SCTS Bulletin Issue 09

the

bulletin

Issue 09 A January 2021

January 2021

Society for Cardiothoracic Surgery in Great Britain and Ireland

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January 2021

the

bulletin

In this issue...

5 6

From the President: We have so much work to do together Simon Kendall

10

Equality, Diversity and Inclusion in Cardiothoracic Surgery Narain Moorjani

14

SCTS at Ease, Diversity is the spice of life

From the Editor Indu Deglurkar

Women in Cardiothoracic Surgical Working Group

Nursing and Allied Health Professional 20

update Helen Munday

22 Thoracic Audit Update Doug West SCTS Education report: 24

“Per aspera ad astra” January 2021

A Virtual meeting in a Virtual City

Sri Rathinam

SCTS forum nursing and allied professional 29

research Julie Sanders

31

Educational NAHP Subcommittee report

32

The National Heart Surgery Clinical Trials Initiative Gavin Murphy

34

Aortic Dissection Awareness UK and University of Leicester partnership: Patients’ and researchers’ joint effort to optimise screening and treatment pathways in aortic disease Gareth Owens, Riccardo Abbasciano

35

Cardiothoracic Interdisciplinary Research Network (CIRN) Luke Rogers, Ricky Vaja,

Bhuvaneswari Krishnamoorthy

Edward Caruana, Akshay Patel

38

Coronavirus - Trainee Representative Perspective Duncan Steele, Abdul Badran

39

SCTS INSINC present the first ever University Challenge

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: sctsadmin@scts.org W: www.scts.org

LAWS Publishing are proud to be corporate sponsors of Heart Resrearch UK

Rules of (Virtual) Engagement 42

Veena Surendrakumar, Ashvini Menon,

Richard Steyn

Aortic Dissection Awareness Day UK 2020 60

Special online COVID edition

Christina Bannister

43

Is there such a thing as truly ‘elective’ cardiac surgery? Samer A M Nashef

61

The Virtual SCTS National Research Meeting (Third Edition) Marius Roman

Heart Valve Disease Awareness Week 2020 Christina Bannister

Training and COVID-19: A new era?

44

Sashini Iddawela, Celine Gravenor,

Amer Harky

The Birmingham Review Course: 62

“Virtually” The same? R. Alam, R. Steyn,

45

Effect of COVID-19 on use of modern technology towards surgical education

SCTS-Ethicon 2019-2020 Cardiac Surgery 64

Fellowship at Massachusetts General

India Premjithlal Bhaskaran

for the future Luke Holland, Ishtiaq Ahmed

47

Surge in cardiovascular academic work during COVID-19 Aditi Sinha,

Maninder Kalkat

Special Ionescu Fellowships celebrating 50 28

years of the Pericardial valve

58

Development of an online training platform 46

during the COVID-19 pandemic – a change

SCTS Education tutors’ report 26

Debbie Harrington, George Asimakopoulos

27

Society for Cardiothoracic Surgery in Great Britain and Ireland

Cardiac Surgery – A brief history of the 40

future Gianni D Angelini

Sri Rathinam, Carol Tan

3

a regional extra-corporal membrane oxygenation retrieval service

Muhammad U Rafiq, Swetha B Iyer, Fouad J Taghavi, David P Jenkins

50

Authors are the parents of ideas

52

Improvement in the Referral Service for patients requiring urgent in-house Cardiac Surgery Steve Clark, Joy Pringle,

Antony Walker

Espeed Khoshbin, Stephan Schueler

54

From Refugee to Cardiothoracic Surgery in Cambridge Navid Ahmadi, Aman Coonar

55

Manchester Peri-CCT National Lung Transplant Fellowship 2019 - a very unique and first of its kind in UK Muhammad Asghar Nawaz

56

Exploring the uncertainty in procedure choice for empyema - a national survey

57

Royal Papworth Hospital win awards for Papworth Haemostasis Checklist

Jordan Green, Syed Qadri

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Rizwan Q Attia

Minimally invasive valve and AF Ablation 66

fellowship - St. Antonius Zeikenhuis,

Nieuwegein, Netherlands Prakash Nanjaiah

midst of COVID-19

70

Society For Cardiothoracic Surgery and The European Society of Thoracic Surgeons - a prosperous, long-running relationship

Hospital, Boston, USA

SCTS Essential Skills Course in 68

Cardiothoracic Surgery for ST2/CT2 in the

Devika Verma

Re-defining the role of the cardiothoracic 48

surgeon in Coronavirus Disease 2019

M. Kalkat, A. Ranasinghe, H Fallouh

Keng Ang, Mubarak Chaudhry

Nizar Asadi

72

(CATS) Cardiothoracic Surgical Skills Course for medical students and foundation doctors Maria Nizami, Aman Singh Coonar

74

Medical students’ perspectives on cardiothoracic surgery during COVID-19

76

SCTS efforts in audit rewarded with nomination for HQIP Audit Heroes Awards

77

The effects of the COVID-19 pandemic on the future of cardiothoracic recruitment and the need for technological innovation

79

Ria Sanghavi, Raneesha Pillay

Elaine Teh

Sarah Pengelly, Chloe Chia

Book Review: A History of Cardiac Surgery - Ugo Filippo Tesler Frank Wells

80 Crossword the bulletin is published on behalf of the SCTS

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January 2021

From the Editor Indu Deglurkar, Publishing Secretary, SCTS “It is not the strongest species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change.”

Charles Darwin 1809-1882

A

s we head into 2021 amidst a UK wide lockdown, it would perhaps be appropriate to say that we will never go back to the pre-covid norm. 2020 was extraordinarily tragic. The global shock and mental anguish at the loss of 1.86 million lives (and still counting) is an unmitigated disaster and a brutal reality.

However, difficult as it may seem, it is worthwhile to pause and reflect on the challenges, the flexibility and responsiveness, the creativity and innovation, the logistical failures, lessons learned and how we have risen and adapted to the challenges.

Simon Kendall, our President, describes the various challenges and SCTS has been working actively towards the publication of Unit outcomes rather than individual Surgeon outcomes. Narain Moorjani’s article on Equality, Diversity and Inclusion and the formation of a subcommittee of Women in Cardiothoracic Surgery is a welcome addition to the SCTS armamentarium as well as two further sub-committees for innovation and transplantation.

For the first time, SCTS has published a separate Fellowship section compiled by Sri Rathinam and Carol Tan. Our patron Mr Ionescu’s generosity has endowed us to seek knowledge and new skills from far and wide.

The multitude of Fellowships depict continuous learning sought diligently to achieve success in life. For knowledge

to be immortal, it must be dispersed. As Mr Ionescu states, in every Fellowship is hidden a grain of Eternity.

Adaptation is a profound process and Prof Angelini’s article ‘Cardiac Surgery – a brief history of the future’ rightly emphasises that as a fraternity we have been slow to embrace technology. Charles Robert Darwin gave up medicine and transformed our understanding of the

topics covered is a comprehensive representation of the “real world and current issues” such as etiquette with virtual reality, the responsibility and impact of sensible writing, service delivery and developing new pathways in addition to regular Executive updates.

We have to comprehend what was hitherto unthinkable and have a complete overhaul in our work culture. Remote working, dependence on digitisation and the precautions during the pandemic are sensible and practical changes that can be carried forwards. Racial inequalities have to be overcome, diversity has to be respected and embraced. Despite the distancing, the global health crisis has somewhat unified mankind strategically.

Ultimately, as Dalai Lama says “If humanity is to thrive, we must remember we are one”.

You may have noticed that we have introduced a “candid column” and letters to the Editor. We are now introducing a brief “News from the region” and significant achievements. Members have requested for a glossary to explain acronyms used in the articles and this has been incorporated. I thank you all on behalf of the team for the positive feedback and welcome your critique and suggestions as always.

The beginnings of a new decade…

Happy 2021! n

“We have to comprehend what was hitherto unthinkable and have a complete overhaul in our work culture. Remote working, dependence on digitisation and the precautions during the pandemic are sensible and practical changes that can be carried forwards.

Racial inequalities have to be overcome, diversity has to be respected and embraced.” diversity in the natural world and survival of the fittest. His theory of evolution by natural selection is the best evidenced based explanation for the diversity and complexity of life on Earth. It is quite a paradox that we have adapted rapidly to the current crisis but have not kept abreast with the slow and sustained technological evolution in cardiac surgery.

Inevitably over the last three years I have drawn a wealth of inspiration by reading all the articles submitted to the Bulletin. The breadth of the

indu.deglurkar@wales.nhs.uk

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From the President:

We have so much work to do together Simon Kendall

2

020 has been a year like no other. It has caused a major disruption to our professional lives and has prompted major changes in our specialty.

Cardiothoracic activity has been significantly reduced as the patients have chosen to suffer their symptoms rather than approach their GP, or present at their local hospital, for fear of contracting coronavirus. In cardiac surgery there has been the added restriction of using our level 3 and level 2 beds to help with the pandemic. It is clear in the second wave there was a determination at all levels of the NHS that surgical services should continue where possible.

The use of virtual platforms has transformed our work – our consultations with patients, attending MDTs, attending local and national meetings, and we are now on the verge of our first virtual AGM.

The pandemic has given us an opportunity to reflect on what we do, why we do it and whether we can do it better.

There is much to do!

better for our patients’ experience and helps better use of our facilities.

In congenital surgery we need to lobby for ring fenced level 3 care to avoid cancellations and to help the days in theatre start on time. And after the divisive agenda of ‘Safe and Sustainable’ the ten congenital units will be working together to share good practice and support each other to keep teams and colleagues confident in their work.

In thoracic surgery we need to prepare for the impact of screening for lung cancer and the demands that will place on the service. Thoracic surgeons are continuing to innovate and it is uplifting to see the safe adoption of new techniques such as robotic surgery and navi-gational bronchoscopy.

We are also presenting new evidence for patients with pectus de-formities to the NHS

whole team, steering away from the long-standing fixation on the individual surgeon. From April this year the threeyear audit cycle will be monitoring multiple outcomes that will need to be reviewed internally on a quarterly basis – no longer waiting three years for the data to be submitted and analysed, but now placing the onus on the team to support each other if negative variance starts to become apparent. There is also the work with BCS and ACTACC on the standards for MDMs for revascularisation, aortic valve, mitral valve, endocarditis and high-risk cases. One major change being considered is to adopt the practice of units such as Freeman and Sheffield with a ‘surgeon of the day’ that is available for a daily MDM for urgent revascularisation involving cardiologists from the DGHs as well as the centre.

SCTS is supporting transplantation with the formation of their own subcommittee. As with congenital surgery, this will facilitate the units to collaborate with sharing of good practice, coordinating training to improve recruitment, maximising organ usage and increasing the number of procedures.

The focus on audit and quality assurance in our specialty has been a proud achievement, but at the same time there is an awareness that we have not adopted innovation with the same effectiveness as other nations. Our new Innovation

“We will need to meet the challenge of the backlog of work that has built up during 2020. And we will have to manage this on the background of an NHS that is weary, especially the intensivists, intensive care staff, and other colleagues who have been redeployed to frontline.”

Firstly, we will need to meet the challenge of the backlog of work that has built up during 2020. And we will have to manage this on the background of an NHS that is weary, especially the intensivists, intensive care staff, and other colleagues who have been redeployed to frontline. It will greatly help if we work with our teams to adopt enhanced recovery pathways, ERAS,

commissioners that there are two distinct groups of patients with physiological and/or psychological impairment that significantly benefit from surgery.

In cardiac surgery we are moving the audit to encompass the whole patient pathway and the involvement of the

January 2021

committee is formed to accelerate that agenda in all aspects of our work and the subspecialties. BISMICS has shown the benefit of bringing like minded innovators together to support the development of minimal access surgery with good governance.

Finally, we are seriously reflecting on the how we deliver the service, enhancing the clinical career progression for nurses and allied health professionals (AHPs) and also the training experience of all our junior colleagues (ie. clinical fellows, trust fellows, SAS and NTN). We work with many AHPs with extraordinary potential who would relish the opportunity to remain clinical and progress their careers. They are motivated to increase their knowledge and portfolio of skills to deliver excellent healthcare.

Around the country there are various initiatives that have given opportunities of clinical career progression to allied health professionals. These initiatives involve determined leadership, a long term strategy and usually a bridge of investment to

introduce the change. SCTS is compiling a ‘toolkit’ to share with all units what has been achieved so far and what challenges have arisen.

As a generalisation there are many middle grade surgeons in our specialty who could have a much improved experience. There are a combination of factors that have led to diminished exposure to surgery, which in turn has led to colleagues not necessarily having reached their full potential when they achieve their consultant posts. The middle grade surgeons in their senior years spend many hours resident on call and performing service tasks rather than refining their surgical skills. We are considering that three days in theatre per week should be our ambition for aspiring cardiothoracic surgeons.

The combined vision is: that patients experience enhanced care from a consistent multidisciplinary team; that AHPs have an ability to reach their clinical potential with defined roles and

responsibilities based on specialty criteria; advanced roles for AHPs will augment training opportunities for aspiring surgeons; it becomes possible to reduce the number of middle grade surgeons and they become non-resident on call in their later years, and throughout their time have enhanced exposure to theatre, and that newly appointed consultants can start their roles with confidence.

When he was President, Richard Page often stated how impressed he was by the ability and enthusiasm of everyone involved in SCTS, and after a few months in the role I have an even greater understanding of his comments.

It is remarkable the high level of enthusiasm, commitment and excellence that everyone brings to our specialty. All of the challenges I’ve mentioned are about our specialty using those qualities to work together and support each other across professional boundaries as well as engaging colleagues in other specialties and in local and national management. n

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Equality, Diversity and Inclusion in Cardiothoracic Surgery Narain Moorjani, Honorary Secretary

A

lthough cardiothoracic surgery has historically comprised of a relatively homogeneous workforce, significant efforts have been undertaken to change this.

Understanding the positive effects that equality, diversity and inclusion can bring on the quality of care given to patients undergoing cardiothoracic surgery and on the well-being of staff that deliver this care is important in the evolution of cardiothoracic surgery as a specialty. Equality represents the rights of different groups of people to have a similar social position and receive the same treatment, with diversity being the involvement of different types of people in a group or organisation, and inclusion defined as honouring, respecting, embracing and valuing the unique contributions and perspectives of all individuals, and removing barriers to individual success.

It has been previously described that the barriers perceived to achieving diversity and inclusion within cardiothoracic surgery include lifestyle concerns as they pertain to a work-life balance with a family; under-representation of mentors and role models from a diverse background (such as females, ethnic minority, LGBTQ+ or those with disability); lack of exposure to cardiothoracic surgery for medical

students and early-stage surgical trainees from a diverse background; and perceptions of unconscious bias by cardiothoracic surgery training programmes towards those from a diverse background. Similarly, nepotism, where friends, family or likeminded individuals are favoured, can also engender a culture that prevents inclusion and diversity.

As part of the Society’s evolving equality, diversity and inclusion strategy, the SCTS have been assessing the opportunities to address the areas of potential inequality that exist in cardiothoracic surgery. In view of this, the SCTS are planning to introduce or evolve a number of initiatives to try and develop a diverse cardiothoracic workforce

These include: 1. Survey the membership in an attempt to get a greater understanding of the issues that exist in cardiothoracic surgery in relation to equality, diversity and inclusion, and how members feel the SCTS can contribute.

2. Increasing the opportunities to encourage those from all backgrounds (such as ethnicity, disability, gender and socioeconomic class) to consider cardiothoracic surgery as a career. The SCTS already runs student engagement events where medical students and 6th formers attend to get a greater insight of a career in cardiothoracic surgery.

As part of the application process, hosting medical schools are encouraged to reach out to schools in local areas of social deprivation to encourage them to attend to consider cardiothoracic surgery as a career choice.

The SCTS also has an active presence at the careers’ fairs, such as those run by the Royal Society of Medicine, Association of Surgeons in Training and British Medical Association, promoting a career in cardiothoracic surgery to a wider audience. In addition, the SCTS is planning to further expand the student outreach and immersion programme, where 6th formers from areas of high social deprivation are given a two-week work experience placement at their local cardiothoracic

“The SCTS are planning to introduce or evolve a number of initiatives to try and develop a diverse cardiothoracic workforce representative of the society around us, and to provide equal opportunities and an inclusive environment for all those wishing to develop a career caring for patients undergoing cardiothoracic surgery.” representative of the society around us, and to provide equal opportunities and an inclusive environment for all those wishing to develop a career caring for patients undergoing cardiothoracic surgery.

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surgical unit and the opportunity to witness cardiothoracic surgery at first hand, which for some is a truly life changing experience. The Society also provides bursaries and travel scholarships for medical students to increase accessibility to exposure of cardiothoracic surgery.

3. Increasing the opportunities and supporting career progression for women in cardiothoracic surgery. The SCTS is planning to launch its Women in Cardiothoracic Surgery Mentorship Programme, with the aim to inspire and support women at all stages of training in a career in cardiothoracic surgery. The programme is an opportunity for female medical students or early stage female surgeons, who are aspiring for a career in cardiothoracic surgery, to develop a mentoring relationship with a female cardiothoracic surgical trainee or clinical fellow; and for female cardiothoracic surgical trainees and clinical fellows to develop a mentoring relationship with a female consultant cardiothoracic surgeon.

The programme will allow the mentee to gain support and advice on a number of areas, including career development, achieving a work-life balance, subspecialty training, working less-than-fulltime, working during pregnancy, research and academic collaborations, returning to work following maternity leave, and leadership development, as well as networking opportunities. As part of the programme, the Society will be running its inaugural Women in Cardiothoracic Surgery Networking Session at the forthcoming Annual Meeting. The Society has also recently set up a Women in Cardiothoracic Surgery Working Group to help evolve the specialty into one that encourages and supports the development of female cardiothoracic surgeons.

4. Increasing the opportunities and providing support for career progression to SAS Doctors, Clinical Fellows and Trust Doctors, who are often from a black, Asian and minority ethnic (BAME) background.

The Society is planning to enhance the SCTS education programme for these doctors to ensure opportunities for

career progression, such as exam revision courses for the FRCS (C-Th) examination, and guidance on obtaining Article 14, applying for consultant posts and consultant interview practice. In addition, the SCTS is planning to develop a ‘role-model’ infrastructure to provide guidance and advice, where these doctors can contact those who have been in their position and overcome the challenges.

5. Ensuring appropriate diversity of the positions of responsibility within the SCTS. The Society is planning to ensure that equal opportunities and encouragement is given to those from a diverse background to produce a leadership of the SCTS that is representative of its workforce. The Society has already made great strides from the composition of the Executive and leadership roles over the past 10 years, as can be seen with the diversity of the current Executive, but appreciates that more progress can be made.

6. Ensuring SCTS policy and documentation reflects the Society’s position on equality, diversity and inclusion, including that attributable to ‘unconscious bias’.

I would like to thank the Equality & Diversity Working Group, and in particular Carin Van Doorn, Indu Deglurkar, Farah Bhatti and Karen Booth for their support in taking this agenda forward. Whilst we strive to achieve a better working environment for those from all backgrounds in cardiothoracic surgery, we are very conscious of avoiding positive discrimination, so not to disadvantage those who are not from a protected background. In preference, we are seeking to develop a programme of positive action by bringing about an equality of opportunities, where we support and encourage all cardiothoracic surgery practitioners to evolve. We also understand there is still much work to be done and that there are many other groups and issues (such as those with mental health issues, disability or from the LGBT community, as well as the concept of intersectionality) that need to be addressed but felt that this would be a good starting point. We would welcome articles for the Bulletin or SCTS website from those who have faced issues related to equality and diversity, and on how to overcome those challenges. Any other comments or suggestions would also be much appreciated. n

Appointed Members: Steven Billing Shakil Farid Thanos Athanasiou Mobi Chaudhry

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

Trainee Representative: Jonathan Afoke

NAHP Representative: Helen Munday

Education Lead: Deborah Harrington George Asimakopoulos

Co-opted Members: David Baldwin (BTS) Ian Hunt (Commissioning) Richard Steyn (Trauma)

Trainee Representative: TBC

NAHP Representative: Amanda Walthew

Education Lead: Sri Rathinam Carol Tan

Deputy Audit Lead: Serban Stoica

Trainee Representative: Joesph George

NAHP Representative: TBC

Education Lead: Attilio Lotto

Audit Lead: Carin Van Doorn

Unit Reps.: Chuck McLean Andrew Parry Mohammed Nassar Osama Jaber Andreas Hoschtitzky Phil Botha Ben Davies Conal Austin Mark Redmond Branko Mimic

Appointed Members: Juliet King Kandadai Rammohan Babu Naidu Aman Coonar

Executive Co-Chair: Rajesh Shah

Audit Lead: Uday Trivedi

Executive Co-Chair: Narain Moorjani

Executive Co-Chair: Simon Kendall

Audit Lead: Doug West

Co-Chair: Rafael Guerrero

Co-Chair: Steve Woolley

Co-Chair: Enoch Akowuah

Trainee Representative: Abdul Badran

NAHP Representative: Emma Matthews

Education Lead: TBC

Audit Lead: TBC

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

Executive Co-Chair: Rajesh Shah

Co-Chair: Steven Tsui

Elected Trustees: Mahmoud Loubani, Carin Van Doorn, Mobi Chaudhry, Enoch Akowuah, Aman Coonar

Co-opted Members: Andrew Goodwin (NICOR)

NAHP Representative: Julie Sanders

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

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

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

Executive Co-Chair: Simon Kendall

Co-Chair: Doug West

Perfusion Reps.: Phil Botha, Chris Efthymiou

Education Secretaries: Sri Rathinam / Carol Tan

Nursing & AHP Rep: Helen Munday

Lay Representative: Sarah Murray

Accreditation Lead: Shafi Mussa

Student Leads: Farah Bhatti Karen Booth

Trust Appointed Doctors Lead: Zahid Mahmood

Consultant Lead: Prakash Punjabi Shahzad Raja

Trainee Representatives: Duncan Steele Abdul Badran

NAHP Representative: Bhuvana Krishnamoortthy

Surgical Tutors: Deborah Harrington George Asimakopoulos Congenital Cardiac Surgery Lead: Attilio Lotto

Executive Co-Chair: Rajesh Shah

Co-Chairs: Sri Rathinam Carol Tan

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

Trainee Representative: Marius Roman

NAHP Representative: Julie Sanders

Patient Liaison: Chrissie Bannister

Research Lead: Julie Sanders

Education Leads: Bhuvana Krishnamoorthy Tara Bartley

Audit Lead: Julie Sanders

Congenital Lead: TBC

Thoracic Lead: Amanda Walthew

Congenital Cardiac Surgery: Massimo Caputo Nigel Drury

Meeting Lead: Daisy Sandeman

Deputy NAHP Lead: Bhuvana Krishnamoorthy

Chair: Helen Munday

Cardiac Lead: Helen Munday

Appointed Members: TBC

Executive Co-Chair: Simon Kendall

Co-Chair: Hunaid Vohra

Thoracic Surgery: Babu Naidu

Adult Cardiac Surgery: TBC

Executive Co-Chair: Narain Moorjani

Co-Chairs: Eric Lim Mahmoud Loubani

Congenital Co-Chair: Rafael Guerrero Research Co-Chair: Mahmoud Loubani / Eric Lim Innovation Co-Chair: Hunaid Vohra Exam Board Chair: Rana Sayeed Tutors: Deborah Harrington, George Asimakopoulos

Co-opted Members

Trainee Reps.: Duncan Steele, Adbul Badran

Honorary Treasurer: Amal Bose

Meeting Secretary: Maninder Kalkat

Thoracic Co-Chair: Steve Woolley Audit Co-Chair: Doug West Transplantation Co-Chair: Steven Tsui SAC Chair: Marjan Jahangiri Cardiothoracic Dean: Neil Roberts

Honorary Secretary: Narain Moorjani

President Elect: Rajesh Shah

President: Simon Kendall

Conference Organisers: Isabelle Ferner Tilly Mitchell

NAHP Representative: Daisy Sandeman

Associate Meeting Secretary: Sunil Bhudia

Deputy Meeting Secretary: Cha Rajakaruna

Meeting Secretary: Maninder Kalkat

Meetings Team

Bulletin: Indu Deglurkar

SCTS Website: Clinton Lloyd

Communications

Sarah Murray Rajesh Shah Helen Munday Doug West

Professional Standards

Emma Ferris

Letty Mitchell

Tilly Mitchell

Isabelle Ferner

January 2021

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the 14 bulletin

SCTS at Ease, Diversity is the spice of life Written by the Women in Cardiothoracic Surgical Working Group

W

e as a society were pleased last year when the Edinburgh seven received posthumous medical degrees from Edinburgh University. Serving a dual purpose, it is a reminder of the difficulty that those in minority face to go against the norm and also to us as a society that we must inspire the brightest and the best to choose a career in cardiothoracic surgery regardless of gender, race or background. 150 years ago, the Edinburgh Seven faced substantial resistance and were ultimately prevented from graduating and qualifying as doctors. The Edinburgh Seven were the first group of matriculated undergraduate female students at any British university. They began studying medicine at the University of Edinburgh in 1869 and although they were ultimately prevented from graduating and qualifying as doctors, the campaign they fought gained national attention and won them many supporters, including Charles Darwin. Their campaign put the rights of women to a university education on the national political agenda, which eventually

resulted in legislation to ensure that women could study at university in 1877.

Just this month the University of Newcastle celebrated the 43rd anniversary of being the only UK University to recognise the civil rights struggle of Dr Martin Luther King, giving him an honorary doctorship in Civil Law. Quoting from his acceptance speech, he wrote ‘Well, it may be true that morality cannot be legislated but behaviour can be regulated. It may be true that the law cannot change the heart but it can restrain the heartless.’ Last month we celebrated the life and work of the ‘notorious RBG’, the associate Justice of the Supreme Court of the United States of America.

Her legacy demonstrated that by ensuring equality we improve the lives of all and had President Clinton not had the foresight of her nomination and support, millions of citizens would not have had a fair hearing or trial on the injustices they suffered.

Within Cardiothoracic surgery, we have our own inspiring female legacies. Nina Braunwald was a true trail blazer, performing the first successful

“In the UK, in modern surgery, women now make up 19% of higher trainees, specialist doctors, and consultants in surgery in England, data from NHS Digital show. However, there remains a gender imbalance among cardiothoracic surgeons and by sheer lack of numbers, it is true that the future of the specialty will suffer.”

prosthetic mitral valve replacement in a human on March 11, 1960, when she was only 32 years old. She was one of the first three women to be board certified by the ABTS in 1961, along with Ann McKiel, the first woman to complete a thoracic surgery residency, and Nermin Tutunju.

She was also the first woman member of the American Association for Thoracic Surgery (AATS) in 1967. Nina Braunwald was born in Brooklyn, New York, in 1928 and obtained baccalaureate and medical degrees from New York University. In 1952, she was the first woman to enter training in general surgery at Bellevue Hospital in New York City, which she completed along with a Master of Science degree from Georgetown in 1957. She became staff surgeon at the National Institutes of Health (NIH) in 1958, subsequently serving as deputy chief of the Clinic of Surgery from 1965 to 1968.

Dr Braunwald was one of the principal designers of the Braunwald-Cutter valve (a cloth-covered mechanical ball valve) that was implanted in thousands of patients in the 1960s and 1970s and also of a stented aortic homograft for mitral valve replacement.

She pioneered the use of tissue culture techniques to develop nonthrombogenic cell layers for nonphysiologic surfaces, and her technical and physiologic data permitted the refinement of next-generation pacemakers.

She published 150 peer reviewed publications. Despite these achievements, she spent 24 years as an associate professor and was never promoted to full professor.

In the UK, Anne June Patricia McKeown (“June”) was inspired to become a cardiothoracic surgeon when she was four years old, recovering from the first operative replacement of a mitral valve using human tissue in the UK. Heart surgery was in its infancy in 1970 and a pioneering technique was used constructing a valve at the time >>

January 2021

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15

the 16 bulletin

of surgery using fascia lata from June’s thigh. This valve lasted seven years.

June’s tenacity allowed her to gain entry to medical school at the University of Glasgow in 1984, despite interruptions to her schooling for two further mitral valve replacements. She trained in cardiothoracic surgery in Cambridge, Hull, Aberdeen, Edinburgh, and Glasgow and also spent a year in Sydney. In 2001 she became the first woman in Scotland to complete the FRCS CTh and gained her CCST in 2005. June was appointed to an associate specialist post when the West of Scotland cardiothoracic units amalgamated to the Golden Jubilee National Hospital in 2008.

June’s complete dedication to her work, unending cheerfulness, and refusal to be limited by her health meant that most of her colleagues didn’t recognise how unwell she was until her last hospital admission.

June was cared for and died in the intensive care unit in which she worked.

Such inspiring stories and yet today in the UK we still have such gender disparity in cardiothoracic surgery. Many examples of sexism have been recounted and for those that are unaware of the issues faced we list a few as commonplace examples. It is not unheard of to be told that as a female you lack the strength of character a man would, when faced with patient death or challenging cases. It is quite often assumed that progress in specialty will halt any personal ambitions for family life and it can be commonplace to be overlooked for promotions or responsibility within the department as it is difficult to be part of a boys club when you are a single entity in the group. It can often feel like you are the token appointment to address an imbalance without being taken too seriously as a colleague.

In the UK, in modern surgery, women now make up 19% of higher trainees, specialist doctors, and consultants in surgery in England, data from NHS Digital show.

However, there remains a gender imbalance

among cardiothoracic surgeons and by sheer lack of numbers, it is true that the future of the specialty will suffer. The figures, collected in January 2018, show that the proportion of women in surgery is lower at more senior career grades. While 54% of foundation trainees in surgery are women and 41% of those in core training are women, 30% of higher specialty trainees, 20% of specialty and associate specialist surgeons, and 12% of consultant surgeons are women.

The proportion of women is higher in some specialties than in others. Paediatric surgery is the subspecialty that has the largest proportion of higher trainees, specialist doctors, and consultants who are women (35%). This is higher than the proportion in oral and maxillofacial surgery (34%), plastic surgery (29%), otolaryngology (26%), general surgery (23%), vascular surgery (18%), urology (16%), neurosurgery (15%), cardiothoracic surgery (14%), or trauma and orthopaedic surgery (11%). n

“When I’m sometimes asked when will there be enough [women on the Supreme Court] and I say, ‘When there are nine,’ people are shocked. But there’d been nine men, and nobody’s ever raised a question about that.”

Ruth Bader Ginsburg (1933-2020) Associate Justice of the Supreme Court of the United States 1993-2020

January 2021

17

A message from our President Simon Kendall

In his own words, “he trained in an era when ‘chauvinism’ and ‘prejudice’ was almost the norm, and he is pleased to see the progress that has been made.”

There is more and more diversity in UK cardiothoracic surgery but there is still much more work to be done, especially in regard to gender ratio and the experiences for females in their training and consultant posts.

What is the best response, how do we lift as we climb? Well, we are pleased to announce the Women in Cardiothoracic Surgery (WICTS) Subcommittee.

The sub-committee will have a responsibility to take on work related to the interests to eliminate gender disparities by the SCTS for its membership. Items of work will come through the Executive, the other SCTS sub-committees and the SCTS administrative office. Examples include: a) Foster an environment that supports women in cardiothoracic surgery through education, mentorship, sponsorship and scholarship b) Exploring opportunities to increase the percentage of women members practicing in cardiothoracic surgery c) Maintain a contemporary female workforce database d) Create an inclusive culture in which women can thrive

d) Eliminate gender disparities e) Celebrate diversity f) Promote fair treatment and wellness for all g) Dealing with all queries sent to the Society from SCTS members and external bodies pertaining to Women in Cardiothoracic Surgery h) Communicate with SCTS members through reports in the SCTS Bulletin, presentation at the SCTS Annual Meeting and the Board of Representatives i) Working in collaboration with sister organisations in surgical specialities and other organisations promoting gender equality nationally and internationally Membership will include two co-chairs (one from the SCTS executive and one from SCTS membership on application), a Consultant Cardiac Surgeon, a Consultant Thoracic Surgeon, a Consultant Congenital Surgeon, a Consultant Transplant Surgeon, a Trainee Member, a Trust Appointed Doctor, a medical student, an AHP member and a Lay-person member.

Our first organised event, the plenary session at SCTS 2021 ‘SCTS At Ease, Diversity Matters’ will be an opportunity for discussion and education for all members of SCTS. We encourage those that are interested in the future of our speciality to apply for sub-committee positions when it is advertised in the near future.

“Our first organised event, the plenary session at SCTS 2021 ‘SCTS At Ease, Diversity Matters’ will be an opportunity for discussion and education for all members of SCTS.”

Facebook – /womenincardiothoracicsurgery

Professor F Bhatti MD FRCS CTh Consultant Adult Cardiac Surgeon Chair of Women in Surgery Council Member RCS England SCTS Student Education Co-Lead Morriston Hospital, Wales Ms K Booth MSc FRCS CTh Consultant Adult and Cardiothoracic Transplant Surgeon SCTS Student Education Co-Lead Freeman Hospital Newcastle upon Tyne Hospitals NHS Foundation Trust, England Ms I Deglurkar MBBS FRCS CTh Consultant Adult Cardiac Surgeon President, Welsh Cardiothoracic Society Editor in Chief, SCTS Taskforce of EACTS Women in Cardiothoracic Surgery Cardiff and Vale UHB, Wales Ms B Evans PhD FRCS CTh Consultant Adult Cardiac and Mitral Valve Surgeon Clinical Lead for Cardiac Surgery Senior Lecturer Leeds Teaching Hospitals NHS Trust, England Ms D Harrington MD FRCS CTh Consultant Adult Cardiac and Aortic Surgeon SCTS Surgical Tutor Liverpool Heart and Chest Hospital, England Ms C van Doorn MD FRCS CTh Consultant Congenital Cardiac Surgeon SCTS Executive Committee Member SCTS Congenital Cardiac Audit Lead Senior Lecturer Leeds Teaching Hospitals NHS Trust n

S C T S V I R T UA L G N I T E E M L A U N AN 2021 T ES A D W NE

9th - 11th May 2021

SCTS welcomes you to the first virtual conference Online Cardiac & Thoracic educational sessions Scientific abstracts & lectures from international key note speakers Registration is open We have extended the early bird registration fees indefinitely

To Register or view the detailed programme please visit www.scts.org Up to 18 CPD points

#SCTS2021

09:00 - 10:30

11:00 - 12:30

13:30 - 15:00

15:30 - 17:00

Room 1

Aortic Valve I

Aortic Valve II

Aortic Surgery I

Aortic Surgery II

Room 2

Mitral Valve Surgery

Coronary Artery Bypass Surgery & LV

Risk Stratification and Outcomes: What every Surgeon should know

Coronary artery bypass grafting: Improving prognosis

Room 3

Technological advances in Thoracic Surgery: Evidence

Sublobar resections for lung cancer

Advances in Perioperative Care in Thoracic

Integrated approach to lung cancer management

Room 4

CT Forum University: Cardiac Session

CT Forum University: Thoracic Session

Adjunct Therapies in CT Surgery

Advance Practice Roles & Evolving Services

Room 5

Student Engagement Session I: Cardiothoracic Anatomy Demonstration

Student Engagement Session II: Why Cardiothoracic Surgery

Student Engagement Session III: Patient interview: future of CT Surgery

Pat Magee Student Oral Abstract Presentations CT Surgery

AHP Research updates

Advisory for the Management of Perioperative AF

Writing for Publications: Workshop

Speed Mentoring

Room 6

15.3016.10

16.1017.00

Diversity

Innovation

Room 1

Decision-making & Surgery for the Aneurysmal aorta

Surgical & Percutaneous Aortic Valve Implantation

Room 2

Anti-platelet Therapy: Conduit choice and Outcomes

Atrial Fibrillation, HOCM & Mitral Valve

Room 3

Cardiac Surgery: General

Research in Cardiac Surgery

Room 4

Surgical Approach

Innovations in Thoracic Surgery

Room 5

Benign Thoracic Surgery

Perioperative Care in Thoracic Surgery

Room 6

MDT Engagement & Success Stories

Communication: Present Challenges in Future Vision

Room 1

Aortic Dissection

Cardiac Transplantation & Circulatory Support

Improving Outcomes in Cardiac Surgery

Room 2

Training & Outcomes in Coronary Artery

Cardiac Surgery during the Covid-19 Pandemic

Aortic Valve: Preservation and Advances

Room 3

Metastasis & Miscellaneous

Covid Infection

Lung Cancer

Rapid fire season

Single ventricle decision-making: When to Operate

Quality & Service Improvement

Advancing Roles and Evolving Services

PLENARY ADULT CARDIAC

Auditorium

Tuesday 11 May

Cardiothoracic Surgery Plenary

Room 5

CT FORUM TRAINEE CONGENITAL

Training in Cardiothoracic Surgery

11.00-11.30

Room 4

THORACIC

Congenital TV disease

11.00-12.40

ECMO Service

Ionescu Fellowships

SCTS Annual Meeting

Monday 10 May

Auditorium

Ionescu University

Sunday 9 May

9-11 May #SCTS2021

the 20 bulletin

Nursing and Allied Health Professional update Helen Munday, SCTS Nursing and AHP Representative

I

am writing this as we enter a second lockdown in England, Wales are preparing to come out of lockdown, Scotland has moved to a five-tier system and Northern Ireland are halfway through four weeks of lockdown restrictions. Who could have possibly imagined? We talk about the second wave when it really doesn’t feel as if we ever finished with the first as we try hard to catch-up on elective work that was stopped earlier on in the year. And in other news ... it looks like the United States of America has a new president!

I remember this time last year when it was all about Brexit and our new PM, fast-forward 12 months and goodness, what a year 2020 has been. I sincerely hope by the time the Bulletin is published and arrives at our door, we will feel more optimistic about 2021, possibly with encouraging news about a vaccine, a hint of economic recovery and an NHS that once again has risen to the challenge of caring for patients throughout this unprecedented time.

Like everyone else, the SCTS swiftly adapted to virtual working and has continued to deliver educational webinars and meetings using online platforms. It was recently announced that the 2021 Annual Meeting will be entirely virtual which I know will be a disappointment to many but was not entirely surprising.

The programme is looking to be every bit as engaging and interesting and it was brilliant to see so many abstracts submitted for the Forum. I do hope that colleagues will take advantage of not needing to travel, as well as the reduced registration fee, to attend the virtual meeting either from their workplace, or the comfort of their own home.

Thank you to everyone who responded to the short survey earlier in

the summer. Its purpose was to understand what members find useful from their membership of the SCTS, how information is accessed and what they would like more or less of. We had an excellent response and the findings will certainly help to inform how we develop the NAHP Five Year Strategy. The top three uses of membership were access to educational courses, the CT Forum at the Annual Meeting and networking opportunities; over half of respondents felt that local communication would be the most effective way to attract new members and advertise what the SCTS had to offer.

With this in mind, the Nursing and Allied Health Professional (NAHP) sub-committee have identified six core areas on which the NAHP strategy is based. These are: • • • • •

Unit level representation Education and Fellowship opportunities Research Website Annual Meeting / CT Forum / University Day • Succession Planning / Team Structure Some of these areas are already very well-established and it is our aim now to draw up our goals and objectives around each area, determining the priorities and planning how these will be delivered to

meet the needs of our members. I am delighted to report that we have NAHP unit representatives in nearly all the cardiothoracic centres in the UK and Ireland and I am immensely grateful to everyone who has volunteered to undertake this role; your contribution will be key to facilitating the two-way dialogue between centres and the SCTS, enabling us to bring the strategy to fruition.

One of the areas that we are particularly keen to focus on over the next 12 months is helping to support NAHPs who wish to progress their clinical careers to a level of Advanced Clinical Practice. The Society has long been an advocate of the role NAHPs have in progressing patient care and improving patient experience; indeed, there are many examples in organisations where introduction of such roles has been very successful with a positive impact not only on patient outcomes, but also on the career development of the practitioners. Our ambition is to help all units establish these roles with a systematic and consistent approach with the ultimate aim of providing a 24/7 service that recognises the Advanced Clinical Practitioner as an autonomous decision-maker. Our first objective is

“One of the areas that we are particularly keen to focus on over the next 12 months is helping to support NAHPs who wish to progress their clinical careers to a level of Advanced Clinical Practice.”

January 2021

to produce a guidance document that will demonstrate examples of integrated workforce planning and building a business case, the requirements that underpin advanced practice and examples of advanced competencies.

This is a highly ambitious project but very necessary as specialist surgical training is reduced from eight years to seven years. In supporting surgical trainees to have greater exposure in the operating theatre, NAHPs, and our patients, can be confident in the knowledge that the SCTS is committed to supporting the clinical career development of NAHPs to deliver skilled care to patients in a way that is consistent across the specialty.

It is a really exciting time to be contemplating the opportunities ahead and I envy those at the start of their careers who have so many options open to them.

I have been involved with the SCTS since I attended my first annual meeting in 2005 at the Olympia Conference Centre in London and I have proudly kept every meeting programme since! I reflect on how much has changed in the last 15 years; my 2005 programme has the banner –

Society of Cardiothoracic Surgeons of Great Britain and Ireland. In 2006, there was a significant name change to The Society for Cardiothoracic Surgery in Great Britain and Ireland, a nursing representative was appointed to the SCTS Executive Committee and the Forum for Cardiothoracic Practice – Nurses Meeting appeared in the programme for the first time. Sessions included “Expanding the role of the cardiothoracic nurse”, “Advanced clinical practice – the nurse’s role in clinical assessment” and “The role of the advanced nurse practitioner in cardiothoracic surgery”. Whilst the subject matter is still very relevant today, I don’t think anyone would dispute the significant progress that has been made, not least in encompassing the multiprofessional team and the collaborative working that has become synonymous with the Society.

It has been a huge privilege to hold the position of Nursing and AHP Lead for the past four years and I am immensely grateful to my predecessors, Chrissie Bannister and Tara Bartley, for their unwavering support and incredible

21

hard work over many years. There is no doubt that we would not be in the position we are today without their tireless work.

I am thrilled to be handing over to Dr Bhuvana Krishnamoorthy whom I know is going to be quite unstoppable in this role. Bhuvana is currently President of the Association of Surgical Care Practitioners and SCTS Education sub-committee NAHP representative. As well as working clinically, Bhuvana is passionate about teaching and education and has an impressive research portfolio; I know if there is anybody who can deliver the NAHP strategy, it will be Bhuvana and I wish her every success.

If you wish to join the Society or become involved with any of the ongoing work streams, please do get in touch. The current fee for Associate Membership (NAHP) is a one-off £10 administration fee and annual subscription fee of £30.

Wishing you all the very best for 2021, stay safe and take care. n Helen Munday Matron – CT Surgery & Respiratory Medicine Email: h.munday@nhs.net

New roles and appointments Congratulations to the following ...

Role

Name

SCTS President Elect SCTS Trustees Cardiothoracic Surgery GIRFT lead SCTS Representative on Congenital Cardiac Surgery CRG SCTS National Cardiac Surgical Tutor SCTS Adult Cardiac Surgery Sub-Committee Co-chair SCTS Joint Education Secretary SCTS Associate Meeting Secretary SCTS Student Education Lead SCTS Consultant Education Lead

Rajesh Shah Enoch Akowuah, Aman Coonar Doug West Andrew Parry (with Massimo Caputo as Deputy) Deborah Harrington, George Asimakopoulos Enoch Akowuah Carol Tan Sunil Bhudia Farah Bhatti, Karen Booth Prakash Punjabi, Shahzad Raja

SCTS Education Accreditation Lead SCTS NAHP Deputy Lead SCTS Deputy Adult Cardiac Surgery Audit Lead SCTS Regional Deputy Adult Cardiac Surgery Audit Leads SCTS Transplantation Sub-Committee Co-chair

Shaffi Mussa Bhuvana Krishnamoorthy Umberto Benedetto Indu Deglurkar (Wales), Alistair Graham (Northern Ireland), Zahid Mahmood (Scotland) Steven Tsui

SCTS Innovation Sub-Committee Co-chair SCTS Cardiac Surgery Research Sub-Committee Co-chair SCTS Thoracic Surgery Research Sub-Committee Co-chair

Hunaid Vohra Mahmoud Loubani Eric Lim

the 22 bulletin

Thoracic Audit Update Doug West, Audit Subcommittee Co-Chair

T

he Society is actively engaged in several audit and quality improvement initiatives across heart and lung surgery. In the majority of these, for example the NICOR audits and in the Lung Cancer Clinical Outcomes Publication, the SCTS either represents its membership to audit providers, or works in partnership with providers to produce high quality audit. In others, for example the current work with Dendrite in cardiac surgery and the thoracic returns, the SCTS leads its own projects.

In adult cardiac surgery, recognising the increasing workload involved in representing the SCTS, we have been delighted to appoint Umberto Benedetto into the new post of deputy audit lead in adult cardiac surgery, supporting Uday Trivedi. Umberto was successful in a very competitive field; a testament to the continued commitment of SCTS members to audit and QI. Umberto is well known to many members as an academic cardiac surgeon in Bristol, and he brings his extensive experience accessing and analysing NICOR data to the audit team.

The remainder of the audit team continue unchanged, with K. S. Rammohan working with me in thoracic surgery, and Carin Van Doorn and Serban Stoica covering the congenital audit brief.

As I write, the adult cardiac update, covering data up to March 2019, has recently gone online on SCTS.org.

We continue to explore how we could make more data available in adult cardiac surgery. Led by Simon Kendall as SCTS President, we are advocating a new approach beyond basic in-house mortality reporting, moving the focus to accrediting the whole team. This recognises that it is

teams rather than individuals who achieve good outcomes, and which could improve them further with the right support. To this end, we are working with Dendrite to pilot a new outcomes audit in a group of collaborating enters, and are engaging NICOR to see whether more outcomes could be reported at unit level. Our thoughts on unit credentialing are being fed into the GIRFT project, and we hope to influence GIRFT’s development of new “Gateway Metrics”, which will be used to assess unit performance in future.

We are acutely aware of the challenges of reporting outcomes data during the pandemic. It is essential that we learn everything we can from the pandemic, but it is just as important that audits don’t penalise individual and clinical teams facing extraordinary events largely outside of their control. We are continuing to liaise with NICOR and others on these issues, guided by the principals laid out in our letter to members following the SCTS Executive on 23rd March 2020 and available on SCTS.org

rate following the early results from the VIOLET trial. The outcomes and report are due out towards the end of the first quarter of 2021.

There will only be a short break before we ask for the SCTS returns data for 2019-20. I hope you’ll still have some enthusiasm left in the tank after the efforts of LCCOP, but we know that members appreciate having the preliminary returns data out at the SCTS annual meeting, and we’d like to achieve this if we can.

Lastly, in the Quality Improvement space, the second cardiothoracic GIRFT report is underway. If you are a clinical lead then please return your questionnaire so that the GIRFT team can prepare data packs for the deep dive visits. Clearly this will need some flexibility as units focus on responding to the second wave of the COVID pandemic. However, if you can schedule a deep dive when they begin in the near future, then that helps us to stay on track.

GIRFT’s role is expanding, and it has been asked to take on an increased role in developing metrics and pathways to support the restart of surgical services after COVID. The SCTS are working with GIRFT to develop some optimal pathways for acute care. These are intended to reflect best practice, based on examples from around the country, evidence and expert consensus. If you are involved in one of the development groups then thanks for your efforts. Deadlines are tight and we are hoping to have the first pathways out early in the New Year.

Thanks to all members and SCTS audit leads for their efforts in audit and QI during these extraordinary times, and very best wishes for Christmas and the New Year. n

“It is essential that we learn everything we can from the pandemic, but it is just as important that audits don’t penalise individual and clinical teams facing extraordinary events largely outside of their control.”

In thoracic surgery, the LCCOP project is running this year, with extension funding from HQIP. Thanks to all of you who have recently supported the vital local data validation round. We anticipate that the outcome metrics will be broadly the same as last year, possibly with the inclusion of the VATS lobectomy

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the 24 bulletin

SCTS Education report “Per aspera ad astra” January 2021 Sri Rathinam, SCTS Education Secretary Carol Tan, SCTS Education Secretary

2

020 has been a difficult year for everyone with the COVID-19 crisis having the biggest impact on lives and livelihoods, but we are even more grateful to our education committee, the wider education team including course directors and faculty, as well as our industry partners for rising to the challenges of delivering education to the SCTS membership. We recognise that the education programme provided by SCTS is highly valuable to its membership and the envy of other specialty associations, from the feedback we have had and reflected in the increase in membership numbers since 2013 when the programmes commenced.

When the pandemic hit earlier in the year, we were so much more determined to ensure we continue to deliver education using new video conferencing technology

when physical meetings were discouraged, and abiding by new social distancing rules when we were able to hold physical courses in September. Many who attended the courses were delighted to be able to reset their focus on cardiothoracic surgery after months of redirecting their attention to the care of COVID-19 patients, and having less opportunity for learning and training.

Ionescu Collaboration In spite of the cloud of the pandemic looming over our heads all year, with the generous support from Mr Marian Ionescu, we were able to hold a further round of Special Ionescu Fellowships celebrating 50 years of the pericardial valve in the summer and the results have been published in a separate article. The Annual Ionescu Fellowship 2021

was advertised in the BORS meeting inviting applications, with a closing date in December and winners will be announced at the virtual SCTS annual meeting in May. The winners of the fellowships have been allowed additional time to complete the fellowship due to the travel restrictions and increased clinical need in the hospitals.

NTN Education Six out of twelve of the portfolio of courses were run in 2020, with necessary modifications made. All courses (ST3B, ST6AB and ST8A) due to take place in Hamburg had to be postponed due to travel restrictions. The NOTSS course (ST5B) and Clinical Examination course (ST7B) were also postponed. Our tutors Debbie Harrington and George Asimakopoulos are working hard on the schedule in 2021 to deliver the full portfolio, accommodating two cohorts where required to account for those who missed out in 2020. This is detailed in the tutor’s report.

Education for Trust Appointed Doctors We have adopted the title of “Trust Appointed Doctor” to replace “Non-NTN Doctor”. This encompasses the large group of doctors ranging from Specialty Doctor, Associate Specialists, Staff Grade, Senior Clinical Fellow/Clinical Fellow and Trust Doctor amongst other titles. We recognise the importance of their role, within Cardiothoracic Units, and the contribution to the specialty with their skills and experience.

We plan to increase the education portfolio for them, ideally to mirror that of the NTN portfolio, within the next five years. We have

January 2021

25

not been able to run the two existing courses in 2020 but have invited Trust Appointed Doctors who are ready to apply for NHS consultant posts, to attend the virtual ST8B Leadership and Professionalism Course in December. We anticipate we will be opening more NTN courses to Trust Appointed Doctors in 2021 whilst we work towards a complete portfolio of courses specific to the needs of Trust Appointed Doctors. After several years of hard work as lead, Uday Dandekar has decided to relinquish his role to focus on increasing responsibilities at work and we thank him for all his hard work.

We have appointed Zahid Mahmood in his place as Cardiac lead, and will be looking to appoint a Thoracic lead shortly.

Consultant Education The 3rd Masterclass which focused on Mentorship took place as a virtual meeting on 30 October and was well attended by Consultants and received positive feedback.

Our new leads for Consultant Education, Prakash Punjabi and Shahzad Raja, will be addressing the needs of Consultants at different levels of their career and will be focussing on the Leadership Academy from 2021.

Medical Student Education The 7th Student Engagement day took place on 14 November, and was held as a webinar for the second time. The number of attendees has increased exponentially since going virtual for these sessions in the summer, reflecting both the interest in young doctors-to-be for the specialty, and also the ease of engaging in webinars. A student working group has been created within the Education sub committee with student members under the leadership of Prof Farah Bhatti and Ms Karen Booth.

Multi-Disciplinary Team Education The Team Human Factors Course which was planned for 30 September 2020 at Harefield Hospital was postponed and we hope to confirm a date early in 2021 pending PHE guidance.

AHP Education Under the leadership of Bhuvana Krishnamoorthy, the AHP team has continued to hold webinars for nurses and allied health professionals covering a wide

“We are pleased to share the good news that Ethicon have agreed to offer cardiac and thoracic simulators which will be delivered to regional hubs under the oversight of the cardiothoracic training programme directors.� range of topics in cardiothoracic surgery. In spite of holding these sessions on Saturday evenings, the attendance has been excellent and significantly better than webinar sessions held during the working week. They have also attracted interest from health professionals around the world.

RCSEd / SCTS Webinars Following a break due to COVID-19, the webinars recommenced in the summer.

Faculty included national and international speakers, and archived webinar recordings can be accessed by RSCEd members (Fellows, Members and Affiliates) on the RSCEd website, and the upcoming webinars will also be published on the site.

SCTS SAC Collaborative projects SCTS Education has always worked hand in hand with our Cardiothoracic SAC. We are working towards assessing the impact of the various training ventures and initiatives.

We are assessing the impact of these training courses by surveying trainees who have completed the courses and are now

consultants or senior fellows. We are also analysing the training satisfaction in our run through trainees appointed to ST1 posts.

We are also pleased to share the good news that Ethicon have agreed to offer cardiac and thoracic simulators which will be delivered to regional hubs under the oversight of the cardiothoracic training programme directors.

These include VATS lobectomy simulator, basic VATS skills simulator, aortic valve replacement and mitral valve repair simulators which can be used by trainees and Trust appointed doctors for simulation training.

The educational subcommittee has grown over the years with expansion of the programmes and fellowships being offered.

More is planned over the next five years as documented in our five-year strategy reported in the last edition of the bulletin. We owe our achievements to many SCTS members who remain enthusiastic to teach and run courses without financial reward, and of course to our colleagues in the SCTS office, Isabelle, Tilly, Letty and Emma, who have worked tirelessly throughout this year, in spite of the pandemic, to help us in our endeavours. We thank each and every one involved, and hope you all have a Happy (and hopefully less restrictive) 2021! n

the 26 bulletin

SCTS Education tutors’ report Debbie Harrington, SCTS Thoracic Tutor George Asimakopoulos, SCTS Cardiac Tutor

S

ince our last report in the summer we are delighted that the education course portfolio has been able to restart, although as anticipated this has been somewhat of a learning curve for all involved. We were able to reschedule the cancelled ST4B Core Thoracic Surgery course which took place at Ashorne Hill on 3rd-4th September. This was the first course to run since the COVID pandemic began and had a slightly shorter format than normal. Unfortunately, due to travel restrictions, some remote attendance from both Faculty and trainees was required in combination with the physical course.

This was followed on 7th-9th September, by the ST3A Introduction to Specialty Training in Cardiothoracic Surgery course, also at Ashorne Hill. Again, this was a blended learning experience, with a number of Faculty and delegates joining via zoom. Despite the logistic challenges feedback for both courses was excellent and we are extremely grateful to the Course Directors, Faculty and our administrative team for enabling both events to run smoothly.

Recently we made the difficult decision to run the forthcoming ST4A Core Cardiac Surgery course completely virtually, due to the current restrictions. We will however reschedule the wetlab aspects of the course as soon as practically possible next year at Ashorne Hill.

Details to follow in due course.

The ST8B Professional Development course on 7th-8th December will also be run via a completely virtual platform this year for

the first time. We have also been able to open this course up to a number of Trust appointed Doctors due to its virtual format.

Going forward, we will be increasingly using virtual platforms for some of our courses.

We hope that faculty and trainees will continue to interact as well as they have done at physical courses in the past and encourage feedback and comments as the portfolio continues to evolve.

We would like to remind trainees that they will

Course

Location

Date

Trainee cohorts

ST6A & ST6B subspecialty theory

Virtual

25th-26th February

2021 cohort

ST7A Revision & Viva course

Virtual

1st-4th March

2021 cohort

ST8A Pre consultant course, theory

Virtual

26th March

2020 and 2021 cohorts

Non operative technical skills for surgeons (NOTSS)

TBC

TBC

2020 and 2021 cohorts

ST3A Introduction to specialty training course

Ashorne Hill

12th-14th July

2021 cohort

ST4B Core thoracic surgery course

Ashorne Hill

6th-8th September

2021 cohort

ST6A and ST6B subspecialty practical

Johnson & Johnson Institute, Hamburg 23rd-24th September 2021 cohort

ST3B Operative cardiothoracic surgery course

Johnson & Johnson Institute, Hamburg 5th-8th October

ST4A Core cardiac surgery course

Ashorne Hill

22nd-24th November 2021 cohort

ST8B Professional Development course

Virtual

6th-7th December

ST8A Cardiothoracic pre-consultant course practical Johnson & Johnson Institute, Hamburg 14th-17th December

2020 and 2021 cohorts 2021 cohort 2020 and 2021 cohorts

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be expected to take study leave for the virtual courses as well as the face-to-face ones.

As we go to press, we are in the process of confirming the provisional calendar for next year, which will remain a combination of virtual and face-to-face courses. Some of the courses cancelled from 2020 will have two cohorts of trainees invited. Unfortunately, due to international travel restrictions, we will not have access to the Johnson & Johnson Institute in Hamburg until the autumn of 2021, so we have decided to split the ST6A and B and ST8A courses into theory and practical aspects.

The theory sessions will run earlier in the year

via a virtual platform and hopefully we will be able to travel to Hamburg as usual, later in the year, for the operative parts of the courses.

In addition, we are hoping to be able to run more Essential Skills for Cardiothoracic Surgery courses, as well as more courses for Trust appointed doctors next year. More details to follow in due course.

We would like to express our enormous thanks to Emma Ferris & Letty Mitchell in the SCTS Education administration team who have continued to work tirelessly throughout the pandemic, including scheduling, cancelling and rescheduling many of our events.

Given the complexities of training this year we would like to request all trainees ensure the team at SCTS Education has your up-to-date level of training and contact details including email address and phone number (edadmin@scts.org). If you think you should have been invited to a course

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and have not been please get in touch with us. Once contacted about a course, please respond as soon as possible so that we can confirm numbers.

Please continue to bear with us over the next few months as we all work through the COVID pandemic, we will be in touch as soon as possible. Stay safe everyone as we look forward to a brighter 2021. n

A Virtual meeting in a Virtual City Maninder Kalkat, SCTS Organising Committee

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he uncertainty and restrictions surrounding COVID forced the organising committee last year to stop vacillating and plan the meeting in a virtual format. Once this tough decision was reached, the “virtual” planning meetings commenced, the programme was finalised and a date fixed for early February 2021 to host the first virtual SCTS Annual meeting, Cardiothoracic AHP & Nursing Forum & SCTS-Ionescu University meeting. A world class faculty agreed to participate and a record number of highquality abstracts were submitted and accepted.

But that was last year. The new year dawned and we are once again finding ourselves drawn head long into the wave of surging COVID infection. We soon realized that even in a virtual format, active and enthusiastic participation of the targeted audience, already over stretched with work will not be possible and will thus defeat the very

purpose of the annual meeting. We had to make a difficult decision to postpone the meeting to 9th-11th May 2021.

The format of the meeting has been altered this year to allow three plenary sessions to facilitate discussion and interaction amongst the wider Cardiothoracic community under one virtual roof. The sessions will be interspersed with abstract presentations and keynote speakers. The two days annual meeting will be preceded by the SCTS-Ionescu University on Sunday, with lectures discussing current updates and evidence.

The registration of the meeting opened in December with greatly reduced fees and is great value for money for the jam packed sessions of great educational content. The success of this meeting is reliant on the cardiothoracic community connecting on line for the three days, interacting with each other, quizzing the speakers and sharing experiences. This virtual

meeting will never make up for the conventional get together in the salubrious surroundings of ICC Wales. However, we cardiothoracic teams are adept at innovation and embracing change and hence will surely explore this new way of the world and make the best of it.

The industry and exhibitors whose generous support has always been welcomed will have virtual exhibition areas and novel ways of engaging with clinicians are being devised.

The organising committee is committed to delivering high-quality educational content, providing opportunities for young and budding surgeons, nurses and students to present their work and to provide a platform for all to meet and interact, albeit virtually.

Also, get ready to don your jogging shoes!

The meeting will have the inaugural 5K run on Saturday evening with fantastic prizes for the winners. You are lucky, as organising committee members can’t participate!! A virtual rule. n

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Special Ionescu Fellowships celebrating 50 years of the Pericardial valve Sri Rathinam, Consultant Thoracic Surgeon, University Hospitals of Leicester

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CTS was honoured and privileged to announce this special round of applications with Mr Ionescu’s continued support to the wider cardiothoracic multidisciplinary community to celebrate 50 years of the Pericardial valve.

The extended range of the Fellowships was to allow all SCTS members to benefit Consultants, all grades of Trainees, Nurses, Allied Health Professionals and Medical Students. The applications were advertised on the SCTS website as well as by flyers to all the members. The deadline was 15th August 2020.

The flyer honoured Mr Marian Ionescu’s companion on all his mountain expeditions, the Stindard. A banner with all the national colours of his ancestry rolled into one.

All applications were scored to the SCTS Scoring Matrix by a panel of SCTS Officers and the scores were averaged to rank the candidates.

All applications were duly considered and recommended after section leads and relevant teams, due to the spread of experience and variation in the speciality.

The final recommendations were finalised by unanimous decision by the scoring teams for various streams and were submitted for consideration and approved by the President and Mr Ionescu.

The Marian and Christina Ionescu Travelling Fellowship for a consultant: 2 awards, £10,000 each Ulrich Stock, The Royal Brompton and

Harefield Hospital, London to visit the Albert Lung Transplantation programme in Melbourne. The visit will focus on donor receipt mismatch solutions and pneumoreduction.

Nizar Asadi, The Royal Brompton and

Harefield Hospital, to visit Prof W Fang in the Shanghai Chest Hospital to understand principles in pathways of care in uniportal VATS lobectomy, as well as gain exposure in Airway surgery.

Ionescu Consultant Team Fellowships: 2 awards, £15,000 each Kandadai Rammohan, University Hospitals

of Manchester, to visit the Shanghai Pulmonary Unit to understand principles in pathways of care in uniportal VATS lobectomy, as well as gain insight into process management of lung cancer patients.

Vivek Srivastava, Oxford University

Hospitals, to visit Mr R Deshpande in Kings College London, to focus on minimally invasive mitral valvular repair techniques.

Ionescu NTN Trainee Travelling Fellowships: 2 awards, £10,000 each Kunal Bhakhri, Specialist Registrar in Royal

Papworth Hospital, to undergo a Robotic Thoracic Surgery Fellowship in the Guy’s Hospital London under Mr Routledge.

Adam Daly, Specialist Registrar in Mater

Miseriecordae University Hospital, Dublin to undergo a fellowship in the Cleveland Clinic under Prof Svensson focussing on aortic and endo vascular aortic surgery.

Ionescu NTN early years (ST1-4) travel award: 1 award, £5,000 Kathrin Freystaetter, Specialty Registrar in

Freeman Hospital Newcastle, to visit the cardiac surgery department in University Hospital of Vienna. The primary goal of the fellowship is to gain insight in the latest

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minimally invasive and hybrid cardiac surgical techniques under Prof Andreas.

Ionescu SAS Surgical Fellowships: 2 awards, £10,000 each Periklis Perikleous, Clinical fellow, Harefield

Hospital, London to visit the Shanghai Pulmonary Unit to focus on minimally invasive surgery and uniportal VATS lobectomy.

Kudzayi Kutywayo, Clinical research

fellow, Glenfield Hospital, Leicester to visit University Hospital of Zurich to focus on Lung volume reduction surgery and Mesothelioma and to visit the 1st Affiliated Hospitals of the Gaungzhou Medical University to focus on VATS surgery.

children in Toronto. The fellowship will focus on paediatric cardiac surgery under Mr Barron.

The first Pericardial Valves

Ionescu 90 Nursing & Allied Health Professional Fellowships: 4 awards, £5,000 each Michelle Brennan, Preoperative care

practitioner, St George’s Hospital, London to visit Cleveland Clinic to gain insight into pre-operative preparation and patient pathways in cardiac surgery.

Ionescu 90 Medical Student Fellowships: 4 awards, £500 each Hanad Ahmed, University of Southampton,

Ionescu small travel awards for FYs and CTs: 2 awards, £5,000 each

to visit the Hospital for Sick children, Toronto for an insight into Paediatric cardiac surgery under Mr Barron.

Nikhil Sahdev, Academic FY2 in Royal

Sam Jenkins, University of Sheffield, to visit

London Hospital, to visit the Mount Sinai Hospital in New York. The fellowship will focus on all aspects of cardiac surgery and cardiothoracic transplantation.

the Queen Elizabeth Hospital Birmingham under the supervision of Mr M Bhabra as part of elective placement to gain further skills in surgery and cardiothoracic surgery.

Neil Marshall, Academic FY in Salisbury

Amerikos Argyriou, University of Manchester,

District Hospital, to visit the Hospital for Sick

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to visit Waikato Hospital under the

supervision of Dr N K Kejriwal as part of elective placement to gain further skills in surgery and cardiothoracic surgery.

SCTS Education thanks Mr Ionescu for his generosity with these additional fellowships in 2020 at the 50th Anniversary of the Pericardial valve which has enabled us to offer all these awards to our membership for the wider benefit of our patients. n

SCTS forum nursing and allied professional research Professor Julie Sanders, Director Clinical Research, St Bartholomew’s Hospital, SCTS Nursing and Allied Professional Academic and Research Lead

The SCTS National Cardiothoracic Research Meeting

The SCTS Forum Research Sub-Committee

On the 7th November the National Cardiothoracic Research meeting took place, for the first time virtually. This was an excellent day with presentations from trainees, nurses and allied professionals, with the largest audience to date attending the nursing and allied professional break-out session. Consensus from attendees indicated that sessions on clinical academic career opportunities and how to interpret research for clinical practice would be welcomed, so we will explore opportunities to provide such sessions in the near future.

Over the last few years we have established a number of initiatives to support nursing and allied professional research, including developing the SCTS Nursing and Allied professional Research Group (NARG) and the Cardiothoracic Interdisciplinary Research Network (CIRN). Due to the success and enthusiasm of SCTS Forum members we now have almost 60 members of the SCTS NARG and nursing and allied professional engagement at many centres across the UK. To support this growth I am delighted to report we have created a

SCTS Forum research sub-committee to continue and expand on our work to date.

I warmly welcome Zoe Barrett Brown (Papworth Hospital), Rosalie Magboo (St Bartholomew’s Hospital), Ashley Thomas (St Bartholomew’s Hospital), Tracey Bowden (City, University of London), Ajoy Sunil (Galway University Hospital), Sean Griffiths (King’s College Hospital), Liril Jacob (Bristol Heart Institute) and Dennis Garcia (Bristol Heart Institute) to the subcommittee. Work will focus on developing the website, promoting research in practice, expanding research opportunities and collaborations, support for clinical academic careers and offering support and advice. >>

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“Magboo and colleagues compared existing pre-op risk assessment tools for SSI (BHIS, ACRI and NNIS) and developed a new risk tool, the Barts Surgical Infection Risk (B-SIR), to predict SSI risk after various types of adult cardiac surgery.”

NEW: SCTS Forum Research strand at the SCTS Annual Meeting 2021 University day

One of two new initiatives from the new sub-committee is the introduction of a research strand to the University day at the SCTS Annual meeting in 2021. Led

by Rosalie Magboo, the programme will include an update on SCTS research developments, a session on the implications of the new Society of Cardiovascular Anaesthesiologists / European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery for nurses and allied professionals, a seminar on writing for publication, and some speed mentoring sessions will also be offered. The day will be available virtually and more details will be available in due course.

NEW: Research round-up

Tracey Bowden and Ashley Thomas are leading the second of the new research sub-committee initiatives which is to highlight and provide a brief bite-size summary of useful research findings that have implications for nursing and allied professional cardiothoracic practice.

These will be delivered through a variety of formats (Bulletin, website, podcasts etc) and will also aim to highlight the role of the nurse or allied professional in the research, where possible. To commence this, Tracey and Ashley have interviewed cardiothoracic critical care nurse, and PhD student, Rosalie Magboo about her research development following her recent publication on pre-operative risk assessment of surgical site infection.

Research round-up: Assessment of surgical site infection (Paper can be accessed at: https://www. jclinepi.com/action/showPdf ?pii =S0895-4356%2820%2930655-7)

Surgical site infections (SSIs) are serious operative complications that occurring in at least 5% of patients undergoing a surgical procedure. SSIs negatively impact patients’ physical and mental health, resulting in increased length of stay and reduced quality of life. Consequently SSIs are associated with increased financial and clinical burden.

Magboo and colleagues compared existing pre-op risk assessment tools for SSI (the Brompton and Harefield Infection Score (BHIS), the Australian Clinical Risk Index (ACRI), and the National Nosocomial Infection Score (NNIS)) and developed a new risk tool, the Barts Surgical Infection Risk (B-SIR), to predict SSI risk after various types of adult cardiac surgery.

In total, 2,449 patients who had coronary artery bypass graft (CABG) surgery and / or cardiac valve surgery between January 2016 and December 2017 were included in this study. Overall, the results indicated that the B-SIR model has a higher discriminatory ability in detecting the risk of SSI after cardiac surgery than the other models, with the NNIS demonstrating no predictive power at all. However, the B-SIR tool is a new tool and requires further external validation to assess its predictive power in other settings. This work is being undertaken as having a tool that can identify patients at risk of developing SSI before surgery would allow targeted interventions in attempt to prevent this serious complication. n

About the author

Rosalie Magboo is a registered nurse with over 22 years of clinical experience. She is currently a senior sister in cardiothoracic adult critical care.

Throughout her career Rosalie has always been passionate about and keen to develop her research skills. She has successfully completed her MSc in Advanced Practice in Health and Social Care at City, University London, funded by UCLH Charity and Barts Charity. Rosalie completed the above SSI project for her MSc dissertation which has led to a change in practice within her Trust, and has presented the work nationally and internationally.

Following this success she has recently been awarded a Barts Charity Nurse / AHP Clinical Research Training Fellowship and will start her PhD in January 2021. The aim of the PhD research is to explore psychosocial outcomes in patients with Marfan Syndrome with aorto-vascular manifestations.

Rosalie continues to develop her publication portfolio and has submitted a number of conference abstracts. Given very few nurses and AHPs engaged in cardiothoracic research are awarded research funding, this is an extraordinary achievement.

An interview with Rosalie, transcript and podcast, will also be available via the SCTS website.

For any further information on above, or to join the SCTS CIRN, please contact Julie Sanders, SCTS Forum Academic and Research Lead at j.sanders@qmul.ac.uk or visit the SCTS NARG website https://scts.org/narg/

January 2021

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Educational NAHP Subcommittee report Dr. Bhuvaneswari Krishnamoorthy, National Educational AHP & Nurses Lead

T

he COVID-19 pandemic has brought us various challenges resulting in the transformation of our way of thinking and carrying out daily activities. This has led to a transformation of our 2020 NAHP educational activities.

All of us were shocked and withdrawn during the initial phase of this virus. I will not lie about the fact that I was not worried, however, in my innocent world, I thought that this was just another saga of over-dramatised news.

To continue with our decades of given us the chance to take education to NAHP education and training, we put the doorstep of our members, pro bono together a series of webinars on the topic and keeping them actively connected of “Educating Cardiothoracic Healthcare with national and international Practitioners during the COVID-19 members. According to the Public pandemic”. We have successfully carried Health England and Royal College of out 10 webinars during the local/national Psychologists, there is an increase of lockdown with 678 delegates and 44 mental health issues by 44% due to the dedicated faculty members who have attended and Figure 1. Fear of aerosol generation during COVID-19 pandemic sacrificed their Saturday evenings for our members’ education (Figure 1).

During this pandemic, we have gone back to the fundamental state of humanity and initiated our first webinar with “Life of CT practitioners during a pandemic” which has brought all of us together to discuss the experience, loneliness and our determination to support the NHS during this crisis.

Our first webinar had given us more promise and enthusiasm to continue these webinar series, with great discussion and providing the opportunity for the practitioners to put their views out to their peers. These webinars have

“To continue with our decades of NAHP education and training, we put together a series of webinars on the topic of ‘Educating Cardiothoracic Healthcare Practitioners during the COVID-19 pandemic’.” lack of interaction during this pandemic.

All elective surgeries were ceased by the NHS and most of the practitioners were asked to work from home or deployed to other areas with uncertainty of their day-to-day work schedule.

Additionally, these webinars have brought not only the CT community together but the surgical companies’ representatives, clinical trainers and the multidisciplinary team together who work closely with our practitioners. The webinars were recorded, edited, and posted on the CTS Net, YouTube and on LinkedIn for members and non-members to access, free of cost, during this pandemic as our educational offer.

This COVID-19 pandemic crisis has taught us a lot. It has taught us that life is more important than anything else in this world.

So, please pick back up the hobbies which you have left for work commitments or friendships which you have forgotten due to your busy schedule and enjoy the moments of life. n

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The National Heart Surgery Clinical Trials Initiative Professor Gavin Murphy, British Heart Foundation Professor of Cardiac Surgery, University of Leicester

T

he James Lind Alliance (JLA) Priority Setting Partnership (PSP) concluded in 2019 and identified the top 10 unanswered research priorities in adult cardiac surgery, for patients, carers and clinicians. The next phase of the initiative aims to translate these research priorities into a national programme of clinical trials that will inform best practice.

With funding from Heart Research UK and infrastructure support from the BHF Clinical Research Collaborative, the National Heart Surgery Clinical Trials initiative was established (https://le.ac.uk/ cardiovascular-sciences/about/heartsurgery/national-cardiac-surgeryresearch-trials-initiative). This has been endorsed by both the Society for

Cardiothoracic Surgery in Great Britain and Ireland (SCTS) and the Royal College of Surgeons (RCS) Trials Initiative.

The initiative is also being supported by the new British Heart Foundation Data Science Centre (HDSC), who have chosen cardiac surgery as a vanguard for the development of a novel health data science platform that will support the design and implementation of pragmatic data-enabled clinical trials.

In this initiative, we have been able to bring together all major stakeholders from across the UK to contribute to the development of a successful patient centered research programme, where patients, researchers and clinicians would be represented equally.

Table 1: Structure and themes of the clinical study groups established

Over 220 participants have registered to take part in this initiative so far. Nine separate clinical study groups (CSG) have been established; each led in equal partnership, by patients, clinicians and health service researchers (Table 1). As part of the initiative the Cardiothoracic Interdisciplinary Research Network (CIRN) have embedded a trainee representative in each clinical study group, who will further support the delivery of national surveys to identify variations in practice, systematic reviews and local delivery of any subsequent trials through the associate PI scheme.

Individual clinical study group (CSG) will be tasked to focus on a different priority arising from the JLA PSP (Figure 1).

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complete their inaugural moderatoronly meetings, which have set the agenda for the remaining programme of work (Figures 2a, 2b). The work stemming from the national initiative has already generated four potential clinical trials and one grant submission, all of which will tackle key unanswered research questions in cardiac surgery.

The coming months will see all clinical study groups holding their second meetings and it is expected that this initiative will enable each group to develop high-quality funding applications for clinical trials that will inform best practice in adult cardiac surgery. n

Figure 1: The 9 Clinical study groups established as a part of the national heart surgery initiative

Each Clinical Study Group will host a series of webinars in order to define areas of uncertainty, develop research themes that will shape the agenda for a national heart surgery research programme, and pump prime potential research teams who can come together to develop high quality research proposals for funders.

The administrative support for this work is being funded by Heart Research UK and the Royal College of Surgeons. The online platform is provided by the new British Heart Foundation Clinical Research Collaborative (https://bhfcrc.org/). As part of this initiative, a National Cardiac Surgery Patient and Public Involvement Group was established, led by Mrs. Sarah Murray, who is also a lay representative on the SCTS Executive. This group consists of all the patient moderators from the nine separate clinical study groups. Its

aim is to give national networks of public representatives a role in shaping the research agenda, and to participate in all aspects of the resulting research programme.

The initial phase of this initiative has seen all nine clinical study groups

We are committed to inclusivity.

If you wish to get involved in any of the clinical study groups please email us on heartsurgerypsp@leicester.ac.uk Please follow our twitter handle: @HeartSurgeryPSP for updates on the project.

“The work stemming from the national initiative has already generated four potential clinical trials and one grant submission, all of which will tackle key unanswered research questions in cardiac surgery.”

Figure 2a: CSG 1 – Quality of life and long term outcomes Professor Mark Petrie, Mrs. Sarah Murray, Professor Gavin Murphy, Professor Linda Sharples

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Figure 2b: CSG 3 – Heart Valve Interventions Professor Gerry McCann, Professor Gavin Murphy, Mr. Paul Haywood, Mr. Will Woan

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Aortic Dissection Awareness UK and University of Leicester partnership: Patients’ and researchers’ joint effort to optimise screening and treatment pathways in aortic disease Gareth Owens, Chair, Aortic Dissection Awareness UK & Ireland Riccardo Abbasciano, Clinical Research Fellow, University of Leicester

F

ollowing the success of Aortic Dissection Awareness Day UK 2019 in Leicester, AD patients, their relatives and experts, have been shaping the research around treatment pathways for aortic diseases.

Non-syndromic aortic diseases are conditions with a strong, often unrecognised, genetic background. Genetic testing could return positive results in up to one out of four relatives, even in families with a first case of aortic dissection.

However, current scientific literature lacks clear recommendations about the management, follow up, and configuration of clinical services for non-syndromic forms of aortic diseases. Nonetheless, a tailored screening programme could result in a timely diagnosis and prevent aortic dissection by offering optimal surveillance,

medical management, and prophylactic surgical intervention when required.

Professor Gavin Murphy’s research team at the University of Leicester, in collaboration with the national patient association Aortic Dissection Awareness UK & Ireland, put in place a research plan that aims to investigate the possibility of setting-up a screening programme for non-syndromic aortic diseases in the UK. A feasibility study (A Study to Evaluate the Feasibility of Screening Relatives of Patients Affected by Non-Syndromic Thoracic Aortic Diseases: the ReST study) has recently been completed.

In this feasibility study, several important aspects of the current pathway were highlighted. Firstly, the diagnosis rate may be high enough to warrant the need for screening, even in patients and families that

are currently not considered by the testing criteria. Secondly, the different modalities of screening may benefit from being integrated into a combined approach. And thirdly, the current service offered by the available clinical pathway may be inaccessible for an important section of the public, or may be inadequately promoted.

A huge opportunity to advance this research initiative was provided by Aortic Dissection Awareness Day UK 2019, which was held in Leicester on 19th September, on the theme of “Aortic Dissection: Research and Innovation”. The event was structured with the specific aim of allowing experts and patients to interact, in order to shape research in aortic diseases. The conference itself was planned as a Delphi Process. This technique benefits from the use of a survey, submitted to experts throughout several repeated rounds. At the beginning of each round, the experts receive feedback of what the consensus was during the previous round. The aim was to reach a consensus on aortic disease research questions that are especially relevant for screening, around four main areas: imaging, genetic testing, clinical genetics, and trial design.

Along with the consensus reached (described in a recent publication in Trials, Report of a Delphi exercise to inform the design of a research programme on screening for thoracic aortic disease), the process created a collaboration of experts potentially required in the management of patients affected by aortic disease and their families. This was the basis to form a working group that met in the months following the conference. Of course, we did not underestimate the importance of

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the involvement of patients, in order to understand the perplexities and concerns of the people that will be ultimately affected by the revision of the current treatment pathways, and anticipate the difficulties that may arise, or at least set up the necessary measures to monitor them.

The group has progressed from the initial focus on screening for thoracic aortic disease to formulating a plan on how to integrate the tests in a revised treatment pathway, obtaining the required evidence to support its application on a national basis, optimise its implementation across the country (overcoming the current equipoise in the screening offer), and ultimately offering holistic care to patients and their families. Members of Aortic Dissection Awareness UK & Ireland are an active part of the working group meetings and their advice and suggestions are shaping the direction of the programme.

In order to achieve its aim, three main lines of research initiatives have been established:

in the UK might be too strict to identify cases that would potentially benefit from a precision-medicine approach to their care, and are not homogeneously applied.

2. Implementation research at an individual and organizational level to define current equipoise in the standard of care; solve possible barriers to the service access and improve uptake; optimize the patient experience and the training stakeholders receive; and ultimately evaluate the implementation of a proposed, refined, clinical pathway.

3. A trial to compare the current scenario with our refined, standardized, approach.

1. Identifying the optimal clinical algorithm to test, treat and follow these families. The current criteria for testing

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Currently, our short-term aim is collating the available information on the existing treatment pathways adopted in the different regions, by performing a systematic literature review on standards of care for people with low, intermediate or high risk, thoracic aortic disease phenotypes, and a survey among the Inherited Cardiac Condition services. There are also ongoing methodological discussions on the optimal trial design to tackle this research problem.

Our medium-term aim is submitting a robust proposal for a programme grant for applied research in early 2021.

We would welcome potential expressions of interest to reach this goal. We believe this is a unique opportunity to join researchers and the public in a project that has an immediate clinical application and could potentially change policies.

Further information on this initiative can be accessed via the Aortic Dissection Awareness UK & Ireland website www.aorticdissectionawareness.org and by contacting the research team at the University of Leicester rga8@leicester.ac.uk n

Cardiothoracic Interdisciplinary Research Network (CIRN) Luke Rogers (CIRN co-chair; cardiac) Ricky Vaja (CIRN co-chair; cardiac) Edward Caruana (CIRN co-chair; thoracic) Akshay Patel (CIRN co-chair; thoracic)

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evere acute respiratory syndrome coronavirus 2 (SAR-CoV2), or more colloquially COVID-19, has undoubtedly changed the world we live in.

This has led to a year of social distancing, widespread use of face masks, national and local lockdowns, delays to surgical cancer resection and ultimately excess untimely deaths. Despite this however, solace can be found in the collaboration that this global

pandemic has catalysed and the opportunities it has provided the Cardio-Thoracic Interdisciplinary Research Network (CIRN).

Not only has this year seen the publication of the “National survey of variations in the prevention of surgical site infections in adult cardiac surgery� in the Journal of Hospital Infection (JHI) (https:// www.journalofhospitalinfection.com/ article/S0195-6701(20)30431-X/fulltext)

it has also facilitated collaboration with COVIDSurg studies (Cohort and Cancer) [2,3] across both Thoracic and Cardiac surgery. Furthermore, submission of an NIHR Development Grant proposal, launch of the Clinical Study Groups following the identification of 10 key research priorities in adult cardiac surgery and the appointment of two Thoracic associate Surgical Specialty Leads (aSSL); Ed Caruana and Akshay Patel. >>

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The JHI publication alone has realised the contribution of 42 interdisciplinary collaborative authors, who are all PubMed citable. They have delivered this study across 19 centres in the United Kingdom (UK) and Republic of Ireland (ROI) and an additional 150 individuals who were named in the Appendix as contributors for their work in gathering the essential data. This has not only demonstrated that the CIRN can deliver national studies, across multiple centres, but importantly for all those involved, can ensure through corporate authorship, that everyone is recognised for their work. This has now set a precedent, outlined in the CIRNs terms of reference, that we hope will encourage others to get involved in the numerous opportunities abound.

The CIRNs first draft of the Cochrane Review “Interventions to prevent surgical site infection (SSI) in adults undergoing cardiac surgery” is currently under peer review and in combination with the variation in practice survey this work has ultimately underpinned an NIHR Development Grant application that if successful will fund three key work packages; 1. A systematic review of studies evaluating risk factors for SSI in clean surgery 2. A study to identify barriers and facilitators to the implementation of SSI prevention strategies and further characterisation of what is ‘usual practice’ 3. A study to identify barriers and facilitators to engagement with SSI surveillance systems This will provide ample opportunity for all those wishing to be involved in research with the occasion to do so, and we hope, will ultimately lead to submission of an NIHR Programme Grant application in the years to come.

Alongside this work an additional interdisciplinary working group of global experts and CIRN members has been brought together to deliver a Cochrane Heart review priority. This proposal “Antithrombotic treatment following coronary artery bypass surgery” was competitively awarded and is currently under review following submission (unpublished).

Nationwide surveys have also been circulated to multiple centres in the UK & ROI through CIRN to outline current

“Not only has this year seen the publication of the ‘National survey of variations in the prevention of surgical site infections in adult cardiac surgery’ in the Journal of Hospital Infection (JHI), it has also facilitated collaboration with COVIDSurg studies (Cohort and Cancer) across both Thoracic and Cardiac surgery.” practise in aortic surgery and redo-aortic valve replacement (RAV study) which have not only continued to grow the interdisciplinary commitment to CIRN but have also expanded to include interested and enthusiastic medical students.

The rapid emergence of the SARSCoV2 virus across international borders has forced the redesign of clinical services to deprioritise non-urgent surgical care.

This strategy however has the potential downside of adversely affecting individuals with cancer, for whom a delay in treatment may result in a change of a cancers resectability. The reverse of this argument is that continuing on treatment which could weaken one’s immune system such as chemotherapy, and indeed invasive surgical procedures can put these patients at a higher risk of postoperative complications due to the current pandemic. Seminal data from the COVIDSurg Cancer collaborative demonstrated that with available resources, dedicated COVID-19 free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks. This international, multicentre cohort study published in the Journal of Clinical Oncology [3] included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theatre, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary

outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). Pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86).

This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists Grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests.

The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76).

Further work, stemming from this collaborative comes in the form of the COVIDSurg-Week study which is an international, prospective multi-centre cohort study that aims to determine the optimal timing of surgery following SARSCoV-2 infection and assess key global surgical indicators, such as postoperative mortality. This study is open to all hospitals including those that have not admitted SARS-CoV-2 infected patients. All patients (from all specialties) undergoing a surgical procedure done in an operating theatre will be included (any SARS-CoV-2 status). For further information and an opportunity to register and take part, visit https:// globalsurg.org/surgweek/

The Cardiothoracic Interdisciplinary Research Network (CIRN) is always looking for enthusiastic, research minded nurses, allied health professionals and surgeons to get involved. Please email CIRNetwork@ outlook.com to be added to the database and hear more about the ongoing projects. n

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the 38 bulletin

Coronavirus - Trainee Representative Perspective Duncan Steele, ST6 Cardiothoracic Surgeon & Senior Cardiothoracic Trainee Representative Abdul Badran, SCTS trainee representative, Specialist Registrar Cardiothoracic Surgery

I

n the midst of a second wave of the COVID-19 pandemic, there continues to be a number of challenges amongst the disruption to surgical training. During the first wave we had many unknowns about the nature of the threat from COVID-19, erring on the Figure 1

side of caution with health care delivery with some detriment to patient care and a severe blow to surgical training. (REF) This was widely variable in different specialties and areas of the country. A realisation from the first wave that the disruption from protective measures against the virus must be minimised. This also holds true for the delivery of training, with trainees bearing the brunt of service delivery. A snapshot of the impact in our specialty from our annual trainee survey this year

raises a number of issues for trainees that require due consideration and support. This was conducted after the first wave, relating to the period in June 2020 prior to the country entering a second national lockdown and we share some preliminary results.

Of the 56 respondents there was a good mixture of different year trainees from across the country and coming from a diverse ethnic background (Figures 1, 2, 3, 4).

Figure 2 Figure 3

Asking about the impact of COVID on trainees. The vast majority of trainees are still feeling a significant impact. In addition to time off work to isolate for health or contact reasons, more than 70% have experienced a reduction in the volume or quality of training. Almost a tenth are redeployed. Even more concerning is that over 50% of these trainees have not been given a date to return to their career specialty (Figure 5).

Figure 4

Figure 5

January 2021

The reported reduction on operative experience slightly favoured trainees working in thoracic surgery (62%) than cardiac surgery (81%) although this was still a significant majority of trainees effected.

Most trainees felt they had good personal protective equipment (PPE) provision although 21% did not. Of these, however, just 9% was due to lack of availability.

PPE usage itself has affected the way we operate. Just under of a third of trainees found that they could not operate with full PPE due to physical and mental health barriers (Figure 6).

With the huge expansion of remote meeting and events, particularly its direct support and promotion by the NHS. The utility of this software to continue educational activities in the ultimate of social distancing has been rapidly take up. All trainees have been invited to a remote teaching event with the vast majority being able to attend (49/54).

Local educational programmes exist in 6 regions with 63% 34/54 attending a national programme and 11% 6/54 an international programme. With this current trend likely to be a permanent fixture, these should be treated as they would physical teaching session with the support and protected time in place.

39

Figure 6

Fellowships and examinations have been hugely affected by the disruption in the COVID-19 pandemic. Of respondents that had a fellowship organised over this period 10% were able to proceed with the experience.

All trainees who had an exam booked or planned to take one have had it cancelled.

With some contingency examinations taking place in Scotland this will provide some relief

and clarity however the disruption is likely to unsettle trainees taking examinations, at an already anxious time.

It has never been more important to engage with the help provided by local deaneries and the society in order to work towards resolving these difficult challenges and come much closer together as a trainee body in this ironic time of social distancing. n

SCTS INSINC present the first ever University Challenge at the 2021 Annual Meeting of SCTS Inspiring Students into Cardiothoracic Surgery (SCTS INSINC) is proud to present SCTS’s first ever University Challenge!

INSINC’s aim is to promote cardiothoracic surgery via education and inspiring the next generation of students into a career in cardiothoracic surgery.

Due to the postponement of the annual meeting in February, please look out for further information about new dates. We will host a live in the box anatomy demonstration, Simon Kendall a.k.a. Jeremy Paxman hosting our University Challenge and our annual Pat Magee Oral Presentation competition.

Check out the SCTS website for more info on how your unit can team up with University students to win free entry to SCTS next year! n

@SCTSINSINC

the 40 bulletin

Cardiac Surgery – A brief history of the future Gianni D Angelini, BHF Professor of Cardiac Surgery, Bristol Heart Institute, Bristol University

Return from a trip to Mars A cardiologist and a cardiac surgeon married-couple return to Earth after a long, twenty years, interplanetary trip to Mars, and they were understandably concerned about re-establishing their clinical practice.

The cardiologist discovered that a lot had changed, a new subspecialty had been created named interventional cardiology and she realised that she would have to undergo new training. Coronary angiography had been almost completely replaced by non-invasive investigations, such as MRI and CT scans with 3D reconstruction.

Patients with unstable angina, acute MI and cardiogenic shock, were now being emergently treated via PCI. These procedures were associated with FFR that offered a functional assessment in addition to the anatomy of the coronary artery lesion. Primary PCI was keeping cardiologists busy night and day, and some patients, who were experiencing out of hospital cardiac arrest, were resuscitated with percutaneous ECMO. Post-MI ventricular septal defects were being treated via the percutaneous route with the deployment of occluding devices.

TAVI technology had rapidly evolved and was now being applied to low-risk patient groups. Mitral insufficiency, was now being treated percutaneously via MitraClip and percutaneous chordae replacement was being performed by cardiologists on a beating heart.

Percutaneous mitral valve prostheses were on clinical trials and likely to replace surgical mitral valve replacement.

Impressive developments had taken place in catheter ablation of atrial fibrillation and other arrhythmias and embolisation due to fibrillation was now being prevented by percutaneous closure of the left atrial appendage.

The cardiologist learned that surgeons had lost ground in the field of thoracic aortic diseases, dominated by vascular surgeons and/

or interventional radiologists with catheter skills. The cardiologist found that there was tremendous enthusiasm from industry in the development of new devices, and she embraced these new technologies.

The cardiac surgeon, on the other hand, was surprised by how minimal changes had taken place in his daily practice.

The last 20-30 years of his career had been good, and it was almost as if nothing had changed. The time spent away had not changed his perception of life. We can call this “the heart surgeon, delusion and denial syndrome (HSDDS)”. Delusion, because he thought he was still at the top of the tree, and denial because he continued business as usual. He felt that he should focus his energy to continue to argue whether coronary surgery should be done on-pump or offpump, arterial grafts via single or double mammary, tissue or mechanical valve, or whether smaller incision (misnomer for so-called minimally invasive) should be used for valve procedures. He was also confident that surgical revascularisation had stood the test of time, and that any new procedures would have to wait for long-term follow up results. How wrong he was. The cardiologist had the vision, the opportunities that existed in the treatment of heart disease and that of forming a partnership with the industry.

Unfortunately, his enthusiasm and confidence were soon dented when he looked at his operating list for the next few weeks ahead. He was perplexed to see that the number of patients referred to his practice had almost disappeared, due to redirection of patients to interventional cardiology. His involvement was now relegated to being on standby in case the interventional cardiologist needed help. He also noticed that patients had become more informed and knowledgeable and that they were voting with their feet. He now accepted that he had to reinvent himself.

A new beginning TAVI remains one of the most disruptive technologies in the last decade. Short-term data shows equivalent, if not better results of TAVI in the low-risk patient groups as compared to surgery. Our cardiac surgeon has lost the argument for performing surgical AVR, certainly for high-risk patients, and more recently low-risk patients. For now, he consoles himself by the fact that long-term follow up of TAVI versus surgical AVR is not available yet.

While it is accepted that mini-sternotomy AVR does not outperform standard sternotomy AVR, mini-thoracotomy AVR holds some promise. Suture-less valves (implanted with some sutures – just less) where a reactive discovery to the development of TAVI. Despite such a sophisticated minimally invasive armamentarium, it is still hard to compete with the 1-2-day hospital stay of TAVI that is more and more demanded by our patients. He will have to reconcile with the idea that the wire skills he found alien some time ago are now the way forward.

When it comes to the treatment of mitral valve disease, the complexity of the valve apparatus makes it difficult, for now, to develop an implantable valve such as the case with TAVI, and the artistic ability and precision of the surgeon remain unmatched. Minimally invasive mitral valve repair via minithoracotomy is now widely performed, offering a fast recovery to patients with similar results to the sternotomy approach. A step forward is totally endoscopic mitral valve repair using endoscopic instruments or robotic techniques.

The left internal mammary artery to LAD graft remains, so far, unequalled by PCI. CABG stands out in left main stem disease treatment or in triple vessel disease with superior long-term outcomes in specific patient subgroups such as diabetic patients, and poor LV. While the volume of CABG has reduced, this technique will remain in the cardiac

January 2021

surgeon’s arsenal for the years to come, and it can and should be further improved.

The use of arterial revascularisation, which at present represents barely 5-10% of the total CABG volume, needs to be embraced more enthusiastically even if it requires a steep learning curve and longer time in the operating theatre. Off-pump CABG using mini-thoracotomy to perform LIMA to LAD anastomosis is an established technique.

Transforming this into a hybrid procedure to stent the by-stander disease originally was performed many years ago but failed to be adopted widely. This could bring the cardiologist and the heart surgeon to work together. Total endoscopic CABG using robotic technology is still in its early stages and limited to specialised centres.

Similarly, the aortic surgeon will have to acquire catheter wire skills to do TEVAR. However, as the surgeon adapts and becomes more experienced in wire-skills, a new dilemma arises. How can he train or maintain skills in open surgery since the volume of cases will reduce and the complexity of cases that need surgery increases? This situation is like the one already experienced by general surgeons with the introduction of laparoscopic techniques.

Significant improvements have been made in heart transplantation.

Immunosuppressive therapies are refining more; however, this is unlikely to overcome the shortage of donor’s hearts. One alternative is the development of bridging to transplantation mechanical circulatory devices or even of total artificial hearts, or xenotransplantation. Unfortunately, despite much effort, advances in terms of battery life and surface compatibility to reduce thrombogenicity are still to be achieved.

In congenital heart surgery, there is more prenatal diagnosis intra-uterine surgery and in last resort, termination of pregnancy. There is more in the way of catheter interventions but complex pathologies that require reconstructive surgery are still amenable and probably will not disappear. The question is where the innovation lies? Congenital heart surgery is still in search of the ideal valve/conduit substitute that could grow and offered durability. An accurate in-utero diagnosis which will then allow the collection of the placenta, blood and the umbilical cord stem cells when the baby is delivered, will allow the bio-engineering of living conduits and valve that can be implanted and able to grow with the patient.

Back to the future The return from Mars has prompted the cardiac surgeon to urgently reflect on the future of the speciality. He realised that he cannot continue in a comfortable life but must adapt to survive. Key to his revival will be the development of innovation that ultimately benefits the patient. This change is not going to be minor, and it will require a brain reboot, a complete change of mindset, and effort that will enable improvement in areas where there is still an opportunity for innovation. This is the case in coronary arterial revascularisation and valve repair, and at the same time, embracing catheter wires and endoscopic skills.

This will require urgent recognition by the speciality to implement major changes in the training curriculum for the next generation.

The end result likely will be merging of the interventional cardiologist and the cardiac surgeon into a new specie (chimaera). n This is a short version of the full paper published in the International Journal of Cardiology: https://doi.org/10.1016/j. ijcard.2020.08.100. Authors: Gianni D Angelini, Tomás A Salerno, Daniel P Fudulu

AQUABRID® Developed for wet conditions AQUABRID® is a fully synthetic surgical sealant for aortic surgical procedures.

In contact with water AQUABRID® forms an elastic layer within 3 to 5 minutes – making it optimal for use on wet conditions. AQUABRID® stretches and shrinks with contraction of the vessel, while maintaining a strong seal in the aorta.1, 2

Benefits of AQUABRID® Reacts with water – Optimal use on wet surfaces, regardless of heparinization conditions

Strong – Maintains bond/seal in the high pressure environment of the aorta

Ready to use – No manual mixing or preparation required

100 % synthetic – No biological origin or risk of infection

Elastic – Stretches and shrinks with the vessel contractions

REFERENCES: 1. Eto M et al. Elastomeric surgical sealant for hemostasis of cardiovascular anastomosis under full heparinization.

Europ. J. Cardio Surg. 2007; 730-734.

2. Oda S. et al. Experimental use of an elastomeric surgical sealant for arterial hemostasis and its long-term tissue response.

Interac. Cardiov. and Thor. Surgery. 2010; 258-261.

Terumo ® is a registered trademark of Terumo Corporation. AQUABRID ® is registered trademark of Sanyo Chemical Industries, Ltd. ©2020 Terumo Europe N.V. CV295GB-0620 OB-I(06.20)E

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41

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23.06.20 11:04

the 42 bulletin

Rules of (Virtual) Engagement Veena Surendrakumar, Ashvini Menon, Richard Steyn Department of Thoracic Surgery, Queen Elizabeth Hospital Birmingham

I

t is seven in the evening. I am sitting on my sofa with a glass of wine, dressed in my pyjamas and ready to settle down to the final session of the Birmingham Review Course. Long gone are the days spent wondering whether smart casual means I can wear jeans, or when the next tea break is and whether there will be free biscuits. In this new social distancing era, video conferencing has become the norm. From outpatient appointments and MDTs, to teaching sessions and international conferences, virtual meetings have made attendance easy, convenient, and overly comfortable, but how often are we at risk of appearing inappropriate and unprofessional?

We share our thoughts on the A-F of video conferencing etiquette.

A is for Appearance Make an effort, after all why would a virtual conference with your consultants be any less formal than meeting them in person?

Joining a video conference having just woken up in bed, as one candidate did at a recent meeting, really is a poor showing.

Although Zoom is unlikely to have a dress code entrance policy any time soon, do be conscious of the meeting’s purpose and audience, and dress professionally.

B is for Background Your chosen background for a video call can unwittingly give other attendees your own personal episode of ‘Through the Keyhole’. Whether it is the pile of dirty laundry or your neatly stacked journals of EJCTVS, your background can quickly deflect attention away from what is being said. Instead, choose a plain unassuming backdrop, or better yet upload a non-distracting

background photo, which in some situations can also be used as an easy icebreaker for the start of the meeting.

C is for Camera We already spend most of our days hiding behind a mask, is it really necessary to keep our cameras off online too? Being present visually not only helps keep the meeting interactive and personable but also allows the presenter to pick up on the usual nonverbal cues.

When using the camera, be aware of how you project. As every keen Instagrammer knows, a good selfie is all about lighting, head position and eye contact.

Sit somewhere with plenty of daylight, but avoid direct light hitting the camera as this can quite literally cast a shadow over your appearance. Position yourself centre screen, without the camera pointing up your nose or showing excessive forehead, and when talking, look directly into the camera, rather than at the projected image of yourself.

D is for Distractions By which we mean, limit them. From the sound of the washing machine finishing, or another new email pinging into your inbox, distractions not only prevent you from concentrating but also disrupt the flow of the speaker. Try and avoid areas with

lots of ambient noise and if at home, keep pets and roommates at bay. Consider using headphones to focus your attention and utilise the mute button, but do not forget to unmute when speaking.

E is for Engagement Engaging in large meetings can be difficult at the best of times and has only become harder in the virtual setting. Help the speaker when interacting by maintaining eye contact, speaking with clarity, and answering questions without talking over other attendees.

Although it may seem like the perfect opportunity to respond to emails or catch up on the news, be courteous by keeping focus and avoid multi-tasking. You wouldn’t do it face-to-face, so why do it virtually.

F is for Formalities No one likes a latecomer, even if they are now able to slip into the room silent and unseen. Join meetings in good time and check in advance for connectivity issues prior to logging on. If you must leave early, avoid sneaking out; if you don’t want to disrupt the flow of the meeting, send a group message with your apologies before logging off.

It is only a matter of time before ‘zooming’ becomes accepted as an official definition for meeting virtually. However despite its many advantages, it is important to remember why video meetings have been created: to replace social interaction. With convenience can come laziness, so keep in mind that the usual etiquette expected of face-to-face meetings still holds true in the virtual realm. This is especially important for trainees, where, much like in reality, every meeting with your bosses should be considered a pre-interview visit. n

IONESCU FELLOWSHIPS

02 | Ionescu Fellowships

A LETTER...

The history is full of examples. The Romans conquered militarily Greece and the Greeks influenced culturally, philosophically and artistically Rome. The result became in a special way the Greco-Roman ‘World’. Two centuries ago Edgar Allan Poe reminded us of ‘the glory that was Greece ‘and’ the grandeur that was Rome.’

Dear friends from afar, we have not met before and even now we meet in thought only.

I encountered your smiles in the photographs you showed us from faraway lands.

I can imagine and understand your enthusiasm and the desire and dreams to climb higher towards more light and more knowledge.

I send a warm thank you to all who engaged in this little voyage of discovery and who had the kindness and the thought to give us some glimpses of their adventure.

For a long time I knew that each Fellowship carries inside it a grain of Eternity, one never knows when it will end.

But in the immediate, it may sweep the cobwebs from your understanding of life and help you to think in the way you have not thought before. In a short time you saw alongside your main goal, aspects of different worlds, landscapes, people, museums and cathedrals, watched different habits, techniques, and also various gastronomical delights.

A varied and colourful world!

Fellowships or their cousins were all built for coming together for safety strength and help and to travel for knowledge.

Some seventy thousand years ago, during the cognitive revolution and the emergence of fictive languages, at the beginning of our written history, life led peoples to congregate and to travel. It started with primitive casts, embryonic states, leagues (the important Hanseatic League), brotherhoods, accords for commerce, economy and defence and all became crystallised progressively in today’s Fellowships.

Great Italian painters of the Renaissance went north to understand and to learn of the Clair-obscur technique, while Dutch and Flemish painters travelled to Italy for the ‘brilliant Mediterranean light’. In the 1920s and 30s, American Fellows used to go to Berlin and Vienna to learn gastric surgery (Sauerbruch, Hoffmeister, Reichel) and later, after the second world war, they came to London for thoracic surgery to lord Brock.

Now our heart and lung surgeons go to Germany and America to learn of the novel creations and new techniques in Cardiothoracic Surgery.

During the last century, the creation of ‘Foundations and Fellowships’ akin to the Rockefeller, Frick and more recently the Fulbright have created a modern, very useful system of international help and learning.

Here in Britain, the NHS system does not facilitate, at present, the creation of long term Fellowships of one or two years. For this reason I concentrated my efforts on smaller but multiple Fellowships. I wish to succeed in my dream to carry on sending out the lovely Flyers for fellowships for evermore.

Please remember that in every Fellowship is hidden a grain of Eternity. Nobody knows when it will end.

With all good wishes of success to all of you, I beg to remain yours sincerely.

Marian Ion Ionescu

Ionescu Fellowships

| 03

The Marian and Christina Ionescu Travelling Fellowship for a Consultant Sri Rathinam, SCTS Education Secretary Carol Tan, SCTS Education Secretary

M

r Ionescu has offered the society donations specifically stipulated for various purposes. SCTS is grateful for his contributed funds towards the various fellowships, the publication of the SCTS bulletin and the proceedings of the Ionescu University published in the form of Perspectives in cardiothoracic surgery.

As a surgeon, educator and trainer Mr Ionescu has seen the value of helping in the development of trainees and consultants; he has donated to and enabled the SCTS to offer fellowships to the multidisciplinary team.

He has supported the SCTS Fellowships programme from its inception

with the establishment of the Marian and Christina Ionescu Travelling Fellowship for a Consultant in 2005. This has enabled our members to travel the world to visit centres par excellence to gain knowledge skills and worldly wisdom.

Christina and Marian Ionescu Consultant Travelling Fellowship

The Christina and Marian Ionescu Consultant Travelling Fellowship has been offered since 2005 to young consultants within their first five years to pay visits to various units to either develop their own skills or to take the team to the centre of excellence.

There has always been a stiff competition apart from one year. All of them have used the funding in a fruitful manner to come back and further develop their service with the introduction of innovative surgical techniques.

Recently the five-year rule has been relaxed to enable established surgeons to seek newer skills for their repertoire as well as hone their established skills by visiting expert centres.

The applications in recent years have been scored by the President, President Elect, Secretary and the Education secretaries and fellowship is offered as a consensus.

The recipients are required to offer a formal report to the SCTS which usually is published in the SCTS Bulletin. >>

Winners

Name

Unit

2005 2006 2007 2008 2009 2010 2010 2011 2012

Domenico Pagano Marjan Jahangiri Steve Rooney David O'Regan n/a Norman Briffa Sukumaran Nair Chris Munsch Bari Murtuza

Consultant Cardiac Surgeon, Queen Elizabeth Hospital Birmingham Consultant Cardiac Surgeon, St George’s Hospital, London Consultant Cardiac Surgeon, Queen Elizabeth Hospital Birmingham Consultant Cardiac Surgeon, Leeds General Infirmary

2013 2014 2014 2015 2016 2016 2017 2017 2018 2018 2019 2020

Debbie Harrington Enoch Akowuah Mahmoud Loubani Paul Modi Pedro Catarino Joel Dunning Keng Ang Amit Modi Fraser Sutherland Mohammad Hawari Kulvinder Lall Lognathen Balacumaraswami

Consultant Cardiac Surgeon, Liverpool Heart and Chest Hospital Consultant Cardiac Surgeon, James Cook University Hospitals, Middlesbrough Consultant Cardiothoracic Surgeon, Castle Hill Hospital, Hull Consultant Cardiac Surgeon, Liverpool Heart and Chest Hospital Consultant Cardiac Surgeon, Papworth Hospital, Cambridge Consultant Cardiothoracic Surgeon, James Cook University Hospitals, Middlesbrough Consultant Thoracic Surgeon, University Hospitals of Leicester Consultant Cardiac Surgeon, Royal Sussex University Hospital, Brighton Consultant Cardiac Surgeon, Golden Jubilee National Hospital, Glasgow Consultant Thoracic Surgeon, Nottingham University Hospitals Consultant Cardiac Surgeon, St Bartholomew’s Hospital, London Consultant Cardiac Surgeon, University Hospitals of North Midlands, Stoke on Trent

Consultant Cardiothoracic Surgeon, Northern General Hospital, Sheffield Consultant Cardiac Surgeon, Papworth Hospital, Cambridge Consultant Cardiac Surgeon, Leeds General Infirmary Consultant Paediatric Cardiothoracic Surgeon, Newcastle

04 | Ionescu Fellowships

“The Christina and Marian Ionescu Consultant Travelling Fellowship has been offered since 2005 to young consultants within their first five years to pay visits to various units to either develop their own skills or to take the team to the centre of excellence.”

The applicants have brought a variety of skills into the speciality and the wider NHS. Healthcare management and modernisation (David O Reagan), Robotic Mitral surgery (Paul Modi) Robotic Thoracic Surgery (Mohamed Hawari), Aortic Surgery (Amit Modi), Non intubated Thoracic Surgery (Keng Ang), Minimally invasive cardiac surgery (Norman Briffa) Thoracoabdominal aortic surgery (Debra Harrington).

Most Ionescu Scholars have progressed well in their units and have incorporated the skills they gained in their fellowships to their practice.

Their career path also has benefited the wider NHS with positions of importance; Education secretary and JCST & SAC Chair (Chris Munch), Director of the Faculty of Surgical Trainers, Royal college of Surgeons of Edinburgh (David O Regan), Training Programme Directors (Marjan Jahangiri London, Steve Rooney West Midlands, Mahmoud Loubani Yorkshire), EACTS Secretary General (Domenico Pagano) SCTS Meeting secretary SCTS (Enoch Akowuah).

Three recipients have become Professors (Marjan Jahangiri, Domenico Pagano and Mahmoud Loubani).

The impact of 15 years of the Marian and Christina travelling fellowship for consultants has brought a wide variety of skills into the NHS practice. These scholars have cascaded their wisdom to their team as well as trainees. The success of these fellowships has resulted in the expansion of Ionescu fellowship portfolio which offers various fellowship to the whole range of our membership.

SCTS is as always grateful to Mr Marian Ionescu and Dr Christina Ionescu for making this happen and for their continuous support to the various fellowships. n

Ionescu Fellowship in the USA Cristiano Spadaccio, Golden Jubilee National Hospital, Glasgow

T

he Ionescu Fellowship award gave me the great possibility to spend time in major aortic surgery centers in USA. The fellowship was indeed intended to obtain knowledge and practical experience in aortic surgery and has been an unevaluable time for me.

I spent two weeks in major aortic centers in USA (as Duke University NC, Cornell Weill, New York) and obtained experience with diagnostic approaches, operative techniques and postoperative management of disease of the aorta including the ascending aorta, arch and thoraco-abdominal aorta.

At Duke University I have been attached to Dr Hughes, Dr Gaca and Dr Plichta during their routine activities. This full-time clinical attachment also allowed me to understand the organization of the work in a well-structured aortic program including outpatient clinics, Heart Team discussion and case scheduling.

Those aspects are fundamental in the view of building an aortic team and program.

Routine weekly schedule was as follows:

• Ward round in intensive care, high dependency unit and ward at 6.00 am • Surgery at 7.00 am • Outpatients clinic at 13.00 (counselling of new patient or follow up of previously operated patients) for 4 hours twice a week • TAVR MDT once a week • Endovascular and TEVAR procedure MDT once a week During my stay I observed several surgical sessions including replacement of ascending aorta, partial arch and total arch. Root replacement and valve sparing surgery is also frequently performed. Also, I have participated as observer in 2 sessions of TAVR and TEVAR.

Interestingly, the follow up of aortic patients is very well defined and includes outpatients visits at six weeks, six months, one year and then every year with CT scan.

Most of the patients not needing surgery but only clinical surveillance will be in any case followed by aortic surgeons.

Considering the different activities that I was involved in, I can undoubtedly confirm that this experience boosted my career as future cardiac surgeon with specific interest in aortic surgery. When I returned to my base unit, I could report and discuss the knowledge gained and several technical aspects of the procedure with the consultants in my Unit, which is currently planning to expand and further develop and implement the aortic surgery program.

I achieved significant experience in the management of aortic disease. In particular, I gained new knowledge on axillary cannulation approaches for the treatment of aortic arch disease and in cerebral perfusion strategies.

With the help of more senior surgeons we are now implementing these approaches in our Unit. In consideration of the recent UK NHS initiative and directives on the implementation of aortic surgery in every UK cardiac units, the development of a dedicated aortic service is paramount and the knowledge acquired would surely assist this process in our Unit. n

Ionescu Fellowships

| 05

Ionescu Non NTN small travel award Andrew Selvaraj, Clinical Fellow, Barts Heart Centre

I

currently work as a clinical fellow in cardiac surgery at Barts Heart Centre, London. I am interested in Aortic surgery and have performed a few ascending aortic surgeries including root replacement and ascending aortic replacement for aortic dissections. I wanted to learn more about aortic valve repairs and valve sparing root replacement.

I identified a course on aortic valve repair in Paris and also decided to spend four weeks with Prof El Khoury, who has pioneered aortic valve repairs at St Luc Hospital, Brussels.

During an earlier conversation with Mr Catarino [Papworth], he had stated that the Annuloplasty for aortic valve repair course organized by Prof Lansac in Paris, was one of the best courses he had attended. I attended this course in March 2019 and I would strongly agree with Mr Catarino in his opinion about this course.

This course focuses on the Yacoub remodeling procedure. In addition to case

selection and investigations, the technical/ practical aspects of surgery are discussed in detail and I found this immensely helpful.

The highlight of the course was the last day, when all of us had a chance to individually dissect the aortic root in a cadaveric human heart, and perform the remodeling procedure and annuloplasty.

Prof El Khoury needs no introduction to his surgical skills. The cardiothoracic unit at St Luc, Brussels is one of the leading cardiac units in Europe and reflects the effects of an outstanding surgeon who is also a benevolent and supportive lead.

I spent most of June 2019 in Brussels.

I assisted in a few surgeries but was able to observe all the major aortic root and arch surgeries. The live camera with screen in theatre was very helpful for this. In addition, Professors El Khoury and De Kerchove took the time to explain the nuances of the procedures and answer my questions. I would like to mention an incident which throws some light on Prof El Khoury. Prof was

scheduled to perform a mitral valve repair on a lady who previously had an open mitral valvotomy for Rheumatic mitral stenosis. Prof took about 10 mins when the heart was arrested, just to demonstrate that some rheumatic mitral valves can be repaired because the layers can be peeled like an onion.

I also attended the EACTS aortic valve repair summit in Brussels organized

by Prof El Khoury and the party after the course at Prof ’s House, to which he had invited all three visiting fellows along with his entire unit.

I would like to thank the SCTS for awarding me the Ionescu Non NTN small travel award. I would also like to thank Professors El Khoury and De Kerchove for taking the time to teach and make my visit memorable.

I am certain that I will be able to use the practical skills and knowledge on valve sparing surgery that I have acquired because of the award. n

06 | Ionescu Fellowships

Cardio-thoracics in The Netherlands Additional Exceptional Ionescu Medical Student Fellowships 2018

Neil Marshall BSc (hons), BM BS, Interim FY1 at Derriford Hospital

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edical school electives are often considered the pinnacle of undergraduate training, an opportunity to organise carry out a placement in a completely different location, and often in a specialty of personal interest. For my elective I was able to secure an eight week placement under the supervision of Professor RJM Klautz at the Leiden University Medical Centre (LUMC) in the Netherlands.

My name is Neil Marshall and I am a recently graduated medical student from the Peninsula medical school, at the University of Plymouth.

Why Leiden?

The LUMC is a large tertiary public funded teaching hospital, located in south-Holland. It is attached to Leiden University, one of the oldest universities in the world, known for its medical discoveries over the past four centuries.

As a dual Dutch and English national, carrying out my elective in the Netherlands was an opportunity for me to experience the Dutch healthcare system, helping me to decide whether I would consider returning to work there later in my career.

LUMC provided the perfect blend of Adult and Paediatric cardiac surgery, as well as a thriving thoracic service.

As a keen cyclist, studying in the Netherlands also provided an excellent opportunity to escape hilly Dartmoor!

A typical day at LUMC My workload expectations at LUMC were high, each day started with an intensive care briefing at 07:45, followed by a paediatric intensive care briefing, which gave us feedback as to how patients were progressing, as well as the space available for the patients that day.

Each morning featured a ‘Harttema’ discussion, where surgeons, cardiologists and

ward staff discussed complex patients, as well as teaching from registrars on relevant topics.

I was welcomed into theatre which featured a mix of both adult and paediatric cases. Whilst being familiar with most adult operations, there were a few ‘up and coming’ operations that I hadn’t encountered at our centre in Plymouth, principally the use of ‘Ventricular Assist Devices’ and using extra-corporeal membrane oxygenation. Being immersed in paediatric operating was another area of Cardiac surgery that I’d sparsely been part of in the UK.

The theatre team were very happy for me to scrub in and get involved, and the registrars and consultants were all excellent and engaging teachers.

My evenings varied between enjoying the surrounding area (often by bike!), joining in with any evening operating, and completing a short research project.

Comparisons to the UK

Several differences were apparent between the set up at LUMC and Plymouth. Principally the use of private hospitals to not only provide referrals, but also to take over the patient’s rehabilitation shortly after their operation. The

benefit was two-fold, the patient is repatriated to a hospital close to their home and family, and LUMC were able to maintain efficient flow through both their ICU and wards.

LUMC is an active academic centre, participating in numerous trials, as well as having many PhD students supporting their department. Their early adoption of electronic record keeping in the early 2000s made pursuing a research project, reviewing the trend in valve prosthesis choice, much easier to complete.

Final Thoughts

Although the Netherlands may seem an odd place for an elective, I had a truly interesting experience, and was thoroughly welcomed as a member of their team. Staying in the EU also gave me the opportunity to work with people I would likely encounter in my future career! Finally, I’d like to thank SCTS and Mr Ionescu for their support, which enabled me to have this wonderful experience, and to Professor Klautz and his team for making me feel so welcome. n

Ionescu Fellowships

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My Fellowship Journey Annual Ionescu Medical Student Fellowship 2019 Zoya Rashid, Medical Student

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y original plan was to undertake research comparing techniques used to assess the indication for surgical repair of atrial septal defects (ASDs).

Having conducted previous research into the management of congenital heart diseaseassociated pulmonary arterial hypertension I was familiar with the techniques used to assess the severity of ASDs. I hoped to spend half of my eight-week elective period gathering data from the Bristol Heart Institute and spend the remaining time gathering equivalent data from the Royal Prince Alfred Hospital. I wanted to compare the approaches of two internationally renowned centres of cardiothoracic surgery to management of patients with differing severity of disease, from those with mildly elevated pulmonary arterial pressures to those with complex ASDs such as sinus venosus. I hoped that greater understanding of the complexities involved in the successful running of a cardiothoracic unit and opportunities to reflect on differences between the two data sets would shed light on ways in which UK cardiothoracic surgery could be further improved.

Unfortunately, however, upon arriving in Sydney I realised I would be unable to complete my project as initially conceived. The Royal Prince Alfred Hospital Department of Cardiothoracic Surgery only see a handful of patients with ASD, and these are purely incidental rather than symptomatic patients. After discussion with registrars in the department I became aware of the large number of aortic aneurysm repair cases taking place at RPA so my intention was still to compare UK and Australian cardiothoracic surgery data, just on a different topic. However, despite several attempts to gather such data during my time there, via multiple emails and reminders in person, I was never able to obtain it. Back in the UK I discussed my predicament with Professor Tulloh. With access to paediatric ASD repair data from the Bristol Royal Hospital for Children (BRHC) I settled on a research project focussing on the role of surgery in ASD repair. I performed a literature search on the topic to gauge the

treatment options available and given the rising popularity of device closures introduced via a percutaneous rather than open surgical approach I decided to assess whether surgery still has a place in the field and if so, what exactly this was.

Using data from the BRCH I demonstrated the specific circumstances where surgery is still the mainstay of treatment.

While my fellowship journey did not follow my original plan and I encountered some obstacles along the way I, nonetheless, learnt a great deal from the experience and met my original aims and objectives. I was able to spend time in theatre where I was uniquely placed to observe and participate in pioneering operations.

Highlights included assisting in a coronary artery

bypass graft operation, witnessing repair of an aortic pseudoaneurysm during which the patient was cooled to 18C with their heart fibrillating and assisting in a pneumonectomy operation on a patient with sarcoma. I attended weekly MDT meetings where I was witness to the extensive discussions and debate surrounding complex cases. I assisted junior doctors with day-to-day clinical duties such as cannulation and administering IV fluids and received teaching from registrars and consultants on specialist interventions such as ECMO. Finally, through my written report, I was able to develop data analytical and critical appraisal skills as well as my written communication skills. n

Global perspectives in cardiac surgery - what I learned in a tertiary center of a developing country Annual Ionescu Medical Student Fellowship 2019 Sashini Iddawela BSc MBChB, Medical Student

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ardiothoracic surgery is a resourceintensive speciality, requiring significant investment in hardware, software and livewire to provide an effective service. Having gained most of my exposure to cardiothoracics in England, I wanted to experience how cardiac surgical care was provided in a different part of the globe where I could explore these aspects in greater detail. On the heels of exams, I took myself to the sun-soaked beaches of Sri Lanka and particularly to the cardiothoracic department of the National Hospital, Kandy.

The cardiothoracic unit is one of the only two in the country and serves a large population. During my six weeks in the unit, I was able to observe an exciting array of surgery (with emergencies!) and the

presentation and management of pathology not commonly encountered in developed countries (such as rheumatic heart disease).

I was able to participate in ongoing research within the department which is currently in the pipelines.

Perhaps most profoundly, my fellowship left me with a deep appreciation for the challenges of providing cardiac surgery in resource poor settings, but also the ingenious solutions that came from such environments.

Its waiting lists are years long and patients often present with advanced pathology that may have been operated on earlier in more developed countries, however they are provided exemplary, conscientious care.

Global cardiac surgery has yet to take off, but I am more convinced than ever that it has to. n

08 | Ionescu Fellowships

Lung Health Check Screening Ionescu Nursing & Allied Health Professional Fellowships 2019 Trudy Elliott, Thoracic Nurse Case Manager

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n 2016/2017 a pilot service to detect lung cancer earlier, in deprived areas of South Manchester was instigated by a collaboration of Macmillan Cancer Improvement Partnership (MCIP) and University Hospital of South Manchester (UHSM).

The conclusions from these programmes were, ‘a targeted community-based lung cancer screening programme, delivered within the NHS, can engage those most at risk and detect a high proportion of curable early stage lung cancers.’ (www.thorax. bmj.com, accessed 13.02.2019)

Much of this success was due to the patients having access to a community based one stop service with instant access to a low dose CT scanner.

Figure 1

In early 2019 NHS England announced plans to implement lung health checks across England with investment in 14 sites, including 10 new sites and Wessex Cancer Alliance – Southampton City CCG has been named as one of these ten areas (Figures 1 & 2).

As a Thoracic Nurse Case Manager, I work within the Thoracic unit at Southampton, pre-assessing patients, managing Consultants waiting lists, scheduling surgery and communicating with the multi- disciplinary teams both locally and within the Wessex region. To find out more about ‘Lung Health Check’ screening prior to its inception in Southampton my aim was to visit the mobile units in Manchester and Wythenshawe Hospital to gain further understanding of its service and

implications for Thoracic surgery. This was possible due to being awarded an Ionescu Nursing & Allied Health Professional Fellowships travel award. The visit took place in early October 2019, whilst lung health checks and scanning were taking place and we were gratefully sponsored by Dr Richard Booton, Honorary Clinical Senior Lecturer/Consultant Respiratory Physician and assisted by Kath Hewitt, Lead Specialist Nurse for Lung Cancer at Wythenshawe Hospital.

Four nurses from Southampton went to Manchester, including myself, Trudy - Thoracic Case Manager, Winnie - Advance Nurse Practitioner, Nicky - Thoracic Specialist Nurse and Dawn Ward Sister.

Figure 2

• North East and Cumbria Cancer Alliance – Newcastle Gateshead CCG • Greater Manchester Cancer Alliance – Tameside and Glossop CCG • Cheshire and Merseyside Cancer Alliance – Knowsley CCG and Halton CCG • Lancashire and South Cumbria Cancer Alliance – Blackburn with Darwen CCG and Blackpool CCG • West Yorkshire Cancer Alliance – North Kirklees CCG • South Yorkshire Cancer Alliance – Doncaster CCG • Humber, Coast and Vale Cancer Alliance – Hull CCG • East of England Cancer Alliance – Thurrock CCG and Luton CCG • East Midlands Cancer Alliance – Corby CCG and Mansfield and Ashfield CCG • Wessex Cancer Alliance – Southampton CCG

As health checks were not being performed on our first day, we visited Wythenshawe Hospital to experience the patient’s hospital-based pathway and the allied support which the nursing/medical team have there. In major contrast to Southampton, Respiratory and Thoracic

Ionescu Fellowships

services at Wythenshawe have a singular central base and the nursing team is managed by Kath. The hospital covers an area of 10 referral hospitals and runs New/Follow up clinics five days a week, larger than that of Southampton.

We spent our morning split into smaller groups and were able to experience the differing outpatient areas of the hospital including Thoracic Surgery Out Patients clinic, ‘Nurse Lead’ drain clinic and Respiratory Hub. Dr Ali Machaal very kindly allowed Dawn and myself to sit in his clinic and verbal consent was gained from each patient, prior to the consultation. There were many similarities between the Wythenshawe clinic and Southampton but one main difference. A ‘One Stop’ framework is used at Southampton based clinics which includes Consultant appointment, Anaesthetic review, bloods, ECG and pre-assessment with physical assessment by trained nursing staff.

This is not the case at Wythenshawe and some patients return there, on multiple occasions for pre-assessment.

During the afternoon we were taken round the ward areas and spent time talking to various nursing staff. Wythenshawe has the benefit of a dedicated Thoracic High Care bed area and ‘Outreach Team’ which we do not have in Southampton. In contrast, we have dedicated Advance Nurse Practitioner Team, which they do not – having to share the Cardiac Surgery ANP team. There is also a role called ‘Navigator’ at Wythenshawe which does not exist in Southampton and it would be of benefit to explore the potential of this role within our local system. This role fulfils many officebased tasks which are currently covered by my role at Southampton. Wythenshawe do not have Nurse Case Managers.

Our main interest was the Lung Health Screening and so we visited the hospital base for the screening project. We met two of the nurses who work within the units and the Project Lead. She described the complexities of setting this scheme up, the difficulties, what they had learnt during its inception and lessons to be taken forward for the next wave of units.

On day two we visited the Screening units which were based at a supermarket car park, Cheetham Hill – an inner-city area of Manchester. It is comprised of three inter-linkable units, which facilitate

a patient’s lung health check, from reception to spirometry check, nurse led health check and scoring and then low dose CT if indicated.

A Research Team and Smoking Cessation clinic, are also based there. The units are staffed from 8am until 8pm, seeing invited eversmokers between 55 and 80 and up to 70 patients each day.

We were shown through the units and had explanation of the process as we went, with details of the challenges of working within them. We were all extremely impressed by the facilities and the staff working there and our impression was, that they had been set up to make it a pleasant experience for patients.

Location of the screening units appeared crucial in the effectiveness of the project with communication and follow up being key to its success.

It is expected that Southampton Thoracic surgery could expect approximately 80 new cases a year once the Health Checks are commenced but this is a small number in comparison with the potential of other life changing/effecting conditions diagnosed during this process.

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Radiology and Respiratory services will see a much larger impact on their services at Southampton than Thoracic.

This opportunity allowed us to explore the Respiratory/Thoracic pathway elsewhere, to reflect on our own unit and experience a new NHS targeted scheme. We were impressed by services within Manchester are very grateful to all we met, who took time out of their working day to speak to us. The whole experience was very positive and in comparison, between hospitals, we felt Southampton provides a good current service to its patients.

I would like to thank Mr Ionescu and the SCTS for this opportunity and all the staff we meet in Manchester. n

10 | Ionescu Fellowships

Reflections on a COVID-19 Elective Additional Exceptional Ionescu Medical Student Fellowships 2019

Jean-Luc Duval BSc (Hons), MBBS, King’s College London

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ver the course of five and a half years, countless hours of studying and numerous exams, there is often a shining beacon of hope as one approaches the completion of medical school: the joy of joining the NHS workforce. Yes, this should be the ideal truth; however, for many students, the truly most symbolic end to your medical school career is the undertaking of your medical elective – travelling to some farreaching part of the globe to explore your interest in any clinical field (and maybe some beaches as well).

I was born and raised in the twin island Republic of Trinidad and Tobago, leaving home in 2014 to pursue my medical degree in London. Throughout my medical school journey, I was fortunate enough to meet mentors who provided invaluable opportunities that exposed me to cardiothoracic surgery. My interest in the specialty evolved rapidly, and I soon found myself planning a completely cardiothoracicthemed elective. The first half of final year would be inundated by foundation applications and final exams, but after March I could look forward to eight weeks of cardiac surgery, spent between centres first in my homeland and then Kerala, India.

Meanwhile, in the Wuhan Region of China in December 2019, a novel coronavirus was identified and beginning to spread. At this time, this was the least of my concerns with my final exams approaching in January; however, little did I know the implications this would hold for my, and the rest of world’s, 2020. Towards the end of March, the severity of this

pandemic began to become apparent.

Teaching, conferences, exams one by one were cancelled, and with the impending closure of the Trinidad and Tobago border I expedited my elective flights and returned home, hoping that my elective would not experience a similar fate. In retrospect, this was wishful thinking. Within days of arriving in Trinidad, electives were cancelled, our graduation was brought forward, and the “shining beacon” was arrived at, as the NHS began early

My colleagues based in the UK could take some solace in this, by means of the Foundation Interim program, where they could enlist in the fight against this disease, but I was now stranded in Trinidad, with no elective, and no possibility of returning to the UK.

As a result of COVID-19, my arrival home saw me mandated to a two-week period of self-isolation and quarantine, which afforded me ample opportunity to bask in my frustration at the situation.

It took some time, but with greater understanding of the toll this disease was taking worldwide I began to appreciate the relative triviality of my own situation and how my feelings could be construed as immature and selfish. People were dying and healthcare systems were being strained to breaking point all over the world, and I was upset because my placement had been cancelled. With this new perspective, I resolved to no longer dwell on the negatives and instead looked forward seeking opportunities to make the most of the situation in which I had found myself.

Initially, I reached out to the cardiac surgery department in Trinidad with whom I was meant to do my elective. I inquired as to whether there was any scope to pursue an unofficial placement, however, quite sensibly, the answer to this was no.

Despite this, a very supportive consultant from the department empathized with my unique situation and generously offered an appealing alternative. I was introduced (remotely, of course) to the department’s research fellow, and together we designed, and are in the process of collecting data for, a comparative study to examine the

“What I initially considered a worst-case scenario has provided these opportunities and allowed time for the emotional and psychological preparation to begin a lifelong career in medicine. This experience has been a true lesson in resilience: life is unpredictable, but one must do their utmost to make the most of a bad situation.” recruitment of our services.

Words do not begin to describe the disappointment that this evoked in me and many of my peers. It felt as if the universe had conspired against us.

After years of hard work and sacrifice, the purported pinnacle of medical school was taken from us, and as if to add salt to the wounds, our graduation ceremonies postponed indefinitely.

Ionescu Fellowships

impact of the COVID-19 pandemic on adult cardiac surgery in Trinidad. While not quite the elective I had originally envisioned, this has been an extremely valuable experience with widely applicable learning outcomes. I have become familiar with the local cardiac surgery service, which consists of three consultants performing approximately 10 cases per week between them, the majority of which are CABGs with occasional valve surgery. Moreover, I hope this study will provide insight into how the service responded to the pandemic, which would be important for guiding practice in the event of a second wave. We sought to examine the number of cases cancelled and the

strategies to manage this backlog, how patients and staff were protected during the pandemic and how social distancing will be incorporated into future practice.

These are questions being asked by cardiac surgery units worldwide, and my “elective” which I had considered ruined, has given me the opportunity to contribute to the understanding of these issues.

As I write this report, Trinidad’s borders remain closed, and despite my involvement with this project I am left with an abundance of free time. However, with my renewed attitude, I have sought to capitalize on this, working on writing up other projects, starting preparation for the MRCS and organizing my portfolio. In addition to these career-centric activities,

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I have also found enjoyment in taking regular exercise, exploring new interests and spending valuable time with my family. What I initially considered a worst-case scenario has provided these opportunities and allowed time for the emotional and psychological preparation to begin a lifelong career in medicine.

This experience has been a true lesson in resilience: life is unpredictable, but one must do their utmost to make the most of a bad situation. As we continue to persevere through these unprecedented times and many individuals and institutions continue to be impacted by this pandemic, it is imperative that we reflect on this, and appreciate the lessons learnt through the hardship. n

An Elective at Groote Schuur Hospital, South Africa Additional Exceptional Ionescu Medical Student Fellowships 2018 Jason Trevis, Medical Student

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y elective took me to a country renowned for being one of the ‘trauma capitals’ of the world, South Africa. I spent four weeks at Groote Schuur hospital in Cape Town, famous for performing the first ever human-tohuman heart transplant back in 1967 by Christiaan Barnard; a legacy that is very much evident at the centre today. There remains a strong focus on research, with tight links with the local University of Cape Town. The hospital delivers a full range of cardiothoracic services to the local popular e.g. adult, paediatric (at the Red Cross War Memorial Children’s Hospital) and transplant.

My time at Groote Schuur hospital enabled an exposure to a patient demographic and disease profile not otherwise typically encountered here in the UK. There remains a large burden of infectious disease upon cardiothoracic pathology e.g. rheumatic heart disease, tuberculosis and HIV. In addition to

the direct impact of these diseases, I also witnessed the impact health inequalities and access to healthcare. Despite being a state-funded public institution, there remains a lack of health education for some populations, resulting in delayed presentations and poor post-operative selfcare. Thus, post-operative complications not otherwise commonly encountered here in the UK were more frequently seen during my time in South Africa.

Furthermore, as a large tertiary centre in Cape Town, the hospital cares for patients following penetrating trauma requiring cardiothoracic input. As a result, I witnessed the management of such patients, particularly gunshot wounds.

Alongside my personal clinical development during my elective, I feel the exposure to a new healthcare system in itself offered valued experience and learning opportunities. This ranged from working in a system that felt more hierarchal in structure, which gave me

a renewed perspective and respect into the vital roles of the allied healthcare professionals here in the UK. As well as ethical considerations that are less commonly seen in UK practice, for example, a memorable discussion was that involving the HIV status of a patient, and refusal to disclose this to a partner.

It was interesting to be a part of the discussion with the doctors, as they debated the guidelines and how they would be protected should patient confidentiality be required to be broken.

Overall, my time in Cape Town gave be a renewed enthusiasm for the speciality and respect for all healthcare professionals involved in its’ delivery here in the UK. The contrasting disease profiles resulting in the performance of familiar procedures gave me a valuable insight into working with a different population group. I would like to than Mr Ionescu for his kind donations, and SCTS for their support during my elective fellowship to Cape Town. n

12 | Ionescu Fellowships

Annual Ionescu Non-NTN small travel awards 2019 Pradeep Kaul, Consultant Cardiac Surgeon

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inally, I was awarded the SCTS Non-NTN Short Travels Fellowship.

“Finally”, because this was my third application. It was a moment of great pride when my name was announced at the annual dinner of the 2019 SCTS meeting. I could not savour the moment for too long as I was off for an organ retrieval before the desserts were served.

During my tenure at the Royal Papworth Hospital, I got a wide exposure to machine perfusion of hearts procured from DCD (donation after circulatory death) donors. DCD heart transplant programme has contributed about thirty percent heart transplants done at Papworth hospital in the last five years. But the overall utilisation of the offered DCD lung allografts is very poor at 9%. The main reason for this underutilization is the inability to assess lungs from a DCD donor prior to procurement.

The best and the busiest transplant centres in the world are using the Ex-Vivo Lung Perfusion (EVLP) for assessing DCD lungs and lung allografts with borderline function. I explored the possibility of visiting a leading lung transplant programme to learn about EVLP. I short-listed Toronto General Hospital (TGH) Lung Transplant Programme. This is one of the largest lung transplant programmes in the world.

TGH performed 197 lung transplants in the year 2018 and had performed 500 plus EVLP assessments. I am grateful to Dr. Jas Parmar, Consultant Lung transplant Physician at Papworth for recommending me to Prof. Shaf Keshavjee, Director of the Lung transplant programme at TGH. The fellowship coordinator at TGH helped me in completing the requisite paperwork.

I booked a service apartment within walking distance from Toronto General Hospital. This facilitated my attending transplant activity at short notice. I started my fellowship on 23rd April, 2019 for a four week period.

On the first day, I was introduced to one of the senior surgical fellows. He gave me a quick induction and introduced me to rest of the team. A WhatsApp group that included all the surgical and visiting fellows was used to intimate us of any activity.

I discussed the following learning objectives with Prof. Keshavjee: • Understanding principles of Ex-Vivo Lung Perfusion • Conduct of EVLP • Monitoring allograft function during EVLP • Criteria of acceptance • Lung block procurement to identify any differences between their programme and ours • Attending Multidisciplinary team meetings • Observe lung transplant surgery to see if there are any variations in the implantation techniques • Find answers for a list of 10 questions given to me by the director of our transplant programme

Procurement and EVLP

On the first day itself, I attended procurement of lungs from a donor who was “assisted in dying” at a local Toronto hospital. This was a first for me. It was an eye-opener for me to see how smoothly this retrieval was managed by just four people, including me in the operating theatre.

I followed these donor lungs to the “Organ regeneration room” for assessment on EVLP. The Organ regeneration room is a dedicated operating suite for solid organ perfusion at the TGH. Having a cytokine analyser in the theatre was a testament to the academic endeavour of this lung transplant programme. It was a great beginning to my fellowship. The surgeons involved in EVLP, perfusionists

and theatre staff were welcoming and made the atmosphere very conducive for learning.

EVLP has increased TGH lung transplant programme activity exponentially. This programme accepts extended criteria lungs declined by most of the North American programmes. These lung allografts are assessed and optimised using EVLP. 75-80% of these extended criteria allografts are used for successful transplantation. One of the successes of this EVLP programme is the strict adherence to a set protocol.

Observing recipient operation

All the double lung transplants at TGH are done through a clamshell incision. About 80 percent are done using ECMO support during the implant procedure. Hands on training for the trainee surgeons was the one of the best I have ever seen. That’s why aspiring lung transplant surgeons all over the world are happy to be waitlisted to get on to this fellowship programme.

Listing MDT (Multi-Disciplinary Team) meetings

These meetings were attended by all the stakeholders responsible for the care of the patients. Some of these patients would not be accepted for lung transplant by most of the programmes. Transplanting such extended criteria recipients with success has defined some medium-term goals for our lung transplant programme.

Research meetings at the Latner Thoracic research institute

I sought relevant permissions to attend these meetings which are held every Thursday.

The meetings are chaired by Prof. Keshavjee.

I was pleasantly shocked to see the sheer size of the research team. The topics researched cover various aspects of lung transplantation

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like allograft preservation and optimisation, lung repair and tissue engineering techniques for lung regeneration. The research group also has bioinformatics experts and clinicians working together to find cellular pathways involved in ischaemia-reperfusion and lung cancer. During my time there, I built bridges for future research collaborations.

TGH researchers are exploring the use of EVLP techniques for lung regeneration with a goal towards the supply of “off the shelf ” lungs for transplantation in future.

I followed this fellowship with further training with other EVLP technology providers like Transmedics and XVivo.

With a view to start Ex-Vivo Lung Perfusion programme at Papworth Hospital, I lead on a small pilot project introducing EVLP at our institution. This resulted in our programme performing eight extra lung transplants using DCD lung allografts. One of the highlights was a successful procurement, assessment and transplant of a lung allograft from a donor

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supported with Bi-Ventricular assist devices for more than six weeks. This was a world first. Being able to put this knowledge transfer into active clinical use was most gratifying.

I would want to conclude by thanking SCTS for supporting my professional development by awarding me this fellowship. I also want to thank my colleagues for facilitating my fellowship by filling the gaps in service that my absence created. n

The Ionescu Nursing Fellowship 2019 - Cleveland, Ohio Alison Woolley, Lead Nurse for Pre-Operative Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust

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he Ionescu Nursing fellowship gave me a great opportunity to experience a different healthcare setting. I used the fund to attend the Contemporary Management of Valvular Disease Conference in Boston and the Heart and Vascular Institute in the Cleveland Clinic, Ohio. I spent two weeks observing the patients’ pathway and advanced nursing practice.

access. There is an information centre with access to all literature and a call centre manned by qualified health care professionals to answer health related queries.

Education is taught during pre-operative assessment, there are sessions for families

I set four main objectives for this visit and will structure this article based on these: Objective 1: To gain insight and ideas on patient education and support, online and in person. To use this to guide and implement online resource for patients.

The education and support for patients flows seamlessly through the Cleveland Clinic ethos and approach to patient care. It is so entwined within the patient’s journey that an untrained eye may assume that this approach is synonymous within all health care settings.

The clinic uses several medias to educate; paper, online, one to one, phone support and group sessions. They cater for different levels of understanding and language requirements to ensure universal

The Heart and Vascular Institute, Cleveland Clinic

whilst the patient is in surgery and postoperative sessions for patients and families.

Each patient is encouraged to keep their individualised information with them for the whole journey and is added to at each stage of their admission.

The intensive care family liaison team ensure flow of information, respond to concerns of families, address and diffuse complaints in a timely manner. The ward-based nurse practitioners ensure postoperative care is comprehended, encouraging adherence to treatments and medications. They complete the extensive discharge information, including clear information regarding medications to start, stop and continue.

The Cleveland Clinic is a large institution with the means and resources to offer this level of education and support for each specialty. Though the NHS is comprised of multiple smaller units, it could be possible for trusts to work towards this level of support with departmental collaboration within an individual trust and shared resources within specialties >>

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Foyer of the Heart Vascular Institute

in the wider NHS. This would enhance patient health literacy and engagement, thus improving patient reported outcome measures, adherence to treatments, recovery, rehabilitation and medications.

Objective 2: Gain further understanding of the utilisation of Advanced Nurse Practitioners and other roles with extended skills to improve and ensure a continued workforce for cardiothoracic surgery.

The Advanced Nurse Practitioner (ANP) is an established clearly defined role in the Cleveland Clinic. Comparatively in the UK the Clinical Nurse Specialist (CNS) and ANP role often blend or amalgamate. The UK use the four pillars to define advanced level practice; advanced clinical practice, facilitating education and learning, leadership and evidence, research and development. In the Cleveland Clinic these pillars are split between the CNS and ANP roles. The CNS team lead Example of Patient information available at the Cleveland Clinic

on research, policy development, education of the ward team, but no advanced clinical practice. Whilst the ANP role is advanced clinical practice with education directed at patients and families, both roles are key examples of leadership.

All ANPs in the Cleveland Clinic are line managed by an ANP improving support, governance and management. There could be a more robust ANP structure in the NHS. It would be difficult to implement in smaller specialty units.

A broader collaborative approach across each secondary care setting, would enable a hierarchy to govern, support and development ANPs locally with specialty support gained from the clinical leads and societies.

Model of the Cleveland Clinic Site

Art Gallery in the Cleveland Clinic

Objective 3: To gain insight into the management of patients living away from the hospital, including how to overcome the obstacles faced with sharing information between different hospitals.

The Cleveland Clinic has a universal IT system across all of its sites, it is well designed to aid communication and share information. There are still similar barriers to the NHS to gaining information from other institutions, which is counterbalanced by an admin and nursing team. The Rooftop view, area for staff and patients to relax extensive discharge letter includes all details required for patients to be

One of the harmful effects of this managed in the community and can system is that medications are not included be accessed in all Cleveland Clinic sites. and pharmaceuticals very costly. I heard

The main learning point for the NHS an anecdote of a patient who had a is the advantage of working in a large heart transplant who could not afford his widespread institute with a universal IT medications, rejected the organ and died. system. The cost of implementing this would This was an extreme example, however as be easily be outweighed by the time and medication therapy is vital for preventing money saved. It would change the face of the disease, managing and treating patients; NHS to become more efficient and would it is incredible that this is not included. aid innovation across sites, cutting down Though the NHS has many flaws, boundaries and improve communication. universal access to healthcare should be valued above all else.

Objective 4: To gain insight to a different approach to healthcare and cardiothoracic This experience has inspired and surgery. The American health insurance motivated change in my current role to system is a dysfunctional system and a improve patient experience and education. barrier to healthcare. A key issue is the The insight into how a different healthcare amount of insurance companies who all system is structured and functions will offer different insurance policies, requiring encourage changes in my future practice teams for admission and discharge to and career. I would like to thank Mr establish eligibility for treatment. It requires Ionescu for this invaluable opportunity time and effort to get through the red tape, and experience. n delaying tests and treatments.

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Paediatric Cardiothoracic Elective at the Royal Children’s Hospital, Melbourne Additional Exceptional Ionescu Medical Student Fellowships 2018 Saad Mahmud Khan, Medical Student

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was ecstatic to undertake my medical school elective at the Royal Children’s Hospital Melbourne, Australia. My placement in the paediatric cardiothoracic department lasted for a duration of almost two months from 8th May 2019 to 21st June 2019, where I experienced a mixture of clinical and research work. The clinical exposure involved attending intensive care ward rounds, multidisciplinary team meetings and the opportunity to observe a number of congenital heart surgeries. Alongside this, not only did I get to attend some educational teaching sessions for medical students but also undertook research investigating the ideal degree of right ventricle outflow tract opening in complete repair for Tetralogy of Fallot.

Why Paediatric Cardiothoracic Surgery at RCH?

One may ask, out of all the specialties available to do my elective in, why did I choose the niche sub-specialist area of paediatric

cardiothoracic surgery. This speciality is unique both in terms of the type of surgery undertaken and the challenges it presents surgeons with compared to other surgical specialities I have experienced. The term “paediatric” might make people think that this speciality involves doing surgical procedures on babies. While partly true, this is not even close to reality where at RCH, I saw surgeons operating on neonates all the way to 16 year old individuals! This variation in patient demographics along with the often complex diseases that this group of patients present with places a big demand on surgeons especially in terms of the skill set needed to perform surgical procedures.

I chose to do my elective at the Royal Children’s Hospital as it is a world renowned centre of excellence where large volumes of surgical procedures are performed, which would give me the ideal opportunity to gain exposure to a variety of congenital cardiac conditions. I was lucky enough to be supervised during my elective period by Professor Yves D’ Udekem, who is the deputy director of the cardiac surgery department at the hospital.

He was a great role model for me especially in terms of how he manages his busy workload.

If he is not operating, he spends his time conducting research including supervising students like me and on other days he might be busy speaking at conferences worldwide.

My Schedule

A typical day started with attending the intensive care ward round at around 8:30am.

I really got to appreciate the multidisciplinary team involvement in patient management, which included inputs from cardiothoracic surgeons, cardiologists, paediatricians, intensive care doctors and nurse specialists. Following this, I had the opportunity to attend various meetings on certain days of the week including

departmental meetings, joint cardiac meetings and teaching sessions led by one of the four paediatric cardiac surgeons. I particularly enjoyed the joint cardiac meeting where cardiothoracic surgeons and cardiologists discussed patients with heart defects including those with transposition of great arteries, ventricle septal defects, atrioventricular septal defects, aortic coarctation and hypoplastic left heart. It was particularly interesting to see the various imaging techniques used like echocardiography, computed tomography and cardiac catheterisation to visualise the heart and great vessels anatomy.

The rest of the day usually involved me spending time in theatre or working on my research project. I got to experience a wide variety of surgeries including the Fontan procedure, Tetralogy of Fallot repair, Aortic Valve Sparing surgery and Interrupted Aortic Arch repair. One patient I saw during my placement was a baby born with a complete sternal cleft or absent sternum where you could see the heart beating away under the >>

16 | Ionescu Fellowships

skin. Seeing this incredibly rare anomaly during my elective period was a great educational experience as I could follow the patient through from diagnosis to staged repair of the sternum.

Personal Impact

Reflecting back on my time during the elective period made me feel really lucky to be a part of the medical profession. The life changing impact that doctors working in the profession have on patients is unmeasurable, especially in the case of paediatric cardiothoracic surgery where lifesaving operations are carried out daily and patients may still require reinterventions in their lifetime after the first surgery. Hence, as a surgeon, one leaves a lasting impact on the rest of the patient’s life both in terms of quantity and quality.

Alongside the direct impact on patients, I also observed how doctors working in the paediatric cardiothoracic surgery field are heavily involved in counselling concerned families as well. I also got to appreciate the fast evolving nature of Medicine and how providing superior patient care is one of the key drivers behind this. Moreover, my experience reinforced the value of research behind these medical advances and how pursuing an integrated academic and clinical career pathway is important to becoming a well-rounded clinician.

Overall Experience

I thoroughly enjoyed my time at the RCH cardiac surgery department who were very welcoming, friendly and supportive during my elective. Moreover, living in Melbourne for

Ionescu Travelling Fellowship Experience in Brussels

nearly two months was a great experience with the city being very multicultural and offering lots of entertainment including restaurants, exhibitions and outdoor activities (the twelve apostles is a must visit!). I also got the chance to visit Sydney for a few days, where I had a memorable time sightseeing the Sydney Opera House, Harbour bridge and taking the ferry rides from circular quay.

All in all, it was an experience that I would highly recommend to anyone considering doing their elective in Australia.

Acknowledgments: I would sincerely like to thank Mr Ionescu for awarding this fellowship, which made my elective experience possible. I am also thankful to Mr Nigel Drury, Professor Yves D’ Udekem and the rest of the RCH cardiac department for their support during my elective. n

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Annual Ionescu Non-NTN Fellowship 2018

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Kirkpatrick C. Santo MBBS, MD, FRCS (C-Th)

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was awarded the Non NTN Ionescu Travelling Fellowship for three months in 2018 under the mentorship of Mr Moninder Bhabra and went to Saint Luc’s Hospital (Catholic University of Louvain, Brussels, Belgium) to work with Professor El Khoury’s Team.

St. Luc’s Hospital is a tertiary-care centre in Brussels, Belgium’s capital city, covering an approximate population of over 2 million people. The Cardiovascular and Thoracic Surgery team at St. Luc’s Hospital consists of five adult cardiac surgeons, three paediatric surgeons, four vascular surgeons and two thoracic surgeons. Around 1000 heart surgery procedures as well as 200 operations in children, 1000 vascular procedures and 300 lung operations are performed every year.

The cardiac surgery team is world renowned particularly for the treatment of heart valve disease.

• Myself with Professor Gebrine El Khoury

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This fellowship gave me exposure to the full spectrum of adult cardiac operations including: • Coronary bypass grafting with extensive use of arterial conduits, sequential grafting as well as Y- and T-graft; • Minimally invasive direct CABG (MIDCABG) with robotic harvesting of the LIMA; • Aortic valve replacement procedures, including the Ross operation, aortic homograft, stentless prostheses, rapid

deployment prostheses, and minimally invasive procedures; Aortic valve repair procedures, including valve-sparing root replacement techniques as well as isolated valve repair; Mitral valve replacement and repair procedures, including DaVinci roboticassisted techniques; Complex acute infective endocarditis cases; Ascending and aortic arch replacement operations; Thoracic aorta replacement, including endovascular and combined procedures; Heart transplantation; LVAD implantation; Surgery for pericardial disease

I was able to scrub daily in the operating room and was actively involved in the surgical programme. I was also able to see how another unit carried out their postoperative management.

Professor El Khoury kept an extensive collection of his operations for which I was exposed to and also Cardiac Case Conferences. I was also given the opportunity to participate in ongoing clinical research.

I have developed a close link with the Unit and continue to use this through my everyday clinical practice. I am thankful to Mr Ionescu for this fellowship and giving me the opportunity to work with one of the world experts in complex Mitral and Aortic surgery and helping me to lay the foundation and to develop in this field of cardiac surgery. n

Ionescu Fellowships

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Exceptional Additional Ionescu Medical Student Fellowships 2019 Arian Arjomandi Rad, Imperial College London

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he great complexity, intricacy, and capacity for innovation which exists around the field of cardiothoracic surgery was one my main motivations for wanting to undertake this elective. During the elective, I visited the cardiac surgery centre at Hammersmith Hospital under the supervision of Professor Prakash Punjabi.

Working with top grade surgeons in a world leading centre allowed me not only to explore routine operations but also gain an insight into more complex procedures performed by surgeons.

During the elective, I examined and followed patients from the ward into the operating theatre, enhancing my understanding of pre- and post-operative patient care after cardiothoracic surgery. Moreover, in the theatres I learnt about basic and complex suturing skills and different operation procedures. I also developed a collaborative clinical project with the surgical team studying the best operative treatment plans for patients presenting with chronic kidney disease, kidney transplant and coronary artery disease. The fellowship allowed me to establish a unique and

constructive research collaboration with the local team which I am still carrying on even after termination of the elective period.

The Ionescu Medical Student Fellowship broadened my understanding of cardiothoracic surgery and made me determined to pursue this unique specialty in my future. It allowed me to gain a deep insight into the potential for innovations in the field and motivated me into pursuing other opportunities to explores other aspects of this specialty such as Robotic and minimally invasive Cardiothoracic Surgery. n

Advanced Clinical Practitioner Service Development: The Sussex Heart Centre, Royal Sussex County Hospital, Brighton Ionescu Nursing & AHP Fellowship 2017 Tara Bartley, Advanced Nurse Practitioner

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his is a review of the impact of having been awarded the 2017 Ionescu Fellowship as part of an ACP service development at the Sussex Heart Centre, Royal Sussex County Hospital, Brighton.

Cardiac Surgery in Brighton celebrates its’ 21st birthday this year and we are very proud of our achievements, not least the development of an Advanced Clinical Practitioner (ANP) service 24/7 as the first contact providers in the ITU and ward area. The generosity of the Ionescu Fellowship has been instrumental in the success of this service development, in conjunction with the Sussex Heart Charity and the Royal Sussex County Hospital (RSCH).

In September 2016, three senior nurses with intensive care backgrounds were appointed as advanced nurse practitioner trainees ANPs. It was these trainee ANPs who, having been awarded the Fellowship, went onto

shape the initial service development along with the wider team.

We have subsequently recruited another four trainee ANPs who started in September 2017 and an additional qualified Advanced Clinical Practitioner (ACP), who is a physiotherapist by background, joined in 2018. Together we have embedded an Advanced Clinical Practitioner workforce across our cardiac surgical service (ITU and wards), with non-resident out of hours SpR from October 2019. The team is no longer known as Advance Nurse Practitioners but Advanced Clinical Practitioners to reflect the allied health professional backgrounds of the team and Health Education England’s directive for this work.

The Ionescu Fellowship enabled our group of three trainee ACPs, Ms. Emma McIntosh, Mr. Roy Pittendriegh and Ms.

Louise Best to travel to Duke University in the US. Additional funding was sourced to support Tara Bartley, the ACP team leader and two the clinical supervisors, Drs. Robert Kong & Nevil Hutchinson, Anaesthetic Consultants to accompany the ACPs. At Duke we were welcomed by Gill Ley, Associate Vice President, Heart Operations, Nursing & Patient Care Services and her team. They provided lectures, clinical opportunities and amazing hospitality. We were privileged to gain a unique insight into how their ACP service had developed over the previous 10 years, to include an 80 strong practitioner workforce, who cover a number of specialties including cardiac. The ACPs are an integral part of the multidisciplinary team and were generous enough to share their documentation, ACP framework, day-to-day management and their wisdom about lessons learnt. >>

18 | Ionescu Fellowships

We were also able to visit a number of centres across the UK, namely Southampton, Birmingham and Nottingham, who had established ACP workforces and were able to share in their expertise with ourselves. They and the team at Duke were also instrumental in shaping our vision for the ACP service.

Our visits followed a structured approach, looking at four important areas – the effectiveness, safety, leadership, and responsiveness of the care provided.

Preparation for the service implementation included trainee ACPs undertaking an MSc in Advanced Clinical Practice, teaching and supervision from that the lead ACP, weekly two hour teaching session from our two Anaesthetic Consultants, and day to day input from the surgical and anaesthetic teams.

We are proud to say that our ACP service is now an integral part of the Cardiac service at the Sussex Cardiac Centre. The ACP team cover the ward and Cardiac ITU, 24/7 on a combined rota with the SpRs who work in theatres, clinics and provide on call. An audit of the support the ACP team have required for out of hours service, has demonstrated a reduction in the need for onsite support and telephone advice. We have been able to demonstrate that the development of the ACP service has influenced consistent quality care and patient satisfaction, with structured ward rounds, patient pathways and a discharge template.

We aim to have a continued positive impact on other quality indicators, including reduced length of stay, a reduction in cancellations for

clinical issues, reduction in readmissions.

Moreover, the ACP team can demonstrate they are fully active in all four pillars of advanced practice. They have contributed in the following ways: Educational: RSCH • Teaching colleagues in the department, BSCH and external organisations • Presentation at Joint Cardiology and Cardiac Surgery Clinical Governance • Review and update of the clinical guidelines in line with current research National • SCTS annual meeting 2017 – ACPs presented their Fellowship work • Faculty members of SCTS Core skills, Advanced course, CALS & BSMS • Point of Care Ultrasound for Medical Students Courses International • European Society for Cardiothoracic Surgery – presented • Society Thoracic Surgery USA – represented Audit & Research: • Optimising pre operative Hb service development with awarded best poster winner at regional meeting & International presentation • ACP Chest Ultrasound – service implementation • Ward attendee clinic to reduce in patient stay and reduce readmission and, or ED episodes

• Review of Perceptions of a Patient pathway pre admission video developed by the department • Contributed to the National SSI Audit • Imaging requesting audit • Review on out of hours calls/support Leadership: • Creation and embedding a new workforce & service delivery within cardiac surgery • Expansion of the ‘Advanced clinical practice’ concept across BSCH HEE support • MDT working • Service development for USS. Ward attendee clinics • Contributed to the National SSI Audit • Revision of the cardiac surgical guidelines against best evidence • Radiological protocol We would like to thank our colleagues in the UK centres we visited and Duke University for helping to shape our service delivery. We would also like to thank Mr. Ionescu for the generous Fellowship that has underpinned our achievements.

Tara Bartley, Emma McIntosh, Roy Pittendriegh, Louise Best, Robert Kong, Nevil Hutchinson, Mike Lewis With recognition to our other ACP colleagues, Louise Bardsley, Heidi Maseyk, Oscar SanchezRey, Joe Johnston, John McShane, the entire Sussex Heart Centre team and the Sussex Heart Charity. n

January 2021

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Is there such a thing as truly ‘elective’ cardiac surgery?

Samer A M Nashef, Consultant Cardiac Surgeon, Royal Papworth Hospital

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here was nothing exceptionally alarming about Nigel, a man in his forties who presented with a murmur and found to have asymptomatic aortic regurgitation. His CT showed that his aortic root was approaching 5.5cm and he was referred to me for an aortic root replacement at the end of March 2020, just as we were in the chaotic grip of the first wave of the Covid-19 pandemic.

Our critical care beds had up to about 60 Covid patients with up to 20 on ECMO. Hundreds of staff members of all disciplines were self-isolating at home. All faceto-face outpatient clinics were cancelled and cardiac surgical activity had virtually ground to a halt, with very few exceptions for in-house urgent and emergency patients. Some provision was also made for those on the waiting list who were deteriorating fast.

All surgeons went through their lists and telephoned patients to find out how they were faring at home. Those whose symptoms were deteriorating and who were deemed most deserving of urgent treatment had to have their case made to an MDT to justify

usage of one of the very few functioning operating lists.

Many Covid patients improved and were discharged. Lockdown reduced new Covid admissions. Gradually, we began to hold some clinics for new referrals and I saw Nigel in clinic in August. He was still asymptomatic but, since his investigations had dated somewhat, I requested an echo which was broadly in line with the previous findings except that his aorta, on echo at least, looked

on the cards. Much has been said about the impact of the pandemic on cancer treatment, but what about cardiac surgery?

Every patient with severe symptomatic aortic stenosis is at risk of sudden death.

Every patient with an enlarged aorta is at risk of rupture or dissection. Every patient with left main disease is at risk of myocardial infarction likely to be fatal. Every patient with triple vessel disease is at risk of myocardial infarction which can be fatal. Every patient with severe mitral regurgitation is at risk of decompensation which, though not immediately fatal, will shorten lifespan. For patients with a combination of the above conditions, the risks are amplified.

The overwhelming majority of our waiting list patients belong to one or the other of the above categories, and the patient having cardiac surgery on purely symptomatic grounds is rare indeed. Back in 1996, when waiting times were long, we showed that in coronary surgery, the risk of waiting was greater than the risk of the operation.

We appear to be heading back into those dark times.

Cardiac surgery is done in units with facilities for critical care and ECMO, those very services essential for the sickest Covid patients.

That means the impact of the pandemic on the national cardiac surgical service in particular will be disproportionately severe, and many more patients will suffer the same fate as Nigel.

We are proud at Papworth to have done our bit in treating Covid patients and to have achieved excellent survival rates in the most serious Covid cases, but we must not forget that we are also there to serve cardiac surgical patients. We owe it to them to increase awareness of this problem and to do our utmost to protect and increase the cardiac surgical resources and throughput.

‘Elective’ cardiac surgery is a misnomer when the majority of patients waiting for it do so with a substantial risk to life.

Nigel died from a condition curable at a relatively low risk. Explaining that to the distraught family is an uncomfortable task. n

“‘Elective’ cardiac surgery is a misnomer when the majority of patients waiting for it do so with a substantial risk to life.” to have grown to nearly 6cm. I therefore placed him on the ‘urgent’ waiting list.

We were able slowly to increase our cardiac surgical throughput. The increase was gradual with the ebbing of the Covid demand and our throughput is currently only around 70-80% of what it should be. Needless to say, a large backlog of waiting patients had built up, the vast majority of them waiting longer than would be safe.

Nigel was pencilled in for a date at the beginning of December. He collapsed and died on the 17th October.

Post-mortem examination showed aortic rupture.

With the start of the second wave, there is already talk of hospitals being overwhelmed. As I write, some hospitals in the North are already at ICU capacity. The cancellation of all ‘elective’ NHS surgery is

the 44 bulletin

Training and COVID-19: A new era?

Sashini Iddawela BSc MBChB, Department of Respiratory Medicine, University Hospitals Birmingham Celine Gravenor, Medical School, Faculty of Health Sciences, University of Cape Town, South Africa Amer Harky, Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool

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urgical practice is rapidly advancing, with the development of minimally invasive surgery, robotic surgery, and a global stage for collaboration; surgical trainees have had to adapt to this nearconstant state of flux as a matter of course and have been faced with another fork in the road, in the form of a global pandemic.

Surgical training in the United Kingdom has been through significant changes within the last two decades, and the impact of the novel coronavirus represents yet another watershed moment.

Evolution of surgical training in the UK

Impact of COVID-19 on surgical training Since March 2020, the volume of CTS procedures has been decreasing across the country in response to the COVID-19 pandemic. As cardiac surgery requires intensive care beds, the increased requirement for anticipated COVID-19 patients led to cancellation of a large number of elective lists.

The impact on training was evident with an increasing proportion

and training courses hindered the acquisition of important skills and points for portfolio progression. While it is likely these changes have impacted trainees at all stages of their career, the reduction in primary operating and cancellation of clinics have had the greatest impact on those in their last two years of training.

In acknowledgement of the severe limitation to progression across surgical specialties, JCST released a new outcome classification to be used at the point of ARCP. Outcome 10 makes the extraordinary provision for the continuation in the programme in the absence of any outcomes being fulfilled, provided that these are fulfilled at a later stage during the training period.

However, this is a “stop-gap” measure and, in a world where this pandemic is anticipated to wax and wane in waves over the next year or two, likely to be unsustainable.

In the SCTS bulletin of August 2020, several colleagues outlined how they have adapted to the challenges during COVID-19 including the need for rapidly learning new information and skills; coping with the stress of infection risk, long working hours, reduced surgical training opportunities due to limitation of elective surgery and dealing with many uncertainties.

“The change brought about by COVID-19 could be analysed in a more positive prospect for surgical training. Conferences, seminars and royal colleges have risen to the challenge, by making their content virtual, they have improved flexibility and accessibility.”

Surgical training has changed from time based to competencybased frameworks in the last two decades, signalling a paradigm shift from the traditional apprenticeship model practiced pre-1990s.

An important critical step in surgical training in the last decade has been the introduction of Modernising Medical Careers (MMC) and the European working time directive (EWTD). While the former shortened and streamlined the process of training, EWTD led to the adoption of shift work as opposed to firm attachments and further shortening of training time. Surgical trainees have fewer years to train and achieve the same competencies as their predecessors, facing concurrent service pressures of an over-burdened healthcare system. However, these changes were not all detrimental, as they exposed trainees to more flexible working patterns and the Intercollegiate Surgical Curriculum set forth concrete competency-based assessments for surgical specialties.

of consultants as the primary operators in a diminishing number of procedures performed. Compounded by the initial cancellation of outpatient clinics and redeployment to ITU in some cardiothoracic units; it is likely that progress was significantly hindered in a manner similar to other surgical specialties. The cancellation of conferences, examinations, seminars

What does the future hold?

Mr John Lund, writing on behalf of the Intercollegiate Surgical Training Programme, proclaimed in no

January 2021

uncertain terms that “No Training Today, No Surgeons Tomorrow”. He emphasised the importance of prioritising training as a key part of surgical practice recovery following the first wave of COVID-19.

Entire healthcare teams have had to “adapt, innovate and communicate” to form a crucial role in the evolving healthcare system. This crisis has opened doors to challenge the status quo and reevaluate traditional methods of training, with an emphasis on developing nontechnical skills essential to become a wellrounded surgeon, such as wellbeing and resilience. NHS England has announced the unprecedented move of allowing trainees to operate at independent hospitals, however the impact this has on cardiothoracic training is doubtful.

The change brought about by COVID-19 could be analysed in a more positive prospect for surgical training.

Conferences, seminars and royal colleges have risen to the challenge, by making their content virtual, they have improved

flexibility and accessibility. Part A of the MRCS examination was held virtually for the first time since its inception in 1860; however this adaptation may be more difficult to translate for Part B or the following practical sections of exit examinations. The acquisition and consolidation of surgical skills is of paramount importance, both to make up for the lost time and also to keep up with intended progression. As per Mr Lund’s suggestions, “slotting in” lists as part of the rota and ensuring the surgical team is aware of the presence of a trainee are simple everyday changes that could be made.

It is important to prevent deskilling and develop familiarity with new techniques in the meantime, and the virtual world has risen to the challenge.

Operative simulators, 3D printing models, and analysis of operative footage have proven beneficial. The use of low-cost laparoscopic simulators that enable live video-feeds to enable

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evaluation and computer physiology simulators may be the way forward.

A key hurdle would be to improve the accessibility and affordability of simulators so its uptake can be encouraged by as many surgical trainees as possible.

COVID-19 will likely stay for the foreseeable future, and it is imperative that surgical training adapts to these changes, incorporating some of the innovation and flexibility to future practice and developing new methods of working.

Training should not be sacrificed at the altar of service provision and tomorrow’s cardiothoracic surgeons must emerge as effective and independent practitioners through this crisis. n

Glosssary ARCP Annual Review of Competency Progression JCST Joint Committee on Surgical Training

Effect of COVID-19 on use of modern technology towards surgical education India Premjithlal Bhaskaran, School Student Ambassador

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he pandemic of corona virus disease 2019 (COVID-19) challenges the commitment of surgical professionals to respond to the current situation. Adaptation to this new situation is essential to prepare future surgeons for preparation. Health instructors as role models face significant challenges in the state of emergency to be qualified as the next generation of doctors. It is essential to act in response to the urgent needs of medical students and trainees, to solve this problem and apply the necessary medical education based on the experiences recognized during pandemics. Following social distancing activities, keeping students safe and encouraged, to help keep educational services continuing at a high quality, regardless of the outbreak of COVID-19 which has changed rapidly.

Simulation is a crucial part of surgical education and it is just not enough for

students to do it. Simulation in virtual reality (VRS) in the surgical field has the special ability to make learners feel that they are in a different environment. This helps medical students and trainees to learn as they would do in actual hospital-based encounters from virtual simulated clinical experiences. Digital medical education focused on simulation was found to be superior to conventional clinical education.

To create an automated solution that enhances clinical results and saves time, the VRS typically alters time-consuming manual processes. The VRS platforms enable learners, irrespective of their venue, to access clinical scenarios through a computer or mobile device, enhance educational task flows, and configure remote learning parameters unique to the programme requirements.

The methods of education are evolving and new fields of medical sciences and

technical advances, as well as educational technology, are increasing. Medical students and trainees today are digital natives and are increasingly dependent on immersive education and interactions simulated by virtual reality. Simulation products for virtual reality are the foundations of simulationbased virtual education that many medical education programmes desperately require.

Simulation-based interactive education has the ability to ensure that medical education around the world continues to benefit from transformative innovations. To promote uninterrupted education and evaluation, we need new innovative methods for the use of the medical education system. In view of the advantages of virtual reality and simulationrelated technology, medical educational institutions should invest in virtual educational products based on simulation to keep education and evaluation of clinical competencies on stream. n

the 46 bulletin

Development of an online training platform during the COVID-19 pandemic – a change for the future

Luke Holland, ST4 Trainee Cardiothoracic Surgery Ishtiaq Ahmed, Consultant Cardiac Surgeon – Royal Sussex County Hospital, Brighton and Lead for Cardiac Education – London Deanery

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he COVID-19 pandemic has caused unprecedented disruption throughout the hospitals of Great Britain and Ireland. Clinical and professional activities have had to adapt to a rapidly changing landscape.

Aside from the effect this has had on patients and professionals, the negative worldwide impact on surgical training at all levels is well documented.

Not only has theatre-based operative experience been diminished due to list cancellations, but the wealth of educational activities that cardiothoracic trainees usually have the opportunity to benefit from – including the biannual SCTS funded courses at each grade of training – have all been postponed or called off entirely. Examinations have also been cancelled.

One positive consequence driven by a need to communicate while adhering to social distancing measures has been the development of online learning.

An initiative has been put together in the London Deanery to enhance delivery of didactic teaching, and also to introduce a practical element to training in our new ‘socially distanced’ environment. This has been a collaborative effort with support from industry partners Edwards Lifesciences, Wetlab Ltd and Connexon365 (webinar hosting platform).

This has 3 components: 1. A program of webinar based interactive teaching in the London Deanery 2. Regular social media feeds on an Instagram education platform (@cardiac_education)

3. Development of a ‘grab- and go’ Virtual Wetlab There is now a rolling program for the London Deanery of interactive curriculum based teaching delivered online through Connexon365. This allows multiple users and multiple presenters, logs attendance and can record seminars on a secure virtual server.

The Instagram social media feed provides updates on the teaching program and delivers ‘pocket sized’ digestible key facts which the trainees can use as a base for further reading.

In addition it provides cases for discussion and provides an environment to stimulate trainees to review guidelines and appraise literature.

The Virtual Wetlab provides a unique environment for trainees to continue to develop practical skills with specific goals. A ‘grab- and-go’ module containing camera, laptop, surgical instruments, synthetic anatomical models and training rig is delivered to trainees and trainer. A demonstration is given by the trainer and then each trainee is personally coached and given real-time feedback. Sessions can be recorded in HD on a cloud based server for the benefit of the trainee to analyse

progression. Successful trials have taken place using coronary anastomosis and aortic valve workshops with excellent trainee feedback.

Prosthetic models of 3D printed mitral pathology are being developed to use within the module to enable mitral repair training.

This will be supplemented by ‘video in a box’ tutorials. This Virtual Wetlab can involve any trainer in the world and trainees can be personally coached in a safe environment in the comfort of their own home.

With crisis comes opportunity. The twofold setback of limited clinical training coupled with a paucity of formal education events ought to be offset – at least partially – by the rise in virtual meeting technologies. This opportunity should be seized to bridge the gap in training through the pandemic.

More than this, we should be looking into the future and strive for these online activities to augment surgical training and purposeful practice way beyond COVID-19, to the continuous improvement of surgical education.

The long term vision would be for all trainees to have access as an adjunct to local facilities especially as length of training is reduced. n

January 2021

Surge in cardiovascular academic work during COVID-19 Aditi Sinha, St George’s University of London Devika Verma, University of Central Lancashire

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here is no denying that health services all across the globe have been burdened by the effects of COVID-19. However, this raises a question about the repercussions of novel coronavirus on academic work and research outputs. With a rise in cardiovascular deaths during this period, research is necessary to illustrate the impact of this virus on the cardiovascular (CV) system. There is more than 70,000 academic works that have been published in 2020 and over 3000 of them are related to the cardiovascular system.

Evidence is continuously emerging as the situation evolves.

The effects of coronavirus (COVID-19) spread among various organ systems within the human body, including the CV system. Variation across testing services, data collection and national surveillance are some factors that prevent an accurate prevalence of cardiovascular disease (CVD) in patients with COVID-19 from being deduced. However, it is clear that CV comorbidities are not an uncommon finding in patients with COVID-19 and as such, these patients are at an increased risk of morbidity and mortality. Arrhythmias, elevated biomarkers, acute coronary syndrome (ACS), venous thromboembolic disease and heart failure are examples of CV complications observed in patients with COVID-19. For example, a range of research was conducted in regard to acute cardiac injury associated with the novel coronavirus. A surge in high quality research has been seen in order to get a better understanding of how the virus impacts this patient cohort.

Angiotensin converting enzyme 2 (ACE 2) is found in a variety of cells and acts as a coreceptor to the virus’ spike protein to allow viral cell entry. ACE2 works by catalyzing the reaction between angiotensin II to Angiotensin which has protective

effects. ACE2 was found to be in higher circulating amounts in patients with heart failure in comparison to healthy patients.

Many patients will be on medications such as ACE inhibitors or angiotensin receptor blockers which can increase the levels of ACE2, providing the virus more opportunity to enter host cells. Several studies reported controversial outcomes and such drugs neither caused an increased or decreased risk of the patient population needing intensive care.

One of the current pharmacological options for COVID is chloroquine (CQ) and hydroxychloroquine (HCQ), drugs commonly used to treat malaria. However, it may not be the safest option for patients with cardiovascular pathologies as such drugs could increase the risk of conduction disorders, ventricular hypertrophy and hypokinesia. Additionally, recent studies have found that they can increase the QTc interval which has been found to occur in a proportion of COVID-19 patients which can increase the risk of torsades de pointes. There are also potential benefits to the CVS system as both CQ and HCQ have been found to reduce risk of hyperlipidaemia and thrombosis in patients with rheumatic disease. Another potential benefit of CQ and HCQ is its inhibitory action on ACE2 by preventing glycosylation to prevent the enzyme receptor binding and reduce viral entry. Therefore, while there is a risk of cardiotoxicity in these agents, there is not enough high-quality data to suggest that they are contraindicated in patients with CVS diseases.

The ability of social media to provide a unified platform not restricted by geography or limitations in time has allowed it to play an integral role in promoting CV research efforts. From advertising clinical trials to developing and

sharing global ACS COVID-19 registries, social media has helped healthcare professionals with similar interests to unite.

The COVID-19 CVD registry developed by the American Heart Association is an example of an initiative that adopted the power of Twitter to promote their work and highlighted the risk factors and treatment strategies. The registry aims to improve understanding of treatment patterns by collecting and analysing data in real time. Social media platforms have also been used in order to share imaging such as angiograms or echocardiograms to spark a discussion between cardiologists around the world. While there is a risk of misinformation, social media allows discussion and support which has been imperative for clinicians, especially during the pandemic.

The matter of cardiac rehabilitation (CR) is another prominent issue that has fuelled professionals to research the role of telehealth in CR in light of the pandemic. High quality research is available establish the effectiveness of cardiac telerehabilitation in treating patients. Improved short-term prognosis in heart failure patients, risk factor reduction and reduced hospital stay are some of the benefits observed from research into cardiac telerehabilitation.

It is evident from the discussion above that the novel coronavirus has prompted professionals to invest time in research about its implication of the CV system. The impact of different enzymes, medications used to treat COVID and CV disease, as well as the importance of social media is just a small window into the vast amount of research produced. This surge of academic work has been integral in shaping the care for patients across the globe and showcases the importance of practising evidence-based medicine. n

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the 48 bulletin

Re-defining the role of the cardiothoracic surgeon in Coronavirus Disease 2019 –

a regional extra-corporal membrane oxygenation retrieval service Muhammad U Rafiq, Swetha B Iyer, Fouad J Taghavi and David P Jenkins Consultant Cardiothoracic Surgeons, Royal Papworth Hospital, Cambridge

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n this second wave of COVID-19, we aim to share our personal experience.

COVID-19 caused severe acute respiratory failure in some patients and early experience showed that patients needing mechanical ventilation had a high mortality exceeding 50%. Previously, a multicentre randomised controlled trial (CESAR) organised by the Leicester group demonstrated the efficacy of extracorporeal membrane oxygenation (ECMO) compared with conventional treatment in adults with severe acute respiratory failure. Following the 2010 H1N1 Influenza pandemic, NHS England Highly Specialised Services commissioned five centres in England to provide ECMO support for adult patients with acute severe respiratory failure who fulfilled the criteria. Each unit provided

Figure 1: Cannulation for ECMO

24/7 service for their region. At the start of the pandemic in the UK, there was little experience available on ECMO for COVID-19 induced acute respiratory distress syndrome (ARDS), but previous experience in other viral pneumonias had proved its benefit.

Re-organisation of the teams It was evident from the early stages that intensive care units were becoming increasingly busy and in our regional hospitals in north and east London were affected first. Our role at Royal Papworth Hospital (RPH) was to support our local acute hospitals, our regional critical care network, and provide an expanded regional ECMO service. As elective surgery and

other services were suspended, medical teams with appropriate skill sets were re-organised to work in an expanded intensive care unit.

Although cardiac surgeons were heavily involved in the ECMO service during the H1N1 pandemic, in more recent years the service had matured and was run by nonsurgical personnel. The service requirement included the need for a consultant delivered service and an airway trained person. During the COVID-19 pandemic there was both a sudden significant increase in ECMO referrals and a reduction in anaesthetist availability as ICU beds expanded and needed more intense rotas. Therefore, we configured a team of ‘volunteer’ cardiac surgeons to provide additional cover for the ECMO retrieval team. This allowed the normal three personnel ECMO retrieval team to expand with the addition of a cardiac surgeon. We organised members in order to have balanced experience, skill mix and utilise everyone to their maximum capacity. We rotated every 24 hours and worked around the clock to provide ECMO cover. Being cardiac surgeons, we relied on our theatre team leadership skills to help manage a team in difficult situations. We also had good knowledge of the principles of ECMO, experience in establishing peripheral vascular access as we do for intra-aortic balloon pump or minimally invasive surgery, confidence in management of very sick patients, and familiarity with the use of ultrasound and fluoroscopy.

Central to the success of the service was a dedicated team of intensivists triaging all the ECMO referrals via an electronic referral portal. The ECMO team aimed to

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leave for retrieval within sixty minutes after activation. We took all necessary equipment and consumables with us including personal protective equipment. We used two vehicles to keep social distances and allow flexibility.

We covered our regional dedicated area of approximately 60-80 miles radius.

The benefit of protocols and team activation We quickly learned from the regular ECMO retrieval team members that the COVID-19 patients requiring ECMO support were very sick and many were ventilated prone and very unstable once turned supine. We relied on the previous experience, tried and tested protocols of the ECMO nurse specialists and anaesthetists. Particular difficulties were harder communication with unfamiliar staff in full PPE, fewer experienced staff in some hospitals and patients scattered in remote ICU extensions. At arrival, we wore full PPE and made our way to intensive care, while the perfusionist and ECMO nurse went to theatres to setup the equipment. Intensive care team briefed us about patient history, clinical status and operational setup regarding theatre readiness. We reviewed the investigations and examined the patient to exclude other options and the final decision regarding retrieval. For difficult decisions we double consulted with the on-call senior intensivist at RPH.

Due to COVID-19 restrictions, in the majority of occasions no family members were present at bedside. All communication Figure 3: ECMO referrals to Royal Papworth Hospital from March to November 2020

Figure 2: Equipment setup and transport challenges

had to take place by telephone. We anticipated that it would be a difficult discussion with the family to explain a high-risk procedure when outcomes were not clearly defined for this new disease. We quoted a mortality of 30-50% with ECMO support. Recently, the 90-day mortality with ECMO in patients suffering from COVID-19 ARDS is reported to be 38% in a worldwide study from 213 hospitals.

Patients were transferred prone to the operating theatre for cannulation. Before the patient was de-proned onto the theatre table, we performed a modified WHO surgical safety checklist. Everyone wore PPE, lead and sterile gowns, a particularly sweaty experience – even for an experienced cardiac surgeon. With both an anaesthetist and surgeon we sometimes performed simultaneous insertion of guidewires with ultrasound guidance into a femoral vein and right internal jugular vein. A heparin bolus administered after wire position was confirmed with the image intensifier.

Cannulae dilators were inserted using Seldinger’s technique with radiological guidance.

Our standard was 19F for the jugular and 25F for the femoral vein.

Once connected, ECMO commenced rapidly with flows of 4-5L per minute and sweep adjusted according to the CO2 levels. Cannulae secured in position with sutures and Hollister dressing for safe transit.

We recommend that insertion of cannulae with continuous radiological guidance to be of paramount importance to avoid any risk that could be fatal.

Outcomes and conclusion Using the addition of the four consultant cardiac surgeons we were able to help maintain a 24/7 service at a time of high and sustained demand. 31 of 41 retrievals at the height of the pandemic were lead by a cardiac surgeon. All patients requiring ECMO were successfully cannulated and there were no cannulation related complications during insertion or transfer.

We demonstrated that cardiac surgeons could be a fundamental part of an ECMO retrieval team when additional personnel were required in a time of crisis. Our skills and experience meant we could adapt and learn rapidly to provide proficient patient care in a challenging situation and add resilience to a service. As cardiac surgeons, with confidence in critical care, and some experience of ECMO and cardiopulmonary bypass, we required little additional training in ECMO to become competent quickly.

We used all opportunities to both supervise and learn from other team members. This arrangement was born out of necessity, available capacity and was highly successful with our intensive care unit recording one of the best risk adjusted survival rates for COVID-19 patients in the UK. None of the ECMO team became unwell or suffered with COVID infection. Approximately 70% of patients were successfully weaned from ECMO, the duration a patients required ECMO support were much longer and there were more thromboembolic complications compare to non-COVID patients.

Overall, the surgeons felt it was a positive experience with the satisfaction of being at the forefront of treatment of a new disease. It also reinforced the value of generic skill sets, clinical acumen and good teamwork in difficult situations, and these lessons remain valuable in our more usual clinical practice. We would all volunteer again, but sincerely hope our service will not be required again. n

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Authors are the parents of ideas Antony Walker, Consultant Cardiac Surgeon

I

magine I have written a novel. A lengthy, fictional tome of which you, dear reader (I assume I have earned a reader for this!), are the principle protagonist. I describe and explore your life, the details of which I have no doubt the literary world will relish. You approved the work. Read my efforts. Praised my pictorial prose. Gave your blessing.

Should I put your name on the front cover, next to my own? Are you an author? Or will you be satisfied by the exuberantly grateful acknowledgement discreetly tucked within the front fly sheet?

In the context of the fictional novel authorship appears easy, usually a single name taking credit for the work that follows.

Acknowledgement generally being given to contributors in all shapes and forms.

This often extends to the ever suffering spouse or significant other who tolerated the lonely moodiness and often generally selfish behaviour associated with such creativity.

So why is academic authorship different and a perennial source of uncertainty, angst and argument? More importantly how can these uncertainties be resolved?

To answer this let’s start at the very beginning. Why write? Why go to the trouble of writing in an attempt to publish? A long and arduous process the benefits of which may not seem to outweigh the effort.

Written communication allows progress, conveying thoughts, ideas, learning, mistakes and creativity between generations. Without the written experiences of our ancestors we might quite literary (sic) re-invent the wheel, again and again and again. From a holistic perspective scientific altruism in clinical practice is an essential component of therapeutic development. We have a responsibility to patients and future generations to share our own endeavours and learning, allowing them to build on and evolve from earlier work and progress.

For some, writing serves a more narcissistic narrative. We insist on evidence of academic achievement through publication or presentation when short-listing for jobs; the writing, submission and acceptance of abstracts is seen as a measure of success

and time-well-spent; names on papers and presentations are seen as advertisements for a departments ability to equip acolytes with the academic currency for future success.

Hitchcock, who knew something about successful writing, said “Ideas come from everything”; in turn everything comes from an idea. The International Committee of Medical Journal Editors recognise the importance of ideas to academic writing and conversely the impotence of authors without a good idea. For this reason authors must have contributed to the conceptualisation of the work.

Ideas feed and grow on the nutrition of experience. In academic clinical work, certainly in surgery, experience is principally, though not exclusively, quantitative; we rarely wean our ideas on the comparison of emotions, sensations or qualitative experiences of our subjects. In recognition of the importance of the nurturing of ideas in this way authors must have contributed to the collection, cleaning, analysis and interpretation of these data. Ideas are intolerant, fastidious children feeding on the carefully selected food of spotlessly cleaned numbers. If the author nurtures with poor quality, dirty, low calorific data he or she will be punished with what the idea disseminates in the diaper. Similarly, the author must accept responsibility and acknowledge their own limitations when analysing these outcomes.

Just as “an idea without action will never get any bigger”, nurtured ideas must fledge and prepare to fly the nest. The parental author is responsible for ensuring adequate preparation of the idea to emerge from their neurological nest, stretch uncertain wings and feel the wind ruffle its’ feathers, rising through the air on thermals of acknowledgement, appreciation and criticism. That responsibility includes an open and honest recognition that very few ideas are born or grow perfectly; an open-minded recognition of the criticisms and suggestions of co-authors, reviewers and editors alike; recognition of the blinding, parental bias brings to the process of an idea’s growth.

Bringing the life of a new idea into the world is a responsibility. The author is responsible and accountable for all aspects of

the work; in academic writing it is entirely proper and right to blame the parents.

Take a moment to think about and begin to comprehend the power of your new fledgling idea flying off into the world. Consider the potential for harm an ill-conceived, incompletely analysed, poorly prepared, badly written idea could have once loose in the world. Decisions will be made based on your idea; imagine the power. Never forget dear author that “with great power comes great responsibility” and as the parent of the nascent idea, the paper trail leads back to that responsibility being yours.

Ghost-writers are to authorship what nannies and teachers are to parenting; working with the data/child to produce the final polished and highly appreciated product. Their existence is known about, but the success of their role largely adopted by others. Professional writers have and no doubt will continue to be used in academia.

It is increasingly recommended that such contributions should be clearly acknowledged within the work and the ghosts emerge into the daylight. Guest and gift authorship are concepts that don’t have parental corollary; it’s difficult to imagine a parent raising a child and then passing on the praise or compliments for such perfect behaviour of the little one to some previously unseen but acknowledged expert. Perhaps this illustrates why such behaviours are frowned upon in editorial circles and most Editors will strive to remove or at least identify appropriate levels of acknowledgment for guesting and gifting.

Just like parenting, authorship is not easy. Few things in life with such rewards ever are. As the saying goes, “you get what you work for not what you wish for”. Not everyone plans to be a parent but with writing, planning is imperative. Clearly defining individual responsibility at the start of projects, facilitates the separation of authorship and acknowledgement.

Cardiothoracic surgery has a strong academic blood-line that will hopefully continue on the sure foundations of sensible thinking, clear communication and good old fashioned hard work. n

YOUR VISION IS NOW A REALITY

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Improvement in the Referral Service for patients requiring urgent in-house Cardiac Surgery Steve Clark – Consultant Cardiothoracic Surgeon, Director of Transplantation Joy Pringle – Senior Sister and Urgent List Coordinator Espeed Khoshbin – Locum Consultant Cardiac and Transplant Surgeon Stephan Schueler – Head of Department of Cardiothoracic Surgery

The need for improvement

All major cardiothoracic centres in the United Kingdom provide tertiary care to a number of major regional hospitals in their proximity. The time between the referral for surgery and the operation is often long, leaving the patients frustrated and puts pressure on NHS resources. The referral process is made even more complex by the recent COVID-19 Pandemic.

Patients are referred to Freeman Hospital, mainly from across the northeast of England. We do also receive national and international referrals. The system receives on average 350 urgent referrals per year.

There have been numerous issues with this system in the past which have resulted in unnecessary delays to the patient’s journey and pathways which have also resulted in increased patient length of stay (LOS) prior to surgery.

Service Improvement Initiative

Patients were previously accepted into the in-house system by the duty surgeon on call. In-house referral proforma were completed by referring physician with minimal data set, and sent to waiting list office. There was limited surgeon involvement and ownership of the patients at that stage. This led to unnecessary delays in patients getting clear treatment plans and clinical decisions. There were on the day cancellations as patients were not fully worked up for surgery due to a lack of clear instruction.

Following a key stakeholder meeting a consensus was gained and it was agreed

that the in-house referral system should be a consultant led service, supported by a senior coordinator and a dedicated admin team. A consultant lead was therefore identified. Following this appointment, a number of changes were implemented by the lead surgeon. A fast track referral pathway to the lead surgeon was developed who immediately initiated the treatment plan, improved communication within the surgical team (consultant to consultant), led to implementation of ad hoc MDTs and allocation of urgent patients to surgeons according to clinical need. The lead consultant also identified a deputy that would ensure continuity of service provision.

We completed a stakeholder analysis mapping exercise to identify key personnel who would and could support this service improvement project. Held Stake holder meetings to discuss issues and progress.

Completed a driver diagram to assist with identifying key components to give the project focus so that the overall aim could be achieved. Utilised a benefits matrix template which enabled us to identify improvement ideas and what would have the greatest impact and be easily implemented. We completed a process mapping exercise, as this is a great tool to help visualize the pathway from start to finish and identify problems, decision points and delays in pathway, in turn identify areas for improvement. We completed two audits pre and post implementation to measure if the change had been a success, completed a standard operating procedure (SOP) & Protocol for the service to ensure continuity and sustainability of the service.

Impact of the Changes

The impact of this new consultant lead service has been positively profound.

Decisions regarding treatment plans and timing of surgery are being made at the point of referral. Number of cancelled operations has reduced. We have eliminated waste such as unnecessary duplication of tests and importantly reduced pre-operative LOS from an average of 7.5 days (SD = 3.3) before the implementation of the Service improvement project (SIP) to an average of 5.5 days (SD = 3.0).

What happens next?

This project has improved the quality of our service by its implementation. It is not difficult to imagine a better quality of care for the patients as a result of this change.

However, a survey of patients experience in the future would demonstrate how this change in service translates in to an improvement in quality of care for the urgent patients.

We would also like to improve the use of information technology in our new service by making it a fully computerised and more transparent service.

On reflection

We believe the success of this project is based on the fact that we were able to secure engagement of the key stakeholders i.e. consultant cardiac surgeons. Without which this project would not have had the success it has achieved. n

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From Refugee to Cardiothoracic Surgery in Cambridge Navid Ahmadi, Clinical research fellow in cardiothoracic surgery Aman Coonar, Consultant Thoracic Surgeon

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t the age of 13 I was a refugee, migrating from a war-torn place to the safe and welcoming UK. I had been good at school, but my worst subject was English! Nevertheless, my parents worked, and us seven siblings studied hard. Having seen so much suffering I wanted to be a doctor. I got 13 GCSEs and 5 A-levels, but I could not get into a UK medical school. I got a BSc in Biomedical Science but now money was even tighter, and it was more viable for me to study medicine in Poland.

At medical school I became fascinated by cardiothoracic surgery, but exposure was limited. With that in mind, I decided to invest a year in research, straight after graduating from Medical School. I decided a placement in a tertiary cardiothoracic unit would be best. This was a big decision. Difficult because all of my classmates went into the routine Foundation training, while I decided to embark into the world of research as a British overseas Medical graduate. I had a great sense of achievement on passing finals. Friends, family and even those I could not remember congratulated me on becoming a doctor. To then not practice and instead choose research was something of a bitter pill.

I applied for various research positions and saw an opportunity at Royal Papworth Hospital.

I had been following the RSM and SCTS Student engagement programme and was aware that Cambridge had a well-regarded training programme. They had also been very prominent early in the COVID-19 pandemic launching student and junior doctor targeted webinars a few days after the 1st lockdown began.

I started as an audit assistant at Royal Papworth Hospital. In my overseas medical school, there had been relatively little focus on the importance of audit which is more prominent in UK medical practice. I was tasked with taking part in the GlobalSurg COVIDSurg audit, an international cohort study. The overall aim of these projects was to find the impact of COVID-19 on surgical patients and their outcomes. Under supervision I was fully involved in data collection, validation, entry and local analysis. I had the chance to review and comment on the outputs and I am privileged to be included as a contributor to this large multi-centre study. I am very proud that our team, led by Mr Aman Coonar, is the highest recruiting thoracic surgery centre worldwide in the COVIDSurg Cancer study (https://ascopubs.org/doi/full/10.1200/ JCO.20.01933). In parallel to the COVIDSurg studies, we carried out an audit on COVID-19 screening and infection in our surgical patients.

This showed how safe our practices are. I am also involved in auditing our LVRS programme which now has more than 250 patients.

Working in a large, leading cardiothoracic centre has been a great educational experience. I have seen an innovative spirit, as well as a sense of togetherness and teamwork.

I was able to witness breath-taking procedures by world-class surgeons. I can see the camaraderie in the trainees.

Apart from carrying out desk-based research, I had the opportunity to observe, scrub and assist under supervision. Despite my limited experience in the speciality, I have noticed unique differences between Cardiothoracic surgery in the UK and Poland.

The most striking difference would be the

team-briefing prior to the surgery, a sense of real teamwork and ownership by all the member of staff at RPH. Assisting in these procedures and witnessing a good sense of teamwork, further implanted my love for the speciality and motivated me to pursue this as a profession. This has been a great opportunity.

In addition, I was part of the team that ran the delayed SCTS annual student engagement day for the first time as a webinar. Meanwhile, I also co-authored an e-book for SCTS Patrick Magee Poster Competition. I wanted to get involved with SCTS and this was a great chance during the COVID-19 crisis.

I have now been promoted to a clinical research fellow in cardiothoracic surgery and am working on a new and exciting project looking at tissue engineered materials.

To conclude, it has been an enriching time working at Royal Papworth Hospital. I hope that this will be a good basis to bring myself back into the UK healthcare system and apply for further training. Even while coping with the COVID-19 pandemic, I have found mentors, new ways of working, inspiration and very much hope that I will be able to continue these stepping stones into a lifelong career. n

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Manchester Peri-CCT National Lung Transplant Fellowship 2019 - a very unique and first of its kind in UK Muhammad Asghar Nawaz, Consultant Cardiothoracic, Robotic and Transplant Surgeon, Dublin

P

eri-CCT cardiopulmonary transplant fellowship has been established in UK over a decade ago. Transplantation is an expanding area in cardiac surgery and currently there are three 18-months Peri-CCT fellowships offered in the country in Manchester, Cambridge and Newcastle.

In 2019 a very peculiar and first of its kind Peri-CCT National pulmonary transplant fellowship was announced virtuously for a thoracic surgeon and I have the privilege to have been awarded with this honour. I have interest in both minimally invasive and transplant surgery. I had some exposure to heart transplant during my early years in the specialty following which I also worked as a transplant fellow in Papworth Hospital in 2014. When the Peri-CCT pulmonary transplant fellowship was announced I was in the process of applying for the consultant job. The decisive moment came when I was interviewed for the post of National Peri-CCT Pulmonary Transplant Fellowship and Consultant Thoracic Surgeon post in the same week. This was a difficult moment to decide which one to choose among the two. Although the consultant post sounded attractive, a friend of mine suggested “you do not really get these kind of opportunities

(fellowships) often’’ and this was further complemented by the memorable words from Pedro Catarino (who was interviewing me as an external) “Asghar, if you take up this pulmonary transplant fellowship, you will really become the National asset as no thoracic NTN has been trained in UK in this field”. I adored transplant anyway but with this strong statement from Pedro and sustenance from Mr Shah and Venkat, I decided to go for the fellowship.

Although, I was offered the Peri-CCT fellowship, it ultimately became the PostCCT fellowship based at Manchester.

The training programme designed for me was excellent, thanks to Mr Venkat who worked really hard for the success of this programme. My job plan included participation in transplant clinics and assessments, weekly MDTs, monthly M&Ms, scrub for every lung implant and choice of retrieval. To make sure I maintain my thoracic skills, this exceptional job plan also included a weekly thoracic operating list and lung cancer MDT making the experience highly valuable. The programme also has a reasonable educational grant through a fund held by SCTS education. I utilized this resource to fund my visiting fellowship at the world’s busiest, successful and high volume centre for lung transplant programme at the Toronto General Hospital in January 2020. The TGH is ranked among the top ten hospitals in the world and rightfully claims that the future of lung transplant lives here. The weather was extremely cold and snowy

but the lung transplants were running non-stop day and night. I not only learnt all the generic aspects of lung transplant at TGH but also particularly focused on optimization and donor management, ECMO and EVLP and in particular with focus on MCS (mechanical circulatory support) as a bridge to transplant and PGD support post-lung transplant. Mr Venkat also supported me to attend the ISHLT where I submitted two abstracts and also to attend the lung transplant master class. All in all, this pulmonary transplant fellowship was particularly designed to flourish me and I thoroughly enjoyed learning this art. I also submitted transplant related abstracts at EACTS that I presented at the October 2020 virtual meeting. The supervision and care for this training was not limited to training but also securing the consultant post. The Mater Misericordiae University Hospital Dublin is a very unique unit in Europe that has it all that I love to do (general thoracic, minimally invasive (Uniportal VATS and Robotics) and pulmonary transplant where all the thoracic surgeons are actively involved with their cardiac colleagues. It is >>

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an exceptionally progressive unit with a very cohesive lung transplant team led by Jim Egan where I learnt the additional skills like convergence procedure for AF, thanks to Karen Redmond.

Thoracic surgery is gradually evolving and technology is playing a crucial role in its advancement and innovation making it highly attractive for the future trainees. Transplant is a very complex and demanding specialty but now I strongly believe that thoracic trainees should have exposure to pulmonary transplant during their training. As thoracic surgeons, we can assist in evolving the lung transplant

programme in the United Kingdom.

The benefit is mutual, as being a lung transplant surgeon I feel comfortable in performing complex resections like sleeve lobectomy, intrapericardial pneumonectomy and using ECMO (extra corporeal membrane oxygenation). This experience is also favourable to carry out the tracheal resections. Likewise, thoracic surgeons can play a significant role in dealing with posttransplant airway problems including rigid and fibreoptic bronchoscopy and airway interventions e.g. dilatations, stents etc.

They may also be valuable in performing lobar transplant and anatomical & non-

anatomical resections to size match the lungs in exceptional circumstances. n

Glosssary CCT Certificate of Completion of Training ECMO Extracorporeal Membrane Oxygenation EACTS European Association for Cardio-Thoracic Surgery EVLP Ex vivo Lung Perfusion ISHLT The International Society for Heart and Lung Transplantation MDT Multi-Disciplinary Team PGD Primary Graft Dysfunction

Exploring the uncertainty in procedure choice for empyema - a national survey Jordan Green, Academic Foundation Doctor, Castle Hill Hospital, Hull Syed Qadri, Consultant Thoracic Surgeon

E

mpyema has been a life-threatening medical condition for centuries.

In approximately 550 BCE, Hippoctares recommended open drainage that has been practiced until the mid-19th century. In 1876, Hewitt described a closed drainage technique with a rubber tube to a water seal drainage system and this has been standard practice to date. Surgical treatment was started in the early 20th century in the form of thoracoplasty and decortications, while video-assisted thoracoscopic surgery (VATS) became the more popular technique in late 20th century; this is considered best practice currently. Not long ago decortication also involved the removal of parietal pleura, which was supposed to be restricted chest wall expansion, while decortication of the lung means to remove the cortex with visceral pleura.

However, with a better understanding of the disease, decortication of the chest wall

and excising visceral pleura is not needed.

Surgical treatment has been evolving with advancement of techniques and technology, and improved knowledge of pathophysiology of the disease process.

Various surgical techniques have been practiced in the UK and all over the world, based on clinical condition, grade of empyema, radiological findings, patients’ fitness, and surgeon’s choice and experience. These are open decortication, VATS decortication, VATS drainage with or without splitting cortex of trapped lung (VATS debridement), rib resection & drainage (RRD) and chest tube drainage only in very sick and unfit patients. VATS decortication has been the reported best practice with a better outcome. The current guidance for UK surgeons is from the European Association for Cardiothoracic Surgeons (EACTS) consensus statement in 2015. This recommends that VATS

decortication/debridement should be performed as first line for grade II/ III empyema, except where there is an increased length of time between diagnosis and management (open decortication is recommended here). There are inherent discrepancies in definitions of VATS noted in the evidence used however, making it impossible to discern which exact intervention is indeed most favourable.

The EACTS statement is based on non-randomised studies that are often comparing one modality to another, yet there is no evidence that examines all the available treatments. The resultant uncertainty present within this subject therefore requires a great deal of focus.

Our thoracic surgical unit has therefore devised a multi-faceted plan to investigate the impact of the mixed evidence on current clinical practice. Firstly, we designed a short online questionnaire

January 2021

aimed at consultant surgeons across the UK and Ireland, which was distributed via the SCTS mailing list. The aim of the survey was to explore individual practice, preferences and rationale for interventions for empyema.

60% of the thoracic services participated in the study. 32 surgeons from 21 thoracic surgical centres completed the survey.

There was a clear variation in the responses reflecting the uncertain foundations of the guidance. In particular, we found that VATS drainage was performed by 94% of the surgeons, mirroring the number of traditional decortication (open or VATS) procedures performed (>90%). Overall 35% of patients underwent VATS decortication, 34% VATS drainage, 23% open decortication and 8% RRD. The Survey showed that only 60% of patients had received full VATS decortication while 40% received partial VATS decortication. It is understandable that full VATS decortication is sometimes almost impossible due to limited access, compared to open decortication. VATS partial decortication is similar to VATS drainage. 22% of surgeons were aware of local guidelines regarding primary procedure of choice.

It is obvious from the survey that VATS drainage was performed as frequently as VATS decortication. However, it has never

been recognised as a major surgical procedure for the treatment of empyema, whilst being the first choice of surgical modality by many surgeons. It could be due to no column in the data collection and coding system. Therefore, it might have been recorded as VATS decortication.

Prolonged air leak is a recognised complication and long term tube in situ is also another source of infection. Under the current COVID pandemic circumstances, air leak is a risk of COVID spread, especially if the patient is COVID positive.

I had to operate on a septic COVID positive patient with empyema and chose VATS drainage with rib resection, washing out with saline, and did not remove any cortex to avoid air leak, which could spread the infection risking medical staff. The patient did very well and was discharged home in a few days. Thus, this technique could be used safely in high risk and complex cases.

In current practice, all surgical techniques are needed but it depends on patients’ fitness, clinical status and effects of disease progression on lung. However, this disparity in procedural practices amongst surgeons is extremely insightful given the lack of evidence comparing VATS drainage to traditional treatment

modalities. It also emphasises how unguided clinical practice is in the UK, which warrants the need for a direct investigation into the efficacy and outcomes of these various surgical interventions. To achieve this, we have designed the project: SEALS-1.

Surgery for Empyema: A Longitudinal Study (SEALS-1) is a multi-centre audit that is examining the efficacy and patient outcomes of the different treatment modalities for empyema. This is a collaborative project, meaning that each centre will individually seek local audit approval. Once this is confirmed, data collection will commence based on the shared SEALS-1 protocol. Collected data will then be transferred back to the lead centre for full analysis. At the time of writing, 17 centres have expressed an initial interest in working with us, and we are currently in the recruitment phase of the project.

The ultimate aim of our project is to eventually design and develop the first prospective study comparing decortication (VATS/open) to VATS drainage. We hope to work with as many other centres as possible in this to increase the reliability of our findings.

We also encourage any further centres that would like to be involved in our project to get in contact with us. We are available at either: syed.qadri@hey.nhs.uk or jordan.green8@nhs.net n

Royal Papworth Hospital win awards for Papworth Haemostasis Checklist

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he Department of Cardiac Surgery at Royal Papworth Hospital, Cambridge were honoured to win the 2020 National Cardiac Benchmarking Collaborative (NCBC) Award for Service Improvement and Good Practice for the introduction of the Papworth Haemostasis Checklist.

The Checklist was also awarded 2nd place and a High Commendation at the National Patient Safety Awards. The introduction of the checklist is associated with a significant reduction in mediastinal blood loss, proportion of patients returning to theatre for bleeding, and the consumption of red blood cells and blood products. This translated into a reduction in the ICU and hospital lengths of stay, which was associated with a significant financial savings.

Please contact Narain Moorjani (Clinical Lead for Cardiac Surgery) or Jason Ali (Specialist Registrar), or view the publication in the Annals of Thoracic Surgery for further details. n

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Heart Valve Disease Awareness Week 2020 Christina Bannister, Patient Lead - Nursing & AHP Committee

H

eart Valve Voice is the UK’s only dedicated heart valve disease charity.

Formed in 2014, we are a patientphysician charity, bringing together heart valve disease patients and those that treat the disease, including cardiologists, cardiac surgeons, physiologists, GPs and nurses.

In September 2020, together with our partners at Global Heart Hub, we celebrated Heart Valve Disease Awareness Week 2020.

This yearly event offers our partners on the Global Heart Hubs’ Valve Disease Patient Council the opportunity to come together to raise awareness of this common, serious, but treatable condition.

The theme of Heart Valve Disease Awareness Week 2020 was #ListenToYourHeart, stressing the importance of stethoscope checks for all over 65s ̶ the first, but most important step to early detection and timely treatment of heart valve disease.

During the week, we released the findings of our European Heart Health Survey. This new survey worryingly reveals how a low percentage of older Europeans who would seek an appointment with their GP if they experienced heart valve disease symptoms such as fatigue (26.2%), reduced physical activity (19.9%) and ‘feeling older than your age’ (12.5%). Such hesitancy could potentially be harmful, as it prevents early detection opportunities.

In addition to this, the survey found that across Europe, access to regular stethoscope checks for over 60s was low. However, senior

people are crucial contributors to the economy and society. The Survey reveals that a third (29.2%) provide care for someone close to them. They are also an active group, 75% of whom regularly participate in voluntary, community-based, social or physical activities.

Increased awareness and early detection of heart valve disease are therefore not only important to patients, but also for those dependent on them, the local community and the wider economy.

“The Survey Livvy Gosney demonstrates clearly that our older population is a key, yet underestimated, contributor to the effective functioning of our communities, families and economies, so improving the awareness, diagnosis and treatment of heart valve disease will benefit us all,” commented Wil Woan, Chair of the Heart Valve Disease Patient Council of the Global Heart Hub.

In the UK, Heart Valve Disease Awareness Week was centred on our Virtual Patient Day #HVV2020, where anyone affected by heart valve disease was invited to come together to learn, listen and inspire. On the day we were joined by leading clinicians, including Consultant Cardiothoracic Surgeon Mr Joseph Zacharias, as well as others from across the pathway and patients both pre- and post-treatment. Our community of experts gave talks on everything from live diagnostics to what to expect during rehab.

Heart Valve Voice advocate Livvy Gosney spoke with fellow advocate and post-treatment surgical patient, Ian Berry, about her pretreatment experience, and had some advice for others waiting for valve disease surgery. Livvy said “My advice to anyone else awaiting surgery, or who has just been diagnosed, is to ask questions if you don’t understand, join Facebook groups (you gain so much info that way), ask what your treatment pathway would look like, and get an estimated timeline. Feelings both good and bad are natural, so don’t worry if you cry, or feel a bit “why me?”, or if you experience anxiety.

They say the wait is the hardest part, and I feel that way at the moment because I am a “now” person, let’s get this done so I can feel like a new shiny penny with a wicked scar to show off how brave I am!”

Awareness Week also saw the release of our video ‘A Message From the Heart Valve Voice Community’, where our community came together to deliver our important message on valve disease ̶ you can watch that video at: https://www.youtube.com/watch?v=hwfrALRhlc. We also announced the winners of our National Photography Competition, held our biggest Mile Walk yet and saw a debate on valve disease in Scottish Parliament.

From grassroots awareness work to TV, radio and printed press, we made a case for increased awareness and better access to stethoscope checks on all channels. By the end of the week, we had reached over 30 million people in the UK with our crucial message.

Awareness Week is a pivotal time for the valve disease community, and COVID-19 presented a unique challenge for this year.

Despite this, we were able to deliver a programme that was impactful and educational.

Through our collaborative efforts with our partners on the Global Heart Hub, we can find the best path towards increased awareness of the signs and symptoms of heart valve disease, and together improve the detection, diagnosis and treatment of the condition. n

FI 19 1.0 10/2020/A-E

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Aortic Dissection Awareness Day UK 2020 - Special online COVID edition Christina Bannister, Patient Lead - Nursing & AHP Committee

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his year, the national patient association AD Awareness UK & Ireland had great plans to celebrate the 5th annual Aortic Dissection Awareness Day UK with its biggest national event yet, hosted by the Bristol Aortic Service at the Gloucestershire Cricket Ground.

The organising committee, including SCTS member Mr. Cha Rajakaruna (Cardiothoracic Surgery) and his colleagues Mr. Marcus Brooks (Vascular Surgery), Dr. Emma Redfern (Emergency Medicine) and Prof. Mark Callaway (Radiology), as well as patient representatives Catherine Fowler and Gareth Owens, were faced with a tough decision due to COVID-19. Sensibly, with the many vulnerable patients who would attend the day in mind, they quickly decided to postpone the physical event in Bristol until 2021. Undaunted by this setback, AD Awareness UK & Ireland then threw themselves into organising the first-ever virtual AD Awareness Day UK, which was held on 19th September.

As Gareth Owens, Chair of the national patient association, explained: ‘Since COVID-19 has dominated the news, especially in healthcare, for much of 2020, it would be easy to forget that another lethal disease, Aortic Dissection, remains a national patient safety issue in the UK & Ireland, killing more people each year than road traffic accidents.

On September 19th – global Aortic Dissection Awareness Day – the UK & Ireland joined with the worldwide AD patient movement to once again raise awareness of this issue and of the urgent need to improve diagnosis, treatment and outcomes for Aortic Dissection patients.’

The content released on the day included radio and

TV interviews with the Association’s Ireland representative, Steve Curry, who survived a Type A Aortic Dissection, aged 29. Steve explained that he owes his life to an ED doctor who had seen the Steve Curry Association’s Think Aorta campaign, which prompted them to request a CT Aorta for an otherwise fit, 29-year old man who presented with sudden-onset intense chest pain.

Some of the many SCTS members who support AD Awareness UK & Ireland also contributed video content.

Prof. Julie Saunders and Prof. Aung Oo from Barts Heart Centre provided a video about their work on the CardiacCOVID study, which was very popular with patients. Also, Prof. Gavin Murphy and Dr. Riccardo Abbasciano from Leicester provided a video update on their long-term research programme, in partnership with the patient association, to develop screening based on imaging/ genetics, identify people at risk of Aortic

Dissection and provide them with a pathway into surveillance and preventive treatment before dissection occurs.

The 600 patient members of AD Awareness UK & Ireland have had a tough year, with many seeing their routine appointments, surveillance scans and even elective surgery postponed due to COVID-19, while trying to stay well themselves and avoid catching the virus.

For most, the pandemic has added significantly to the psychological burden of living with and recovering from Aortic Dissection.

In recognition of this, on the evening of 19th September, Gareth & Catherine opened the doors of the world’s first virtual Aortic-surgery themed pub – ‘The Swab & Scalpel’. With everyone sitting comfortably at home and bringing their own drinks, a convivial evening of sharing and supporting each other was enjoyed by all!

All of the content from AD Awareness Day UK 2020 is available to watch online on the Association’s website: aorticdissectionawareness.org.

The organisers would like to thank SCTS and its membership for their ongoing support of the patient-led movement to improve diagnosis and care for Aortic Dissection in the UK & Ireland, which now has substantial momentum.

When we’ve all had our COVID-19 vaccine, there will be an opportunity for our SCTS friends to attend the amazing AD Awareness Day UK on 16th September 2021 in Bristol.

Please save the date! n

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The Virtual SCTS National Research Meeting (Third Edition) Marius Roman, MD (Cantab), ST5 Cardiothoracic Surgery, Academic Clinical Lecturer in Cardiac Surgery

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his year, the widespread COVID-19 pandemic has prompted researchers and clinicians alike to seek virtual alternatives to continue the educational development of doctors and allied health professionals.

With the postponement of the Annual Meeting and reconfiguration of the 2021 Annual Meeting to a virtual platform, the 3rd edition of the SCTS National Research meeting has moved to the Teams Conference platform on the 7th November. This was supported by the society through the president, Mr. Simon Kendall, the members of the SCTS Research Committee, the Interdisciplinary Cardiothoracic Research Network (CIRN) and the wider membership of the society. The meeting was well attended, with over 160 participants registered and over 80 attendees. Mr. Kendall introduced this meeting and emphasised the contribution of academic activity to the speciality.

The sessions were structured in a morning cardiac surgery session, culminating with the inspirational keynote lecture from Prof. John Dark on “Standing on the shoulders of Giants”.

This lecture emphasised two of the key skills required in our speciality: resilience and innovation.

Each of the 5 minute presentations was followed by excellent discussions and Q&A sessions, which were possible due to the intuitive platform and IT support as well as the pro-active moderators: Prof.

Mahmoud Loubani, Mr. Nigel Drury, Mr. Enoch Akowuah and Mr. Marius Roman.

The lunch meeting was led by Prof.

Julie Sanders and was aimed at increasing the engagement of nurses and allied health professionals, while highlighting research opportunities. The final presentation of the day was an update on the CIRN

activity from Luke Rogers and Ricky Vaja, which encouraged collaboration on the upcoming activity of the network and highlighted its national role in Cardiothoracic Surgery research.

The sessions culminated in the award of two prizes for best presentations and one poster prize consisting of free registrations to the 2021 SCTS Annual Meeting. These were awarded to Dr. Sara Tomassini for “Interventions to reduce the burden of peri-operative sarcopenia in adults: a systematic review and meta-analysis”; Mr. Vito Domenico Bruno for “Proteomics and regional myocardial strain changes in a large animal model of acute myocardial infarction”; and Dr. Anna Avrova for “The type of aortic valve prosthesis doesn’t influence long term survival – a single centre experience”.

Of course, this meeting would have not been possible without the relentless work and diligence of Sue Page, the

University of Leicester (UoL) IT team support (Sandip Tailor) who proficiently troubleshot any Teams related issues, as well as the UoL organising research team. The meeting has received excellent feedback from the faculty and participants alike, and despite the limitations of the virtual platform had reached a wide audience.

Once again, the third edition of the SCTS National Research meeting has consolidated the importance of research networking and collaboration between Cardiothoracic Surgery researchers. It provided an excellent opportunity for trainees and healthcare professionals to get a first-hand taste and provide a platform for involvement in upcoming high quality research. We are looking forward to the next years’ meeting, which will aim to further increase its profile with a possible move to a new location, virtual or face-to-face. n

“The third edition of the SCTS National Research meeting consolidated the importance of research networking and collaboration between Cardiothoracic Surgery researchers, providing an excellent opportunity for trainees and healthcare professionals to get a first-hand taste and provide a platform for involvement in upcoming high quality research.”

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The Birmingham Review Course: “Virtually” The same?

Miss Ruhina Alam, Mr. R Steyn, Mr. M Kalkat (pictured), Mr. A Ranasinghe & Mr. H Fallouh

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ix o’clock on a September Morning – the education centre in Heartlands Hospital in Birmingham, which was being used as the central command headquarter not so long ago for effective co-ordination of Junior Doctor rotas during the first wave of Covid-19 pandemic, seems unusually busy, but for a different reason; this would be the mission control centre to deliver the Birmingham Review Course virtually for the first time in 27 years.

The Birmingham review course in Cardiothoracic Surgery (BRC) is the longest running course in the Cardiothoracic Specialty worldwide, with 2020 being its 27th year. This course has always been popular for

its relevant course content, to enable trainees to apply their knowledge to the daily practice as day one consultant cardiothoracic surgeons, attracting delegates and reputed faculties from all across the UK and the world. In the pre-Covid era, the course would only allow up to 50 delegates and would run for 3.5 days with a course fee of £800.

Add to this the cost of accommodation and travel, the course would cost UK delegates around £1,000 with more for international delegates. The faculties would also have to travel to Birmingham from all across the UK and the world to teach in the course.

However, 2020 has been a different and difficult year, especially for the team

in Birmingham. Elective surgeries were paused for almost three months due to the pandemic and when elective surgeries were allowed to resume, a lot of planning was required to ensure safe and expeditious surgeries for our patients. This was complicated by the move of the Thoracic Surgery Unit from its home for many decades at the Heartlands Hospital site to the Queen Elizabeth Hospital to aid in the safe delivery of elective surgery in a Covidfree pathway.

Through all these disruptions, the organizing committee of the BRC had a choice of cancelling the course like almost all other events till then or continue with the tradition and

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run the course, albeit in a different format. The course went ahead in a virtual format with the course fee reduced to a nominal £50 to cover the administrative costs. The virtual format and a reduction in the fees meant more delegates had the opportunity to attend, leading to a substantial number of 234 registrants including delegates, faculties and members from the medical industry.

And, that brings us to the September morning, where the organizing didn’t include the usual hustle and bustle of welcoming the delegates and faculties into Heartlands and opening the course with coffee and bakeries; it included setting up green screen, computer monitors, laptops, checking speakers and microphones and welcoming more than 150 delegates virtually via Zoom.

Around 40 faculties from 20 different cardiothoracic units from 10 different countries also joined the meeting. The course ran for two days, instead of three, but had all the iconic sessions as previous years including case discussions, the MDTs, with the Aortic Symposium session being broadcast worldwide in collaboration with CTSNet. Despite some minor technical difficulties, the course was well received by the delegates with very positive feedback; however, one feedback gave us a moment of pause:

“Meeting via Zoom ran really well and should be given as a choice to delegates even when back to normal face-to-face conference.”

As we closed the course after two long but productive days, logged off Zoom, rolled our green screen and packed up the gadgets and more cables than we could care for, an obvious question emerges – Is this the new way? Is there only virtue in “Virtual” ̶ something to ponder over in the coming months?

The virtual platform offered a large number of delegates (almost threefold compared to previous years at a fraction of the cost) the opportunity to attend this comprehensive course and more faculties could accept invitations as the lectures could be conducted from the comforts of their own offices, without needing to travel. On the flip

side, the human connection was missing – the welcome dinner, the lively discussion, the networking amongst faculties and delegates during coffee breaks.

After an exhausting few months, the BRC provided a different and welcome sense of normality; it managed to deliver comprehensive information to a large

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number of delegates without anyone needing to leave their home/offices (except for the organizers of course!!). The success of this year’s virtual BRC during these unprecedented times will surely give us an opportunity to look at how knowledge can (and should) be delivered in the 21st century. n

“The virtual platform offered a large number of delegates (almost three-fold compared to previous years at a fraction of the cost) the opportunity to attend this comprehensive course and more faculties could accept invitations as the lectures could be conducted from the comforts of their own offices, without needing to travel.”

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SCTS-Ethicon 2019-2020 Cardiac Surgery Fellowship at Massachusetts General Hospital, Boston, USA Rizwan Q Attia BMedSci (Honours), MBChB (Honours), MS, MD, PhD, FRCS-CTh “Ars longa, vita brevis, occasio praeceps, experimentum periculosum, iudicium difficile” - Life is short, the art long, opportunity fleeting, experiment treacherous, judgement difficult Hippocrates

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flew to Boston in autumn of 2019 as an ST8 London deanery trainee.

Undertaking Step 2 and 3 in the United States allowed me to travel the country and speak to surgeons at major cardiac centres.

Whilst presenting at the AATS I met Dr. Thor Sundt, chief of division of cardiac surgery and director of Corrigan Minehan Heart Centre. Following this, a visit to the unit affirmed my belief that this was the right place for me. As a major academic cardiac unit performing around 2000 cases annually, it is recognised as a globally premier medical institution. It delivers excellent research programmes, a high degree of specialisation and an emphasis on teaching. The unit is staffed by eight cardiac surgeons undertaking complex aortic cases, minimally invasive surgery, advanced heart failure treatments and transplants.

The next steps were the unglamorous mountains of paperwork required for accreditation, licensing, certification and visa. After this was organised, I could look forward to the fellowship.

I rented an apartment a short walk away from the hospital as my working day began with rounds at 5:30, ICU handover at 6:30, starting in the operating room at 7:15.

I operated 4-days a week with 1st on-call (24-hour shift) once a week, 2nd on-call from home and procuring organs (once a week). This in effect implied a 1/3 on-call commitment. Procurement required flying off to various locations in New England to get heart and lungs. This turned out to be

a wonderful way to see the country and visit the surrounding hospitals.

The cardiac surgery operating rooms are affectionately called ‘The Big Red Machine’ and it certainly does not disappoint! Day one involved me placing an axillary Impella in a patient with an ejection fraction of 10%. There is no end time to the day, we finish when we finish and help others out till everyone is done and we start again the next day. Sending for add-on cases at 7pm without the

theatre team batting an eyelid was one of the stark cultural differences that made an impression on me. The operating extending 7-days a week with extra cases for bank holidays. The expectation for residents and fellows being that they will be the primary operator for the vast majority of cases. The work schedule was organised in firms where I rotated through aortic surgery service first. I have had the absolute privilege of being trained by Dr. Duke Cameron in performing valve sparing root replacements,

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Bentall’s, replacement of arch/descending aneurysms and assist with 3/4th time redo cases along with complex GUCH patients.

Working with Dr. Arminder Jassar, who is a Penn trained surgeon under Dr. Joe Bavaria, I furthered my open aortic skills, undertaking redo aortic replacements, emergency surgery for aortic dissections and TEVAR. Moving to the minimally access valve rotation I undertook open and over 20 mini mitral repairs with Dr. Sergei Melnitchouk, a Columbia trained surgeon, who gained experience at the world-renown Leipzig Heart Centre. It was excellent to learn and consolidate mitral repair techniques. Dr. David D’Alessandro provided experience in advanced heart failure surgery. Involving VAD implants, ECMO and undertaking transplants. This is all along with undertaking coronary, aortic and mitral cases. Operating with Dr. Thor Sundt, he tends to perform Commando operation it seemed every Sunday or redo double valve and grafts in patients that have been turned down by other units. I have learned lots inside and outside the operating room from him.

He has been a role model for a generation of surgeons and has worked hard in developing high calibre inherently safe surgical systems. I have taken to heart the moto: ‘Do what needs to be done’.

Everything suddenly came to a halt when SARS-CoV2 pandemic hit USA in March 2020.

We restructured the service and expanded ICU capacity to deal the massive influx of COVID cases. I had the opportunity to look after complex ICU patients and provide ECMO support, whilst we carried on emergent operating. This provided an opportunity for me to see how good leadership and resilience in an organisation are important to deal with adversity. This time allowed me to publish papers, write bookchapters and submit work to be presented at international meetings.

As the first wave came to an end we built back to full speed. During my time I was the primary surgeon for 184 cases as the primary surgeon and assisted in another 96 cases.

Reflections

‘A journey is best measured in friends, rather than miles.’ By this measure my journey has been worthwhile, having gained many friends from fellow residents,

anaesthetic attendings to surgeons.

The warmth, friendship and sense of camaraderie I have felt has been humbling.

It has been an absolute pleasure being involved in the care of the sickest patients in testing times with superb colleagues.

I will have many fond memories of the fellowship that helped me grow as a surgeon and a person.

Much has been spoken about the transatlantic special bond. This has historically been true of surgeons who have visited either side to expand their horizons and practice healthcare in a different system. I recall reading the SCTS Bulletin and listening to Mr. Graham Copper as The SCTS president and Dr. Duke Cameron as The AATS president discuss the intertwined relationship in the history of the two societies. This sentiment is truer now than ever before.

I certainly hope to move forward and build standing on the shoulders of giants that I have had a privilege to train with and who have contributed enormously to our specialty and global cardiac surgical community. n

Glossary

AATS American Association for Thoracic Surgery ECMO Extracorporeal Membrane Oxygenation TEVAR Thoracic Endovascular Aortic Repair VAD Ventricular Assist Device

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The host Institution: St. Antonius Zeikenhuis (Hospital), Nieuwegein, Netherlands

Minimally invasive valve and AF Ablation fellowship - St. Antonius Zeikenhuis, Nieuwegein, Netherlands Prakash Nanjaiah, Consultant Cardiac Surgeon

Time Period - 10 weeks 7th October - 10th December 2019

Trainers Dr. B. van Putte, Dr. T. de Kroon, Dr. R. Heijmen, Dr. F. Hofman

Facilitators Dr. Uday Sonker, Mr. Govind Chetty

Aims To progress further on the learning curve of performing minimally invasive valve (inclusive of TAVI, TEVAR, port access mitral valve surgery) and totally thoracoscopic AF Ablation procedures

St. Antonius Zeikenhuis (Hospital) Hart Centrum It is the biggest tertiary cardiac unit in Netherlands catering to a large volume of complex and specialized cardiothoracic conditions, with direct referrals from throughout the country, because of the excellent minimal invasive surgical pedigree that the team there has built up over the past couple of decades. It has the largest volume of Totally Thoracoscopic AF Ablation procedures performed anywhere in Europe. A large volume of TAVI & TEVAR procedures (about 300) are also being performed annually – half of them by cardiac surgeons! There is also an active port access mitral valve surgery service

with approximately 125-150 cases a year being performed. It also has the reputation of being one of the biggest training units for cardiothoracic trainees in Netherlands with a constant stream of visiting surgical FELLOWS from Italy and elsewhere in Europe.

My experience I had already spent my latter years of national training in cardiothoracic surgery in the UK, pursuing a special interest in minimal access valve and AF ablation surgery. To this effect, I had already undertaken an Out-of-Programme training (OOPT) year at Northern General Hospital, Sheffield. This stint had initiated me on the learning curve for such minimally invasive surgery.

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Total Thoracoscopic Pulmonary Vein AF Ablation & left atrial appendage clipping with Atriclip® ̶ Dr. B. van Putte

I have always believed that the current cardiothoracic surgical practice needs mandatory acquisition of minimal access and catheter wire skill sets to provide optimum outcomes.

I was awarded the SCTS ETHICON travelling fellowship through a competitive process in March 2018, but couldn’t undertake the same within that academic year partly due to family constraints and partly because I couldn’t be relieved from my senior surgical fellowship at Royal Papworth Hospital, Cambridge, as they were relocating to their new facility in the Addenbrookes’ campus. The selection panel kindly agreed for me to undertake this fellowship in latter part of 2019.

Hence I embarked on this fellowship in the first week of October 2019. After obtaining the relevant clearances from the host Hospital authorities, the training started right from day one. I was given opportunity to attend the theatres every day, scrub into the relevant minimally invasive procedures and pick up the tips and tricks going along. During the 10 weeks that I stayed there, I was allowed to scrub into 12 port access mitral valve procedures, 14 totally thoracoscopic AF ablation, 21 TAVI procedures inclusive of 3 subclavian access ones and 3 TEVARs. The TAVI team used different types of valves available including Edwards Sapien 3®, Medtronic Evolut-R®, Acurate neo® and SJM Portico® system. This resulted in me getting familiar with various deployment systems.

The AF ablation was performed using Atricure®RF system and Left atrial appendage management was with Atriclip®.

I was also given training with a table top dry run for a TENDYNE® trans catheter Mitral valve implantation, which we undertook the following day as part of the manufacturers getting CE marking process for the device.

TENDYNE® transcatheter mitral valve implantation table top training resource

During all this activity, the trainers were extremely supportive and accommodative, switched their working language to English from Dutch and all the instructions and discussions with the team were predominantly in English. There were valuable tips and tricks elucidated and passed on with each type of procedure and a description of how their surgical practice had evolved primarily over the past decade. I also attended their various MDTs which showed a strong and ethical ´Heart Team´ approach to every patient that was being referred for surgery.

The trainers made this significantly interactive

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to get me involved in the discussion, leading to exchange of views and gave me valuable insight into their decision making process with the cases discussed. I received as much hands on training in every case as was permitted within their remits and performed part procedures under supervision. The time in hybrid labs allowed me to progress further on my catheter & wire skills. During this stint, I also attended a joint Belgium & Dutch Cardiothoracic conference which showcased the best of both their practices.

Towards the end of my fellowship, I was planning to extend it more, but had to be cut short because the consultant job opportunity came calling in Royal Stoke University Hospital, where I currently practice.

Needless to say that this fellowship made my application extremely competitive and gave me that edge over others in securing the job!

Going forward, I have secured a fantastic proctorship for this program to be initiated at my current centre with support from my colleagues. It has also pushed me further on that learning curve enabling me to take those primitive steps towards initiating and ultimately establishing this minimal access surgical practice.

The Hartcentrum staff and the Dutch people are very pleasant and extremely accommodating and made my stay very enjoyable. Utrecht, the closest city, with regular tram and bus services to the hospital, is very vibrant and family friendly with good localities to stay. It is also well connected by national rail services to Amsterdam, making it easy to access within an hour of flying to Schipol airport.

I have an open invitation from the unit to visit them anytime and spend more time with them in the future. I would highly recommend this unit such a training! n

Port access mitral valve surgery in progress - Dr. de Kroon

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SCTS Essential Skills Course in Cardiothoracic Surgery for ST2/CT2 in the midst of COVID-19 Keng Ang, Consultant Thoracic Surgeon, Glenfield Hospital Mubarak Chaudhry, Consultant Cardiac Surgeon, Castlehill Hospital

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uring these unprecedented times, many training events in our specialty have either been suspended or delivered in a virtual platform. With a bit of good fortune, the SCTS was able to host the annual SCTS Essential Skill Course for ST2/CT2 on 2728 September 2020, at Nottingham City Hospital Postgraduate Centre, before the second England lockdown came into force.

This annual course was designed for Cardiothoracic Surgical Trainees in ST2/

CT2, to equip them with the necessary knowledge and skills required for their stage of training and prepare them for transition to ST3. The highlights for the course included 2 full day sessions in cardiac and thoracic skill laboratories, whereby delegates were able to learn skills such as sternotomy, conduit harvesting, thoracic approaches, principles of lung resection, airway management and chest draining management, using a variety of cadaveric models, animal models and

dry laboratory simulations. In between sessions, there was also small group teaching and virtual lectures. This year’s guest lecture was delivered by SAC chair, Professor Jahangiri. We also had a special lecture on Congenital Cardiac Surgery by Ms Van Doorn.

In order to comply with the COVID-19 regulations at that time, we had to make several adjustments. First of all, we had to reduce the number of delegates accepted for the course to

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around 10 (previously, we usually had 16 delegates). At the end, we could only have 9 delegates as there was a last-minute drop-out because of local travel restrictions.

We were also not able to host the annual delegates dinner, which was a pity as this was usually a good opportunity for delegates and faculty to interact in a more relaxed setting. Throughout the course, we had to adhere to the 2 metres social distancing rules when we were not in the clinical skill laboratories. For the first time, we had included virtual lectures in our programme for our guest lecture and special lecture. This may be something we may have to incorporate for further programmes depending on delegate feedback. Fortunately, despite these changes, we were able to retain most of the core content of the courses, especially in the clinical skills and small group teaching sessions, while retaining those precious face-to-face interactions.

2021. However, we may need to adapt to the requirements of a new “normality� at that time.

We may have to make changes accordingly, as we had done on this occasion, to ensure our trainees will not miss out on this valuable training experience.

This was one of the key elements that the majority of the delegates found most useful, and something we have to bear in mind for the planning of future courses.

As England enters the second lockdown with the resurgence of COVID-19 at the time of writing, there are uncertainties as to when everything will ever normalise again, and when face-to-face training courses can resume.

Provisionally, there are plans to re-run this course in the last week of September

Acknowledgement: We would like to take this opportunity to thank: all course faculty members and the Nottingham City Hospital Postgraduate Centre team for their hard work; past and present delegates for their participation; participating industrial collaborators (such as Storz, Ambu, Medtronic, Ethicon, etc) for their direct help with equipment and hardware; all relevant industrial sponsorships, Marian Ionescu’s grant for shaping this course in the past, and last but not least, the SCTS for making this possible.

During this challenging time, we like to wish everyone well and stay safe! n

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Society for Cardiothoracic Surgery and The European Society of Thoracic Surgeons -

a prosperous, long-running relationship Nizar Asadi, MD, Consultant Thoracic Surgeon, SCTS regent to ESTS

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he Society of Cardiothoracic Surgery (SCTS) and the European Society of Thoracic Surgeons (ESTS) possess a strong bond, and maintain a meaningful collaboration dating back to nearly three decades.

The diligence exhibited by the thoracic surgeons of the United Kingdom had been undeniably pivotal to the foundation of the ESTS in 1993; Professor Peter Goldstraw served as the first vice-president of the newfound society and was elected president of the ESTS the following year.

Many more colleagues from the United Kingdom have assumed senior roles at the ESTS over the years, contributing not only to the growing success of the society but also to the evolution of thoracic surgery in Europe and worldwide. In an everchanging and interconnected world, the society has bridged the borders of Europe and currently welcomes almost 1700 members from all continents.

The unique focus of the European Society of Thoracic Surgeons on purely matters of thoracic surgery, thoracic oncology and lung transplantation sets it apart from other national and international societies. The selfproclaimed aim of the society “to promote education, research and patient care by the study and practice of thoracic surgery and related medical subjects” can have an important role for the thoracic community, by creating an exceptional network of specialists across the globe.

Education remains a cornerstone of the ESTS, with multiple annual events covering a multitude of subjects ranging from clinical skills to leadership, communication and research.

Educational content and information on courses can be found on the society’s website, or by following the direct link http://www.ESTS.org/education.

I regret to inform you however that the majority of the courses scheduled for 2019-2020 continue to be on hold due to the coronavirus pandemic. Members of the ESTS enjoy privileges of online access to the European Journal of CardioThoracic Surgery (EJCTS), participation to the ESTS working group (available on the website), access to webinars or other events and a reduced registration fee for the society’s highly acclaimed annual conference. Surgical trainees may become members of the society with a reduced fee and can maintain their trainee membership for a period of up to 5 years. Becoming part of the society will allow you to establish a network with renowned specialists and centres across the globe, thus providing support to your career progression.

I recently had the honour of being appointed as SCTS regent to ESTS and I am keen to consolidate the collaboration between our national society and the ESTS.

ABSTRACTS TYPE ESTS Dublin 2019

ABSTRACTS BY TOPIC ESTS Dublin 2019 300 250 200 150 100 50

Interesting Cases

0

oral/poster video

Interesting Cases

Total Number of Abstracts submitted:

oral/poster

811

video

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I encourage all of you to become members of the European society and to engage in its remarkable scientific efforts.

This is a great opportunity for the UK to present to the rest of the world our outstanding results achieved from clinical trials and other research activities. My personal aim will be to work towards achieving integration of the robust British culture of clinical governance and quality improvement, which stems from collaborative efforts in our daily practice.

The Society for Cardiothoracic Surgery in Great Britain and Ireland SCTS was founded in 1934 with a very different role from the one it has today.

Through constant evolution it is now in a position to oversee a wide range of surgical activity while aspiring to achieve excellence in cardiothoracic surgery.

Cardiothoracic surgeons in the UK must continue to be part of international communities, not only to contribute with our knowledge but also to learn from the knowledge of others. A lasting partnership between the two societies can only benefit us both.

I welcome any communication for further discussion or inquiries, and I look forward to future projects and effective collaboration between our society and the ESTS. n

“The unique focus of the European Society of Thoracic Surgeons on purely matters of thoracic surgery, thoracic oncology and lung transplantation sets it apart from other national and international societies.”

WEBINARS 2020 - 2021 All ESTS Webinars will be submitted for CME accreditation

12 October 2020 6:00 pm CET MULTIDISCIPLINARY CASE DISCUSSION Stage 3a and Stage 2b Lung Cancer

16 November 2020 6:00 pm CET

14 December 2020 6:00 pm CET

18 January 2021 6:00 pm CET

MEDIASTINUM Role of Neoadjuvant and Adjuvant Treatments for Thymomas

PRO - CON MEETING Squamous Cell Esophageal Cancer

TRACHEA Carinal Resection and Reconstruction

Frank Detterbeck (USA)

Karin Haustermans (Belgium) Xavier Benoit D’Journo (France)

Walter Klepetko (Austria)

15 February 2021 6:00 pm CET

15 March 2021 6:00 pm CET

12 April 2021 6:00 pm CET

17 May 2021 6:00 pm CET

CHEST TRAUMA Initial Assessment and Management

LUNG CANCER SCREENING Role of the Thoracic Surgeon: An Update Giulia Veronesi (Italy)

PERIOPERATIVE MANAGEMENT Preop Functional Assessment

PRO - CON MEETING Stage 1a Lung Cancer

Solange Peters (Switzerland) Esther Troost (Germany) Jozsef Furak (Hungary)

Didier Lardinois (Switzerland)

Alessandro Brunelli (UK)

Hale Basak Caglar (Turkey) David Waller (UK)

COMMITTEE FOR LEARNING AFFAIRS Enrico Ruffini, Torino, Italy President

Apostolos Agrafiotis, Brussels, Belgium Online Video Library Co-ordinator

Alessandro Brunelli, Leeds, UK Secretary General, President Elect

Jalal Assouad, Paris, France E-learning Co-ordinator

Isabelle Opitz, Zurich, Switzerland Treasurer

Niccolo Daddi, Bologna, Italy Survey Co-ordinator

Gaetano Rocco, New York, USA Editor

Lieven Depypere, Leuven, Belgium E-learning Co-ordinator

Hasan Batirel, Istanbul, Turkey Director of Education, Secretary General Elect

Olivia Lauk, Zurich, Switzerland Trainee Representative Nuria Novoa, Salamanca, Spain Knowledge Track Co-ordinator

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(CATS) Cardiothoracic Surgical Skills Course for medical students and foundation doctors Maria Nizami, Clinical Fellow, Royal Papworth Hospital Aman Singh Coonar, University and RCS tutor, Royal Papworth Hospital

Introduction

By Aman Singh Coonar As the University and RCS tutor at Royal Papworth Hospital it was with regret that I saw less frequent and more superficial engagement with students and juniors who have moved away from the apprentice model of learning.

It is something we all see and continually seek

ways to augment and guide their learning in surgical skills, decision making and wider professional areas.

I believe that one way to do this is to channel their enthusiasm and ability by facilitating the development of student and trainee led courses. It has been a great pleasure to encourage Maria in the co-development of

this CATS course which has features which complement the successful CALS course.

The Summer 2020 course was cancelled due to the COVID pandemic. This has accelerated our adoption of hybrid and remote learning and we look forward to welcoming delegates to our socially distance course in 2021.

January 2021

Background

By Maria Nizami Royal Papworth Hospital is a busy cardiothoracic surgery hospital. We are the country’s largest heart and lung transplant center, national center for pulmonary endarterectomy and have a very high VATS rate including subxiphoid surgery. Every year at Royal Papworth, a large number of foundation doctors are recruited.

The requirements for junior doctors’ training are continuously evolving: from large scale changes to program structure, to smaller ones, such as approval processes for study leave and taster opportunities. The majority of the foundation doctors consider their time taken up just by service and ward work, with fewer opportunities to attend theatre sessions. A limitation of functioning skills and simulation centers within hospitals increases the gap in surgical training.

Some concerns have been voiced recently as to doctors being less ‘well rounded’ and lacking in surgical skills compared with previous generations. “Foundation doctors have so little experience of craft skills that sometimes they struggle with their practical stations” R. Kneebone professor of surgical education at Imperial College London noted. The importance of surgical exposure in early years of training is supported by a cohort study from Goldacre et al which found that over a ten-year period 88% of men and 79% of women who went on to apply to a surgical specialty had made the decision about surgical career choice by their first year after graduation, i.e. F1.

Often the consultant has the responsibility for the standards of education and practical exposure for the junior doctors. Many consultants feel they do not get to know their FY doctors, as not only do they change jobs frequently (most FY jobs are four months) but with on-call and shift patterns there is little continuity. Although a

73

Figure 1

formal and timetabled theatre session would improve FY’s theatre attendance, in some cases it is hard to fulfil the rota needs and to cover ward duties.

In a recent survey from Bristol NHS Trust, 12% of respondents had never been into theatre as a foundation doctor to assist or even to observe. When asked why, 77% of respondents said they because they were too busy on the wards. Almost half (46%) felt that going to theatre did help with explanations to patients and their families, 34% believed it improved the postoperative management of their patients and 20% wanted to do a surgery related specialty and therefore tried to get into theatre (Figure 1).

Undoubtedly, observing how skilled and experienced surgeons perform has many benefits, however when the time comes to perform, repetition is a key.

In order to achieve that, we set up a functioning skills and simulation course that focuses on Cardiothoracic surgical skills.

Aims and Objectives Our skills course seeks to provide training in simple procedures and crisis management in the simulation suite and also to give the opportunity for students and junior doctors to learn important surgical techniques which can be used throughout their career.

It was designed and delivered successfully with great interest and welcomed delegates from all over the UK.

A key to the success of the course was its layout and accessibility, due to the fact that it was organized as a 2/3 day course.

It was facilitated by junior and senior registrars as well as consultants who ensured the high quality of surgical techniques and monitored the progress of the participants.

Junior doctors rotated between different stations and were exposed to the following subjects: • • • • • • • •

Surgical Gowning and Gloving Suture Techniques Surgical Knots Thoracocentesis Vessel Anastomosis Bronchoscopy Techniques Chest Drain Insertion VATS Basic Skills

The CATS course provided simulation training in which specialist training equipment was used to recreate clinical situations in cardiothoracic surgery. >>

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‘Very practical and interesting.

Approachable and skilled teachers, staff.’

It allowed delegates to practice rare and critical scenarios in a safe environment, to learn surgical skills and to practice skill stations for NTN applications. The feedback received was extremely positive with comments such as:

‘Lots of skills, well organised’, ‘Great equipment, range of activities and quality of teaching. All the demonstrators were very enthusiastic and passionate about what they do, making us medical students more inclined to apply for Cardiothoracics! I’ll definitely recommend this course to colleagues if there are future sessions, it was very fun!

Thank you.’

‘Very well pitched to medical students. All educators were very open and friendly, allowing opportunity to ask questions.’

‘Excellent practical opportunities with good equipment, great quality of teaching, well developed.

Covered a lot of skills.’

The participants learnt, practiced and repeated procedures, improved their skills, and mastered clinical protocols designed to improve outcomes before seeing patients.

Due to COVID-19 restrictions, the Summer 2020 CATS course was postponed (we ran webinars instead) and is evolving into a hybrid and simulated course. n

‘Organised and kept to time.

Enthusiastic and inspiring teachers/surgeons.

Gave many tips.’

‘High tutor to delegate ratio, all stations useful. Faculty approachable, friendly and encouraging.’

Medical students’ perspectives on cardiothoracic surgery during COVID-19 Ria Sanghavi, School of Medicine, University of Central Lancashire Raneesha Pillay, School of Medicine, Barts and The London, School of Medicine and Dentistry and Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London

T

he coronavirus disease (COVID-19) has caused a global pandemic and today, the death toll is currently at 1,976,998. It may be trivial to think of how COVID-19 may hinder or progress our career towards cardiothoracic surgery (CTS) whilst people are still dying. However, it is key to reflect on how this virus has impacted our future careers because we are the next generation

of doctors, and as disturbing as it may be to think, we may be the ones that fight the next pandemic. We discuss how COVID-19 has reduced exposure to CTS in some ways and increased it in others.

It is the time exposed to a specialty first-hand that enables you to decide if it is what you want to pursue. When we began medical school, we quickly realised that there is little exposure, if any at all,

to CTS in the undergraduate medical programme. Exposure was further reduced when the pandemic caused medical schools around the UK to close a semester early.

Additionally, COVID-19 pushed hospitals to only undertake urgent surgeries and CT surgeons were selective on the type of surgeries that were performed due to unquantifiable additional risks because of COVID-19.

January 2021

This reduced exposure to students who were able to go on placement after lockdown rules eased. The most awaited part of medical school are the electives and unfortunately, they were cancelled due to COVID-19. The electives gave students an opportunity to see various aspects of the specialty, network with surgeons and observe a wide-range of surgeries. Many university hospitals do not offer CTS, making electives one of the main ways undergraduate students access cardiothoracic units. Therefore, COVID-19 greatly reduced exposure to CTS and ultimately, even interest in the specialty.

COVID-19 restrictions continue to display its domino effect. There is limited involvement in extracurricular projects as current policies of various trusts, in accordance to government rules, prevent medical students from coming into hospital for non-essential placements.

As a result, it has been a challenge for the societies in our universities to set up any in-person mentorship schemes. Mentorships are an effective way of establishing early engagement between CT surgeons with medical students and inevitably exposes students to CTS at an earlier stage. Academic societies act as a bridge between medical students and consultants via these mentorship schemes that would normally be offered every academic year. The pandemic has clearly brought on an additional set of challenges already present in the efforts to foster early interest, especially amongst preclinical students, which is crucial in the efforts to entice them into fields like CTS.

On the other hand, the pandemic provided exposure to CTS in an unconventional way. As students, we had more free time and were able to call on CT surgeons to host talks through various societies. It certainly helped that the surgeons had more time on their hands due to less surgeries being performed. Furthermore, organising and attending talks virtually removed the

need to factor in travel logistics. We also noticed that more students were present at webinars than at in-person talks because comparatively, they were more easily accessible and free of charge.

Another advantage was that the virtual conferences enabled students to present their projects at a national level, gaining valuable portfolio points. These online webinars pushed students and surgeons to become proficient at using video conferencing software such as Zoom and Microsoft Teams. On that account, we

individuals when attending events in person and this helps to gain more insight on what it entails to be a surgeon.

We are cognizant of the fact that when COVID-19 halted our world to a standstill, it made people rethink various life decisions. For us, it made us contemplate whether CTS is what we really wanted to do. The emergency medicine and intensive care doctors were at the frontline of the pandemic and it was like they were fighting the war on behalf of all of us. Even though all doctors in hospitals were risking their lives for patients, it was the emergency medics and intensive care doctors that were directly dealing with the deadly virus.

As the second wave of COVID-19 continues and cases soar once again, it makes us realise that when humanity was in peril, it was these specialties that were most useful. Frankly, it has actually made us look into emergency medicine and intensive care as future career options.

COVID-19 has impacted us all in more ways than one. We could barely process one change before another came along, forcing us to adapt and prepare for what is to come. The pandemic compromised medical education, but technology was the golden ticket that helped us continue learning and engaging in extracurricular events in some form despite its obvious limitations. In the meantime, we hope to remain optimistic, proactive and ultimately make the most out of the current opportunities available to maintain our interest in CTS.

“COVID-19 restrictions continue to display its domino effect.

There is limited involvement in extracurricular projects as current policies of various trusts, in accordance to government rules, prevent medical students from coming into hospital for non-essential placements.� note that the pandemic truly enabled us to appreciate technology and its impact on our world.

As creative and adaptable as organisers were in hosting virtual workshops, there was considerable difficulty in organising practical skills like surgical and suturing skills. The conventional curriculum does not dedicate much time to surgical skill development and students rely on their respective surgical societies on delivering these sessions. The imposed restrictions prevented in-person events from taking place and students were unable to practice remotely unless they had access to suturing kits which are costly to some.

Skills sessions and in-person conferences are also a means of networking.

As commendable as it is on the part of organisers of these virtual conferences, in our experience at least, there is nothing like connecting with like-minded

Acknowledgement: We would like to thank Mr. Amer Harky – ST4 Cardiothoracic surgery for his support during this period and guidance in writing this article. n

Glossary

CTS Cardiothoracic Surgery

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SCTS efforts in audit rewarded with nomination for HQIP Audit Heroes Awards Elaine Teh, Nationally Appointed Surgical Trainee

A

udits are a benchmark for standards and can be used on an individual, unit-based, national or international level. Simply put, it ensures evidence-based and best clinical practice is at patient-level, and not just in clinical trials or an ideal world setting. Cardiothoracic surgery has been a trailblazer in this respect. Patient’s safety is always the top priority and as a society, we have been collecting data to improve the quality of care for cardiothoracic patients.

One of our members, Doug West, who has been involved in Lung Cancer Audit and recently appointed Chair of the Audit Subcommittee, has been nominated and shortlisted for the annual HQIP Audit Heroes Awards.

His nomination reads: “Doug West is an audit hero because he works tirelessly to promote quality improvement and encourages audit at a local and national level. He is full of enthusiasm and motivation. He organises regular multidisciplinary QI meetings within our department with our Clinical Nurse Specialists, physiotherapists, junior doctors and anaesthetists to encourage the unit to assess our clinical care and pathways, making sure that we are practising evidence-based medicine to give our patients the best possible care with good outcomes. He actively encourages the junior doctors in the department to be involved in audit and QI projects to improve patient care, efficiency and outcomes. Whenever we approached him with a project proposal, it is always met with an enthusiastic ‘Yes, let’s do it!’.

This is swiftly followed by emails and correspondence to various important

stakeholders, which is an essential component of a successful audit project. As a result, there have been many successful audit and quality improvement projects in the department such as a target 24-hour chest drain removal project, advanced emphysema audit, chest wall resection for primary sarcoma audit, nurse-led chest drain clinics and a one-week nurse-led follow-up clinic.

“Besides, he sets an exemplary model to the department with his open-mind, willingness to learn from best practice around the country and collaborative spirit. He was very impressed with the unit in Southampton for achieving the shortest length of hospital stay after lung cancer resection and was very keen to learn from them. A team of us from the department recently visited a high-volume thoracic centre in Shanghai with the aim of improving our protocol-based and perioperative care. He actively seeks out learning points from the practice in China and as a group encouraged us to seek ways to implement similar principles to our

practice in the UK, taking into account the differences in cultural background.

“His enthusiasm for audit and quality improvement extended nationally, too. He has been the audit chair for the Thoracic Subcommittee in the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) for a few years and has worked tireless in this role producing the Lung Cancer Clinical Outcomes Publication annually. He was recently appointed as Chair of the Audit Subcommittee and he now is the cardiothoracic national clinical lead for the Getting It Right the First Time (GIRFT) programme. Lastly, he was also involved in the recent update in NICE Guidance on Lung Cancer: Diagnosis and Management (NG122).

“In conclusion, Douglas West is my audit hero for his consistent enthusiasm for audit and quality improvement, for his positive attitude in empowering everyone to make a change and impact in clinical care and for his leadership in setting this vision in the team, both locally and nationally.” n

“There have been many successful audit and quality improvement projects such as a target 24-hour chest drain removal project, advanced emphysema audit, chest wall resection for primary sarcoma audit, nurse-led chest drain clinics and a one-week nurse-led follow-up clinic.”

January 2021

77

The effects of the COVID-19 pandemic on the future of cardiothoracic recruitment and the need for technological innovation Sarah Pengelly and Chloe Chia, Cardiff University School of Medicine

T

here is a general need for increased cardiothoracic surgery exposure via clinical placements to inspire interest in the field. However, the COVID-19 pandemic has made this much more challenging, as students have been pulled off their clinical rotations globally to reduce the nosocomial spread of the virus. We propose that there is also the need for technological innovation in the training process to allow for the delivery of educational content for medical students in the midst of the pandemic, with the aims of offering an insight into the specialty to drive recruitment.

Surgeons have been practising and acquiring skills from mentors and predecessors under an apprenticeship model since the field of cardiothoracic surgery began. Despite the numerous technological advancements in management strategies in various sub-specialty fields in cardiothoracic surgery and alterations in the training pathway, the principles of training surgical trainees and medical students remains largely unchanged since 1896, when Ludwig Rehn of Frankfurt was the first to successfully repair a stab wound of the heart.

Aspiring cardiothoracic surgeons in medical schools worldwide can also be

considered the future of cardiothoracic surgery, as it is up to future generations of cardiothoracic surgeons to lead the field forward with new inventions and improved surgical techniques as technology grows exponentially. However, exposure to cardiothoracic surgery during medical school is limited, often leaving medical students to organise opportunities for themselves. The COVID-19 pandemic has caused placement cancellations, restrictions on the number of theatre staff present, and additional PPE requirements as part of hospital infection control policies. Medical students who have already missed out on placements are set to further lose out on theatre time when placements resume.

With a speciality that already has reduced exposure, further reduction in theatre opportunities could lead to a lack of interest in the area, especially for students with no prior experience of cardiothoracic surgery.

The lack of surgical placements has placed additional barriers to the recruitment of medical students to the field. Medical students are more likely to select a career in a field they have had early exposure to. In 2015 only 32% of trainee cardiothoracic surgeons were UK graduates. Students who

“With a speciality that already has reduced exposure, further reduction in theatre opportunities could lead to a lack of interest in the area, especially for students with no prior experience of cardiothoracic surgery.�

remain untrained in donning and doffing PPE will miss out on early opportunities to be involved in theatre. This issue is further compounded by PPE shortages.

Another barrier to recruiting interest in the speciality is the lack of mentorship for under-represented groups. Only 5% of cardiothoracic surgeons are female, making it difficult for the increasing number of female medical students to find a mentor whom they can relate to.

In the UK, surgery still has a traditional teaching style starting with observation and leading to increased responsibility as experience develops. The use of new technologies such as virtual reality is already being used to aid laparoscopic teaching.

Translating its use to cardiac surgery could help trainees practise procedures and students gain a more realistic understanding of what a career in cardiothoracic surgery involves, even in remote settings where entry to theatres are restricted to essential staff.

As several websites provide free of charge surgical videos e.g. medtube.net and websurg.com, these could be more widely advertised by medical schools as an electronic surgical shadowing alternative.

Despite this, pre-recorded procedures can be hard to follow if a student is not familiar with the procedure and anatomy. Videos with a commentary explaining the procedure would be a highly valuable resource.

In conclusion, as medical technologies advance, so should surgical training. While the pandemic has brought numerous hardships to various sectors worldwide, it has also highlighted shortcomings in the traditional methods of surgical training for medical students. We should use this opportunity to revolutionise teaching and invest in medical student education, bringing it further into the 21st century and increasing mediums in its delivery to ensure. n

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New Consultant Appointments - March 2020 to January 2021 Name

Hospital

Specialty

Starting Date

May Al-Sahaf

Hammersmith Hospital, London

Thoracic

March 2020

Kostas Kotidis

Aberdeen Royal Infirmary

Cardiothoracic

April 2020

Igor Saftic

University Hospitals Bristol

Thoracic

June 2020

Udo Abah

Royal Stoke University Hospital

Thoracic

July 2020

Leanne Ashrafian

Guy’s Hospital, London

Locum Consultant Thoracic

July 2020

Vanessa Rogers

Queen Elizabeth Hospital, Birmingham

Thoracic

July 2020

Rory Beattie

Victoria Hospital, Belfast

Locum Consultant Thoracic

August 2020

Saleem Muhammad Jahangeer

Manchester Royal Infirmary

Locum Consultant Cardiac

August 2020

Prakash Nanjaiah

Royal Stoke University Hospital

Cardiac

August 2020

Ahmed Othman

Liverpool Heart & Chest Hospital

Locum Consultant Aortic

August 2020

Ana Lopez-Marco

Barts Heart Centre, London

Locum Consultant Aortic

September 2020

Marcello Migliore

University Hospital Wales, Cardiac

Locum Consultant Thoracic

September 2020

Muhammad Umar Rafiq

Royal Papworth Hospital, Cambridge

Cardiac/Transplantation

September 2020

Selvaraj Shanmuganathan

Liverpool Heart & Chest Hospital

Cardiac

September 2020

Aleksander Mani

Queen Elizabeth Hospital, Birmingham

Locum Consultant Thoracic

October 2020

Eltayeb Mohamed Ahmed

Bristol Royal Infirmary

Cardiac

October 2020

Shirish Ambekar

Barts Heart Centre, London

Cardiac

October 2020

Dincer Aktuerk

Barts Heart Centre, London

Cardiac

November 2020

Rashmi Birla

Golden Jubilee National Hospital

Cardiac

November 2020

Ashok Narayana

Royal Sussex County Hospital, Brighton

Locum Consultant Cardiac

November 2020

Somshekar Ganti

Castle Hill Hospital, Hull

Thoracic

December 2020

Vamsidhar Dronavalli

Royal Papworth Hospital, Cambridge

Locum Consultant Cardiac & Transplantation

January 2021

January 2021

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Book Review:

A History of Cardiac Surgery - Ugo Filippo Tesler Publisher: Cambridge Scholars Publishing [2020] Frank Wells, Consultant Cardiothoracic Surgeon

T

ime passes inexorably and the number of cardiac surgeons who lived through and contributed significantly to, perhaps, the most exciting times of surgical development inevitably diminishes. Thus, the testimony of a lived experience of those times becomes, perforce, less available; history becomes second and third hand and thus in the hands of the author1. We are truly fortunate that Dr. Ugo Tesler being one of the dwindling few is such a man. He is able to claim as a friend many of the most significant names in the development of this wonderful and exciting surgical specialty.

His book, A History of Cardiac Surgery, is testament to that. This personal insight makes this book quite special in the annals of surgical history. It is beautifully written with many first-hand anecdotes and a profound knowledge of the history of the development of surgical techniques and so importantly, the development of the necessary technology. Dr Tesler covers the history from the dawn of modern surgery and anaesthesia to the most modern times.

From the position of Billroth and other

19th century voices, who spoke against the idea of operating on the heart, to the cutting-edge developments today. He puts into perspective the profound early contributions of Alexis Carrel and William Osler amongst other great pioneers. In this discourse he reminds the reader of the profundity of timing. In little known correspondence between Sir Henry Souttar

and Dwight Harken where Harken asks Souttar why he only performed one closed valvotomy, which was a success, Souttar answered that “it is no use to be ahead of one’s time”.

An in-depth knowledge of history is essential for forming perspectives for the future, in the words of John Maynard Keynes, “ideas shape the course of history”. Reproducing the mistakes of history can be avoided and new ideas can be informed by experiences of the past. It is particularly important for the new generations of cardiac surgeons to be informed of their history and this book is a wonderful education.

The book is a treasure trove of fascinating detail and pantheon of names that must not be forgotten in our specialty. Written with a light touch and a real sense of humour and an appreciation of the lives that we strive to enhance, this book should be compulsive reading for all setting out in this wonderful specialty. n In Hebrew there is no word for History. The closest is memory. Memory frequently distorts.

1

“This book is quite special in the annals of surgical history it is beautifully written with many first-hand anecdotes and a profound knowledge of the history of the development of surgical techniques and so importantly, the development of the necessary technology.”

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Crossword

Set by Samer Nashef

1/4 Brave to enter duel, as to be shot in legal break-up (6, 8)

9 In the meantime, agree it’s inadequate (6)

10 They say think over drink if more than one (8)

12 Bangers and pie in just a little onion sauce for starters (8)

13 See 5 Down

15 See 16

16/15/21 Drop bun party (3, 4, 4, 4)

20 Index of flirtation? (7)

21 See 16

25 Fliers sent back from the Postmaster General (6)

26 A nuisance having to chase American friend in

European city (8)

28/29 Steal from connoisseur’s restoration novel (8, 6)

30 Instrument here, Max? (8)

31 I understand you had tea (6)

Please email solutions by 31/03/21 to: sctsadmin@scts.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE The winner will be randomly selected from all solutions sent and will be able to choose between a bottle of ‘fizz’ or a bottle of fine olive oil.

See the solution for the August 2020 Bulletin crossword competition (right).

Across

Down

1 Drew odd characters on motorway toilet for 13 (8)

2 Minister’s man reclined (8)

3 Some amateur operation that the UK abandoned (6)

5/13 Fly down with courage (10)

6 Unfashionable slut, not half doomed to fail outside (8)

7 Arrogant to raise compassion (6)

8 Side location for memento (6)

11/27 Monitor unusual element of behaviour first or you

will die (7, 4)

14 Shred of dignity in crisis at first welcomed by mother (7)

17 Carry on being cute in order to carry on (8)

18 Professional since rehabilitated criminal (8)

19 Start to meddle in articles of abomination (8)

22 That’s coming up in dry city (6)

23 On vacation, Lebanese follow their kind to be

productive (6)

24 Bob for one hospital radio broadcast (6)

27 See 11

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