detailed application form was followed by a shortlisting. The interview process was to sieve the candidates based on their aspirations, the unique “bring home” skill and finally how to earmark the funds. That moment! Having my name called out as the winner of the SCTS Ethicon Trainee Fellowship award at the SCTS annual dinner was truly memorable! Now with the funds in hand, I started the bureaucratic process. This involved the hospital contract, Medical council of Hong Kong’s approval, Visa permission, Indemnity cover, accommodation and travel arrangements. This took a good four months’ time. Living in a foreign land without the comfort of my family was a challenge! Hong Kong is a buzzing, vibrant and cosmopolitan city. The development of modern transport infrastructure, the high-rise buildings that test the gravitational forces, being the epicentre for technological advances and a financial hub, all make it the city of the future. But the beauty of the place is its preservation for natural habitat which forms 75% of the land area. The spirit of the people to maintain their culture and habitat is commendable.
The Prince of Wales Hospital cardiac surgery division performs 1000 major cases annually and has carved a niche in delivering high quality surgical care in the South East Asian territory. The unit has 2 operating theatres with 30 ward beds, 6 HDU and 6 dedicated cardiac ITU beds. The chief of the unit, Professor Malcolm Underwood, is a reputed Cardiac surgeon. Having trained and practised in the UK, he set up the division in Hong Kong. His strong ethos in training and understanding the trainee needs has
resulted in his division hosting several international fellows. His clinical interests are centred on aortic root and arch surgery, aortic valvular repair surgeries and mitral valvular surgeries. Every day, we would start the ward rounds by 7:30 a.m. and on completion proceed into the theatres. On my 3rd day at work, I remember operating on a young 52-year-old with rheumatic aortic valve stenosis and mitral stenosis. The cases just went on in incremental complexities from thereon. Aortic dissections were referred on
“The working environment was such a good reflection of the NHS working system that it was such a seamless transition for me. The MDT’s were a valuable source of knowledge exchange.” Prince of Wales hospital, Hong Kong
a regular basis, with at least 1 patient a week requiring surgical intervention. Whilst working in the hospital, I was in theatre 5 days of the week and was permitted to scrub in with every team for the entire 5 months of the fellowship. I was second oncall for aortic dissections for the entire time. This great amount of theatre time gave me ample exposure to complex aortic surgeries. I was the primary operator in nearly 50 cases with a mix of aortic dissections, aortic root replacements, arch surgeries, descending thoracic aortic replacements and rheumatic aortic and mitral valve repairs & replacements. I learnt the “Kawasaki” method of surgeries on the arch and thoracic aortic aneurysms from the Japanese surgeon Mr Fujikawa. The attention to detail in haemostasis, the spinal cord protection, the precise dissection and a forethought for preparation for future interventions were the take home messages from every case. I also had an exposure to the Hong Kong technique of aortic surgery from the 3 native surgeons. Finally, I was honing my UK styled aortic surgical skills from my mentor, Prof Underwood. Having to weigh the pros and cons of each and every method, deciding
what would be ideal in every situation and having the various techniques in my armamentarium, made me a competent and confident surgeon. The working environment was such a good reflection of the NHS working system that it was such a seamless transition for me. The MDT’s were a valuable source of knowledge exchange. Different specialists integrating and ideas amalgamating, it was such an enriching experience.
Take Home Messages: l With a good exposure to a high-volume aortic centre, I got to experience managing a wide spectrum of aortic diseases. Working under such experts in this field has helped me enhance my abilities to learn and reproduce the same whilst managing similar patients in the NHS. l Working in a hospital in another country gave me a first-hand experience in the quality of patient care delivery. This, when transferable to the NHS, would help in better governance. l This fellowship will also act as a precedent for future fellowship exchange programmes.
l Interacting with the industry personnel there has inspired me to implement new innovative ideas that will benefit the NHS and I would like to integrate my overseas experience for improving patient care and service delivery.
In conclusion, it is with utmost gratitude that I would like to thank the Society for their generosity which has allowed me to gain the experience. I would extend my thanks to Ethicon in helping trainees to pursue their ambition. I would like to thank my TPD Mr Punjabi and my educational supervisor Mr Jon Anderson for their support during the year. I would also mention a special thanks to Mr Mike Lewis who advised me on this fellowship opportunity in Hong Kong and helped me in time lining my training pathway. I am ever grateful to Prof Malcolm Underwood who has been an excellent trainer and a guide during my training in Hong Kong. Finally, thanks to my wife, Hyma and my daughter, Avni who are really the heroes; who have allowed me to travel to pursue my goal and tolerated my absence for a long time. n
Cardiothoracic Interdisciplinary Research Network (CIRN) Luke J. Rogers (ASSL) Ricky Vaja (ASSL)
he Cardiothoracic Interdisciplinary Research Network (CIRN) has been steadily growing since its inception in March 2018. Over 100 healthcare professionals are now included on the SCTS CIRN mailing list, approximately 150 individuals have helped deliver the networks Variation in Practise (ViP) survey and it has seen its first publication; the proposal for a Cochrane Review (QR Code 1). Alongside this work, the James Lind Priority Setting Partnership has determined the Top 10 key research priorities for adult cardiac surgery and the
NIHR Associate Principle Investigator (PI) Scheme has been launched. These initiatives are laying the foundations necessary to allow the CIRN to develop nurses, AHP’s and surgeons with an interest in research to develop the skills necessary to deliver a portfolio of clinical trials.
Surgical Site Infection (SSI)
Surgical site infection has been identified as one of the Top 10 priorities for adult cardiac surgery research and the focus of the CIRNs first projects. Public Health England (PHE) and the National Cardiac
Benchmarking Collaborative (NCBC) data demonstrates variation in the incidence of SSI across the UK & Ireland that may be explained by a variation in the interventions utilised to reduce the incidence of SSI. To this end, a CIRN review group was formed to explore the published evidence and identify any knowledge gap that exists. This Cochrane Review is currently in the process of being written but has so far identified over 100 randomised control trials, investigating 22 interventions across the perioperative period. The vast majority of these studies are of poor quality with a high risk of bias >>
the 70 bulletin
and demonstrate significant heterogeneity in intervention and outcomes reported. The final results of this will be presented at the SCTS Annual meeting in 2020. Alongside this review nursing, allied health professionals and surgical trainees co-led delivery of a national survey to explore the “Variation in Practise of Interventions to Prevent SSI in UK & Irish Cardiac Surgery Centres”. This survey has now closed and includes 19 cardiac surgery centres and 140 consultant teams. Thank you to everyone that was involved! Without nurses, allied health professionals and surgical trainees across the UK & Ireland this work would not have been possible. All will be recognised for their contribution as per the CIRN Terms of Reference. The final results will be presented at the SCTS Annual meeting in Cardiff. A snapshot of these results from the pilot survey have already been presented earlier this month at the SCTS Research Day in Glenfield Hospital, Leicester. This work will underpin a grant application for funding to investigate the implementation of a cardiac specific care bundle to reduce SSI in adult cardiac surgery. It is hoped that this will be delivered by the CIRN across all centres in the UK where a nurse, allied health professional and/or surgical trainee can be identified as an Associate Principle Investigator. If you are interested in being involved, please email CIRNetwork@outlook.com with your: 1. Place of work 2. Professional role 3. Level of training (if appropriate) 4. Brief outline of any prior experience in research and 5. Details of likely place of work in the future (if known/likely to change)
Patient and Public Involvement
Alongside the work outlined above, we are also in the process of setting up a patient & public involvement team specific to SSI in cardiac surgery to aide both trial development and its eventual delivery. If you know any patients, families or carers who have experience of a SSI after cardiac
surgery who would like to be involved please email CIRNetwork@outlook.com with the subject heading PPI. Further details to come.
Associate Priciple Investigator (PI) Scheme
The West Midlands Research Collaborative (WMRC) and Birmingham Clinical Trials Unit developed the Associate PI Scheme to develop junior doctors, nurses and allied health professionals to be the PIs of the future. The scheme has been fully endorsed by the Royal College of Surgeons (England) and the NIHR Clinical Research Network’s (CRN) Cancer, Surgery, and Oral & Dental Speciality Cluster. It aims to promote engagement with NIHR portfolio research by ensuring all future NIHR portfolio trials led or coled by a Surgical Specialty will have an Associate PI at each open site. This will not only allow healthcare professionals to integrate clinical research as part of their routine clinical training but also gain experience of leading clinical trials locally under appropriate mentorship. Furthermore, this scheme ensures that the contributions of those involved across all NIHR portfolio trials are recognised in a standardised and consistent manner. Endorsement l
Associate PI status will be awarded by the NIHR CRN following recommendation by the local PI and Clinical Trials Unit (Study Coordinator/Trial Manager)
A minimum of 6 months commitment is required
The NIHR CRN will issue a certificate to confirm Associate PI status
To be registered studies must have a minimum of 6 months of recruitment activity left to ensure the checklist activities can be completed (QR code 2)
National Research Collaborative Meeting
The NRCM will take place in Newcastle on 6th December 2019. It is hosted by
Northern Surgical Trainees Research Association (NoSTRA), the Collaborative Orthopaedic Research Network (CORNET) and the Intensive Care and Anaesthesia Research Network of North East Trainees (INCARNNET). The meeting aims to celebrate the work achieved by collaborative groups, develop collaborative relationships and equip delegates to design more complex and robust studies. The course is free, following a £50 deposit to secure your place which is refunded on attendance. Program to be confirmed. QR Codes 1. Cochrane Proposal (left) 2. Associate PI Scheme Checklist (right)
NIHR Associate PI Scheme: https://www.nihr.ac.uk/documents/ associate-principal-investigator-pischeme/11694 Study Registration Form: https://docs.google.com/ forms/d/e/1FAIpQLScdYW2qyKvOtBSf kAD3psY_ Ab0426sZIETeumtSptnjBFQzw/ viewform Associate PI Registration Form: https://docs.google.com/forms/d/e/1F AIpQLScv5XTwVbbRNXhru1jDU70u 1bE8xw3UaHW2XCoYmQ4FIXgcvQ/ viewform
Interventions to prevent surgical site infection in adults undergoing cardiac surgery. Cochrane Database of Systematic Reviews. Cardiothoracic Interdisciplinary Research Network. Cochrane Systematic Review Intervention – Protocol. Published: 15 May 2019. https://doi.org/10.1002/14651858. CD013332 (QR code 1) n
Obituary: Edward (Ted) Thomas Brackenbury Bsc, MBChB, FRCS C/Th, ChM, Consultant Cardiothoracic Surgeon, Royal Infirmary of Edinburgh and Honorary Senior Lecturer, University of Edinburgh
Maziar (Maz) Khorsandi, FRCS C/Th, Kasra Shaikhrezai, FRCS C/Th
ed was born and raised in an impoverished, working-class family. His ailing father, who was the main income source for the family, died as Ted started primary school. Ted managed to escape poverty through excelling at school. He entered Palmers Endowed Grammar school in Essex where his talents were nurtured and where he first developed an ambition to become a doctor. His dreams of becoming a doctor became a reality when he was accepted in Medical School and matriculated at the University of Manchester Faculty of Medicine and graduating in 1984. Following graduation, Ted engaged in multiple surgical rotations including urology (his initial career intention) and cardiothoracic
surgery. He was inspired to become a cardiothoracic surgeon by Mr. Evan Cameron, FRCS (Consultant Cardiothoracic Surgeon, Royal Infirmary of Edinburgh) and changed course in his career towards cardiothoracic surgery. Ted undertook cardiothoracic surgery training at King’s College Hospital, London and subsequently entered formal training on the Trent regional specialist registrar training scheme in cardiothoracic surgery rotating through Glenfield Hospital, Leicester; Northern General Hospital, Sheffield; and City Hospital, Nottingham from 1995-1999. He was appointed as a consultant cardiothoracic surgeon at the Royal Infirmary of Edinburgh in 1999. He contributed greatly to the services at that institution by developing total arterial revascularisation and mitral valve repair techniques. He had a passion for teaching and training. He regularly engaged with the University of Edinburgh and taught medical
students. He trained many registrars who went on to take consultant posts of their own and continue to utilise his methods of operating and training younger generations of registrars. He always considered his generous offer of training as an “investment in the future of cardiothoracic surgery”. Ted also had a passion for medico-legal work and served as an expert witness for numerous cases throughout the country. Ted was diagnosed with a life changing condition in 2011. However, he continued to work and teach until April 2016 when he formally retired from clinical practice. During his retirement years he continued to advise and support his former trainees and his consultant colleagues. He died at the age of 60 in August 2019 after a long illness. He leaves Penny (his second wife) and two children from his first marriage. As his last two trainee registrars prior to his retirement, we were honoured to have learned from him many things, about surgery and life! n
“He was appointed as a consultant cardiothoracic surgeon at the Royal Infirmary of Edinburgh in 1999, and contributed greatly to the services by developing total arterial revascularisation and mitral valve repair techniques.”
the 72 bulletin
Letters to the Editor Indu Deglurkar, Publishing Secretary, SCTS
Dear Editor, it introduces an interactive The decision of the Bulletin to publish Letters to the Editor is welcome news; debate topical issues. element into the SCTS periodical and allows members to raise concerns and Guardian’s Office (NGO), Interestingly, this coincides with the ‘Speak Up’ month, led by the National culture and make Freedom which aims to increase NHS commitment to fostering a strong speaking up to Speak Up (FTSU) guardians more visible. The GMC 1 supports the initiative and suggests that: ging a culture where “It’s important all doctors feel able to speak up. Everyone has a role in encoura people can raise concerns, confident they will be listened to and acted upon.” concerns, often at the Over the past 50 years, cardiothoracic surgeons have been avant-garde in raising establishment, the and es colleagu by ed expense of being labeled “trouble makers” and being ostraciz reform. about brought despite the fact that in some cases it laid bare deficiencies and centres were, and continue My personal observations and experience suggest that many cardiothoracic within the NHS to be, clannish and that the culture of bullying and suppressing voices of dissent g the Griffith report, which appeared and grew out of the ‘managerialism’ of the 1980’s, notably followin practically provided unlimited power of intimidation to Managers. an organisation vie I, for one, am not sure that re-assurance and the measures available within ns of long-term suspicio allay to a hospital ‘Chain of Command, as suggested, will be sufficient a Freedom to speak up 2 of hment recrimination. Only time will prove or otherwise whether the establis respond to the clarion of in each Trust will encourage more Doctors and Health care professionals to ethics and standards. For me the jury is not yet out. s nationally and locally; A totally independent, independent of Trusts, is needed to listen to concern as.” Christm for otherwise the situation may as well be akin to “a turkey voting References 1 GMC News for doctors firstname.lastname@example.org 2 Freedom to Speak Up Guardian - Northern Lincolnshire and... www.nlg.nhs.uk/about/trust/freedom-speak-guardian Keyvan Moghissi The Yorkshire Laser Centre, East Yorkshire email@example.com
To the Editor: We read with interest the “Aortic Dissection: A UK strategy” article in the SCTS August 2019 bulletin. Acute aortic dissection (AAD) is an infrequent but devastating disorder that has a mortality up to 50% if not treated in the first 24-48 hours.1 The immediate and accurate diagnosis of AAD from initial patient presentation is currently reported in as few as 15% to 43% of verified AAD cases.2, 3 Mortality associated with this condition may be significantly reduced if our ability to correctly identify and diagnose AAD at very early stage was further developed and the management was performed at specialist, high volume centres.4 We therefore appreciate and commend the needed efforts to improve patient outcomes by increasing awareness of aortic dissection in the acute setting. We are particularly interested with the education theme mentioned in the bulletin that suggested “every UK medical degree programme” should include “a module on aortovascular medicine”. This is very interesting, and without speculating on how implementable this is, we would like to comment on the effectiveness of this strategy if it will be realised. Firstly, medical schools may see this as another tick box exercise to comply with new recommendations. Similarly, medical students may struggle to see the importance of AAD if it was one module throughout a five- or six-year course. As founder and president of a university cardiothoracic society for many years, our feedback on teach cardiothoracic related conditions has centred on consistency and relevance. In light of this, we propose some initiatives that can put this suggestion forward and possibly in better shape for implantation in real time and daily practice. If aortic dissection were to be tested consistently throughout medical school, in some capacity, students would be more likely to remember the topic and also hold it in high regard considering its lethality and seriousness. This could also work alongside a module on the topic. Additionally, a national junior doctor and student committee, working with local university cardiothoracic societies could serve to hold events, seminars and lectures for students to increase their awareness of AAD without increasing the burden on the medical curriculum. This committee could also focus on research projects that aim to investigate attitudes toward aortic dissection in medical school and provide more targeted approaches to increase awareness for both medical students and junior doctors. Finally, the delivery of this service by junior doctors will, without a doubt, increase their awareness on the topic and the importance of correctly recognising AAD. We can alter the mortality associated with AAD through implementation of such practice and increasing the awareness among the clinicians starting from medical school, and it is important that we do so at the earliest possible opportunity. However, it is also imperative that its education does not become a tick box exercise. It is also important that we do not just instruct our medical students to learn about AAD but also embed awareness of the deadly condition into their development as clinicians. References Spinelli D, Benedetto F, Donato R, Piffaretti G, Marrocco-Trischitta MM, Patel HJ, et al. Current evidence in predictors of aortic growth and events in acute type B aortic dissection. J Vasc Surg 2018;68(6):1925-1935.e8. Doi: 10.1016/j.jvs.2018.05.232. 2 Wu L. The pathogenesis of thoracic aortic aneurysm from hereditary perspective. Gene 2018;677:77–82. Doi: 10.1016/j.gene.2018.07.047. 3 Lau C, Leonard JR, Iannacone E, Gaudino M, Girardi LN. Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Semin Thorac Cardiovasc Surg 2019;31(1):11–6. Doi: 10.1053/j.semtcvs.2018.07.018. 4 Bashir M, Harky A, Fok M, Shaw M, Hickey GL, Grant SW, Uppal R, Oo A. Acute type A aortic dissection in the United Kingdom: Surgeon volume-outcome relation. J Thorac Cardiovasc Surg. 2017 Aug;154(2):398-406.e1. doi: 10.1016/j.jtcvs.2017.02.015. 1
Ter-Er Kusu-Orkar, Amer Harky Liverpool Heart and Chest Hospital, Liverpool
the 74 bulletin
Set by Samer Nashef
Please email solutions by 31/03/20 to: firstname.lastname@example.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE A bottle of champagne or fine olive oil will be sent to the winner of the competition Congratulations to Jonathan Hyde for winning the August 2019 bulletin crossword competition (right) who has selected a bottle of champagne.
1 4 9 10 12 13 15 16/21 20 21 25 26 28 29 30
Mark the return of a thousand bastards (6) Runs unclothed a person with no special powers (8) Aladdin almost ridiculously pretentious (2-2-2) Without a discount at the end this would be jolly steep (8) Fine material from bull or cow? (8) Newsreader’s fix (6) Divulge information twice in prison (4) Amen, Lord, what set out the best decision (3, 4, 4) Escape entry having dined, on reflection (7) See 16 Overheard a salacious hint (6) Bent writer, 15 (8) Approve punishment (8) April’s multimodal component (6) Are they out to lunch or out to get courtesans? (8)
1 2 3 5/14 6 7 8 11/27 14 17 18 19 22 23 24
Boots and pants (6)
Smile, cos’ it could be a grammatical error (8) Kind of undressed and fast becoming lazy (8) In second course... (6) ... met clever chopper, as included (4, 7) Being suave is a mixed blessing (8) See articles producing hate (6) Audience follows quiet clips (6) Which gay dissolute poem rules? (7, 4) See 5 Examine soldiers about death feud (8) Place showing tenfold boost to start of career (8) Rabble-rousing leader gets to the base of the issues (8) Mother and child can make jam (6) Jett’s world (6) Funny top out of sight (6) See 11
Upcoming SCTS Courses - January to June 2020 Date/s
9th January 2020
Surgical Skills in Cardiothoracic Surgery, Manchester
13th – 14th January 2020
ST5A – Intermediate Viva Course – Ashorne Hill, Leamington Spa
15th January 2020
Non NTN Course - Wetlab for SAS Doctors
5th – 7th February 2020
ST6A and ST6B - Cardiothoracic Surgery Sub-Specialty Course – Johnson & Johnson Institute, Hamburg
2nd – 5th March 2020
ST7A – Revision and Viva Course for FRCS (C-Th) – Ashorne Hill, Leamington Spa
10th – 11th March 2020
ST3B – Operative Cardiothoracic Surgery Course – Johnson & Johnson Institute, Hamburg
8th – 10th June 2020
ST8A – Cardiothoracic Surgery Pre-Consultant Course – Johnson & Johnson Institute, Hamburg
ST5B – Non-Operative Technical Skills for Surgeons (NOTSS) Course – Advanced Patient Simulation Centre, St George’s Hospital, London
15th – 17th June 2020
ST4B – Core Thoracic Surgery Course – Ashorne Hill, Leamington Spa
PERCEVAL PLUS ®
THE OPTIMAL MIX Facilitates Minimally Invasive Surgery
Designed for Durability BASED ON A CLINICALLY PROVEN TECHNOLOGY
FREE INNOVATIVE FREE TISSUE TREATMENT
UNIQUELY SUITED FOR ViV* PROCEDURES
VIABLE FOR MULTIPLE VALVE PROCEDURES
SIMPLIFIES COMPLEX PROCEDURES
Available to a Wide Patient Population * Valve-in-Valve
Sorin Group Italia Srl
A wholly-owned subsidiary of LivaNova PLC Via Crescentino - 13040 Saluggia (VC) Italy Теl: +39 0161 487472 - Fax: +39 0161 487316 email@example.com
LivaNova Canada Corp.
5005 North Fraser Way Burnaby BC V5J5M1 - Canada Tel: 1-604-412-5650
INDICATIONS: Europe - The Perceval Plus prosthesis is indicated for the replacement of diseased native or a malfunctioning prosthetic aortic valve via open heart surgery. The prosthesis is indicated for use in adult patients who are diagnosed to have aortic valve stenosis or steno-insufficiency. TOP POTENTIAL SIDE EFFECTS: The risks or potential adverse events associated with cardiac valve replacement with a bioprosthesis include, but may not be limited to: cardiac arrhythmias, death, endocarditis, heart failure, hemorrhage, intravalvular and/or paravalvular leak, stroke or any related neurologic disorders, structural valve deterioration, reoperation and explant. Beyond the previously mentioned adverse events, specific events related to the implant of the Perceval Plus prosthesis may include, but not be limited to dislodgment and/or migration of the prosthesis. The decision to make a transcatheter aortic valve implantation in Perceval Plus compared to other options should be done by the Heart team based on individual assessment of the patient’s conditions. The safety and efficacy of Valve-in-Valve procedures in a Perceval Plus valve have not been established. Valve-in-Valve procedures in a Perceval Plus valve should be performed according to indications provided by the transcatheter valve manufacturer. The decision of using Perceval Plus in patients should be based on a careful individual assessment and limited to cases in which the benefits of using Perceval Plus justify the risks. The available clinical data indicate that using Perceval Plus in patients with other prostheses may result in intraoperative valve misplacement or insufficient leaflet coaptation leading to valve replacement, due to possible interference with the other prostheses. MRI conditional. For professional use. Please contact us through our website to receive instructions for use containing full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Not approved in all geographies. Follow your labeling.
© 2019 LivaNova all rights reserved.
Perceval Plus, an ideal solution for minimally invasive surgery, makes sutureless aortic valve replacement available to a wide patient population Designed for valve durability Based on more than 10 years of successful clinical experience with Perceval.
TRIFECTA™ GT VALVE
Beca u se yo ur p a t i ent s ’ live s matte r.
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 Trifecta and Trifecta GT are all trademarks of Abbott Corporation. © 2018 Abbott. All Rights Reserved. 9-EH-3-7621-01 02-2018