annual meeting london 2011 - society for cardiothoracic surgery

Society for Cardiothoracic Surgeryin Great Britain and Ireland

Annual Meeting London 2011

SCTS University

Quo Vadis Cardiothoracic Anaesthesia?

Advances in TAVI

The SCTS serves WHO first?

The Demise of A Thoracic Surgical Service

The SCTS response the NICE Guidelines

theJuly 2011

www.scts.org

www.sctsltd.co.uk

Patrick Magee1947-2011

1. Royse AG, Royse CF. Epiaortic ultrasound assessment of the aorta in cardiac surgery. Best Pract Res Clin Anaesthesiol. 2009 Sep;23(3):335-41.2. Hilker et al., Minimizing the risk of perioperative stroke by clampless off-pump bypass surgery: a retrospective observational analysis. Journal ofCardiothoracic Surgery 2010, 5:14

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July 2011 3

Society for Cardiothoracic Surgery in Great Britain and Ireland

The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PETel: +44 (0) 20 7869 6893 Fax: +44 (0) 20 7869 6890Email: [email protected] www.scts.org

Report from The President 4

Honorary Secretary's Report 6

Patrick Magee - Obituary 7

Annual Meeting London 2011 8

SCTS University 12

Cardiothoracic Dean’s Report 14

SCTS Cardiothoracic Forum Report 15

Deputy Nursing Representative’s Report 17

Patient’s Representative 18

Quo Vadis Cardiothoracic Anaesthesia? 19

Advances in TAVI 24

Prize Winners 25

The CALS Course goes International 26

The EACTA Lecture Series of PerioperativeEchocardiography 26

IVATS Lobectomy Training Proctorship 28

Safe and Sustainable Review 29

NICE Guidelines Response 31

New Appointments 31

The demise of a thoracic surgical service 32

The SCTS servers WHO first? 34

Other Interests 35

The UK Cardiothoracic Research Collaboration 36

The Wessex School of Surgery 38

Crossword 39

Contents

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Edited by Vipin ZamvarPublishing Secretary

Contact: [email protected]

Designed & produced by CPL Associates, London

This issue of the Bulletin is tinged withsadness. Pat Magee passed away in May.To many in our Society he was a friend,mentor, trainer. He meant a lot to manypeople. To me he was a well-wisher, whoprovided a lot of support during mytrainee years, and then especially when Iwas looking for a Consultant job at theend of my training. Many have offered towrite remembering him, and we have anObituary on page 7. There is also aphotoboard with photos spanning hisentire life. He will be sorely missed.

As always this Bulletin has reports fromthe office bearers of our Society, updatingus on what’s happening. Many have alsocome forward with articles they wish toshare with colleagues. Hopefully, this trendwill continue, and this Bulletin will be aforum for all to share their views (on anytopic under the sun).

Over the last few years we have reviewededucational courses in this Bulletin. Fromthe next issue we will also start reviewingbooks. If you have read an interesting book(medical or not) recently and would like toshare your thoughts, please write a reviewfor the Bulletin.

We all have other interests and if you oryour colleagues have done somethingrecently that you are proud of please let usknow, and via this Bulletin we will leteveryone know. In our inaugural “Otherinterests” column (page 35), we featureSam Nashef, Rob Lamb, and ShyamKolvekar. The Edinburgh Chess Club (theoldest in the world) annual championshipis on, and I am through to the third round.If I progress any further I will let you knownext time.

Have a relaxing summer break, and doplease send in your articles. There are nodeadlines, just send them to Isabelle at theSociety Office, or to me whenever you areready.

Vipin Zamvar

From the Editor’s QWERTY 3Vipin Zamvar Publishing Secretary

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It is difficult to believe that already the firstyear of my Presidency has already passed.And this last year witnessed a number ofvery important highlights which will largelydetermine the future of our specialty. First,and on an optimistic note, was theproduction of the “Lilac Book” outliningSCTS’s view of contemporary medical

professionalism which not only reinforcedcurrently well established concepts suchas publication of outcome data but alsodiscussed a number of other possibilitiesfor the future including continuingprofessional development, measuringpatient experience and multi-sourcefeedback. I have to acknowledge a

tremendous amount of work and initiativeby Ben Bridgewater in pushing this projectforward and with considerable assistancefrom Graham Cooper and many othersincluding James Roxburgh, MalcolmDalrymple-Hay, Steve Livesey and Raj Shahwho wrote several of the chapters as did anumber of external experts. I am very

Report from The PresidentI start this report with a heavy heart having just learnt of the death of Mr Patrick Magee. Pat wasone of the best respected cardiac surgeons in the UK and held in the highest regard by all whoknew him. He was a clinician who genuinely cared about his patients, expressed great interestin trainees and was never scared of being on the side of the underdog. Although not a traditionalacademic Pat showed great interest in research and was very supportive of my studies,intellectually and financially, when I was his Senior Registrar at the London chest Hospital.Politically he was one of the most shrewd men I have come across and I frequently sought hisadvice on complex issues; his exceptional wisdom was matched by great commonsense and healways acted with the highest degree of integrity. As President of SCTS he exhibited thesetalents effortlessly and in abundance and was a great champion and ambassador of our Society.His untimely death is a real loss to all who knew him and in particular SCTS. Our thoughts arewith his wife Patricia and family.

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Professor D P Taggart, MD, PhD, FRCS

aware that several of these issues can appear challengingand unsettling but so was the publication of outcome datamore than a decade ago. Furthermore, we live in a societywhich increasingly demands transparency. The public andprofession want access to health outcomes in a similarway to having access to expense claims of MPs. It is thiskind of initiative which has promoted the influentialposition of SCTS within the profession and political circlesand was in no small measure partly responsible for theappearance of the Right Honourable Andrew Lansley MP,at our annual meeting. This was the first appearance of theSecretary of State at an individual medical societyconference.

Another optimistic development is the increasingresection rate for lung cancer almost certainly due to amarked increase in thoracic surgery consultants over thelast few years. However there are still markeddiscrepancies in the resection rates in different areas and

the potential reasons are being explored through thoracicdata collection submitted to the National Lung CancerAudit. SCTS is currently looking for funding to support thethoracic database. I was also very struck at the thoracicforum, organised by Alan Kirk in Glasgow last year, by thestrong support for SCTS as a whole and a generalrecognition that we really are much stronger together thanas separate and smaller specialities. However, there isalso increasing recognition within SCTS that we need tohave more thoracic surgeons on the Executive andconsequently it was therefore agreed to support aninitiative from the thoracic forum that in addition to thetwo recently elected thoracic representatives (DavidWaller and Rajesh Shah) the organizer of the next thoracicforum would join the Executive albeit in an initially non-voting format. With John Duffy still acting as the chair ofthe thoracic surgery sub-committee this produces apowerful thoracic line-up.

Another important initiative within the last year was thepublication of the ESC/EACTS Guidelines on Myocardial

Revascularisation. These Guidelines are very importantnot only in ensuring that patients have access to the besttreatment options but also for our speciality.Consequently I believe cardiac surgery is currently at acritical crossroads and that whether we thrive or declinewill depend on whether the Guidelines are actuallyimplemented. If we fail then we not only do our patients adisservice but the outlook for cardiac surgery will becomemore precarious because the tendency for someinterventional cardiologists to treat patients with eitherstents or with percutaneous valves will becomeincreasingly common even if this is not always the besttreatment for the patient and is not supported by anappropriate evidence base. For example, it is especiallynotable that in Germany last year one third of all aorticvalves were done percutaneously without reference tomulti-disciplinary teams or guidelines. In particular SCTSwere extremely concerned with the initial version of theproposed NICE guidelines on stable angina whichrecommended that a cardiologist could treat any severityof coronary artery disease if they considered ‘the anatomysuitable’ and without reference to the multidisciplinaryteam. SCTS responded robustly (see letter) stating why itwould not support these proposed guidelines and DavidGeldard our patient representative wrote to NICEregarding their apparent undermining of the MDT.Encouragingly, the revised NICE proposals are much morebalanced in their recommendations for stents vs surgeryand now accept the importance of the MDT.

For our paediatric colleagues there is still uncertaintyregarding the final reconfiguration of these services whilethe situation for transplant centres also continues toevolve. That there needs to be rationalization of theseservices is beyond dispute although there is still vigorousdebate over the final resolution.

Finally, I would like to acknowledge the outstandingefforts of Simon Kendall, Ian Wilson and Tara Bartley inorganising the annual meeting. I am privileged to havehad the opportunity to attend many cardiac surgery andcardiology meetings over the last few years and I can saywithout any exaggeration that the quality of the last SCTSmeeting was truly outstanding both in its academiccontent and in its social events. Ian Wilson’s and RajShah’s organisation of the SCTS University within themeeting was absolutely outstanding and one of thehighest quality programmes I have ever attended. Thehighlight of the social event was the River Thames cruiseand I personally was delighted and honoured to be able togive Professor Sir Magdy Yacoub, to whom I was a seniorregistrar, his Lifetime Achievement Award, after anexcellent tribute by John Pepper.

David Taggart, President

The increasing resection rate for

lung cancer almost certainly due

to a marked increase in thoracic

surgery consultants over the last

few years.

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Our Annual Meeting this year was once again atriumph; The SCTS University was outstandingand significantly impressed our internationalfaculty. The breadth of papers presented waseven greater than at previous meetings. Wewere able to listen to an impressive range ofspeakers, including the Secretary of State forHealth.

Whilst it was interesting listening to him and hewas positive about SCTS, that he accepted ourinvitation to speak is also important. We usedthis opportunity to launch the Lilac book 'ModernMedical Professionalism'. This has made asubstantial impact Neither of these things, inthemselves will change the way we practicetomorrow but they do contribute to ability topromote professional values and influence.

One area where we will use this influence iscommissioning. The mechanism forcommissioning of cardiac and thoracic surgery inthe future is an issue that will change the way wepractice in the near future. It is unclear, as I writethis, how the healthcare that we provide will becommissioned. The NHS Listening Exerciseclosed on 31st May and the outcome of this willinfluence the shape of the Health and Social CareBill following the pause in its passage throughParliament. A few principles seem likely toremain. The National Commissioning Board willdirectly commission some services and hold toaccount consortia for the services theycommission locally. The focus is likely to be onoutcomes rather than process measures. QualityStandards developed by NICE will form the basisupon which service are commissioned.

As far as I understand within cardiothoracicsurgery, transplantation and paediatric surgerywill remain nationally commissioned, adultcardiac surgery may be nationally commissionedand thoracic surgery will be locallycommissioned. This an area that clearly calls forprofessional input and we are developing ourideas about how this is best provided. We will bedrawing up commissioning guidance for adultcardiac surgery and thoracic surgery,transplantation and paediatric surgery arealready covered. The Royal College of Surgeonsof England has defined seven principles forcommissioning:

1. Training the healthcare workforce: acontractual commitment to training and theability to deliver the standards and outcomesagreed and published by the professions.

2. Educating the healthcare workforce: acontractual commitment to provideappropriate education and continuingprofessional development opportunitiesfor all health professionals.

3. Clinical audit contractual agreements: toensure participation in clinical audit andpublication of audit outcomes.

4. Research and development contractualagreements: to ensure participation inhigh quality research which is essentialfor advancing and improving patient careand outcomes.

5. Commissioning a complete service:ensuring the service includes arrangementsfor full emergency provision at theappropriate level. There must also be properfollow-up and a commitment to dealing withlong-term complications and carrying outrevision surgery.

6. Measuring outcomes outcomes: to bemeasured coherently to enablecomprehensive benchmarking across theNHS, with the data made available to theprofession and used to inform practise andimprove patient safety.

7. Appropriate impact on the local healthcareeconomy: when commissioning a service, afull assessment must be made of the impactof the decision on existing patients pathwayof care in order to safeguard patient access.

These will guide the guidance that we draw up.We would like to hear from anyone wishing tocontribute to this process and especially anyonewho is already working on this locally.

To ensure the guidance is implemented we willneed a national and local strategy. Locally we willrely on our unit representatives both to make theguidance locally relevant and to implement this.

We learnt that Pat Magee has passed away withgreat sadness. An obituary appears elsewhere inthis Bulletin. His wisdom, sense of duty, dignityand unfailing consideration for others willcontinue to inspire me. The debt SCTS owes himfor his strong leadership over many years isimmeasurable and we are thinking of a suitableway of recognising this.

Honorary Secretary’s ReportGraham Cooper

July 2011 7

Patrick Gabriel MageeConsultant Cardiothoracic SurgeonBorn 25th February 1947, Died 30th May 2011

Celebrities feel they have “arrived” when they are known to allby their first name – in our specialty we all knew who “Patrick”was - great family man, friend, colleague, mentor, role modeland inspiration to many in Cardiothoracic Surgery andbeyond….

Patrick Gabriel Magee graduated from University College Dublinwith Honours MB, BCh, BAO in 1971 and went on to obtain a 1stClass Honours BSc in Anatomy and Physical Anthropology in1973. He obtained his FRCS (Edinburgh and Ireland) in 1976 andFRCS England (ad eundem) in 1996.

He undertook his higher specialist training at Brompton Hospital,National Heart Hospital and The London Chest and The RoyalLondon Hospital working with many of the renowned surgeons ofthat era. He also spent one year as a Fellow at Johns HopkinsHospital in Baltimore. He became a Consultant CardiothoracicSurgeon at The London Chest Hospital and The Royal LondonHospital in 1982. He was also an Honorary Senior Lecturer inCardiothoracic Surgery at The University of London from 1982.

Patrick contributed to many publications in leading internationaland national journals. His publications and presentations coverall aspects of cardiothoracic disease but particularly myocardialprotection, coronary artery disease and its complications and,more recently, studies on the appropriateness ofrevascularisation. He supported clinical research and researchersand greatly enjoyed being a Council member for the British HeartFoundation.

Patrick undertook many of the big jobs in the specialty and waswidely known nationally and internationally. He was President ofthe Society for Cardiothoracic Surgery in Great Britain and Ireland(SCTS) 2004 to 2006 and was on the Council of the Royal Collegeof Surgeons of England. Hewas formerly President of theCardiothoracic Section of theRoyal Society of Medicine andPresident, Section ofCardiothoracic Surgery Unionof European MedicalSpecialities (UEMS) 2004 to2010. One of his greatestcontributions was as Chairmanof the Specialist AdvisoryCommittee in CardiothoracicSurgery and previously asPostgraduate Dean of the SCTS– a great involvement intraining and education for theUK and Ireland from 1995 to2002 - identifying and inspiringsubsequent members and SACchairs to date. He was amember of the SpecialtyAdvisory Board for The RoyalCollege of Surgeons of

Edinburgh since 1999 .He was a member of theIntercollegiate ExamBoard in CardiothoracicSurgery; an examinersince 1995 and morerecently wasresponsible for QualityAssessment of theexaminers during theexaminations. He wasLead Examiner for theT r i - C o l l e g i a t eExamination inCardiothoracic Surgeryof the Royal College of Surgeons Edinburgh, Academy of MedicineSingapore and College of Surgeons Hong Kong since its inceptionin 2003. Patrick was the David Chan Visiting Professor at theChinese University of Hong Kong in 2005 and greatly enjoyed hisvisits to the Far East – always accompanied and minded byPatricia! He sat on and chaired many other committees and waswell known for his diplomatic and organisational skills.

Above all though Patrick was a great bloke – approachable;humorous; kind and worldly wise. A great host and raconteur – healways brightened up any social occasion. He weathered twomajor episodes of surgery during his career and returned to fulltime working after both. Many of us have sought and beengrateful for his advice and input into our careers over the yearsand he will be greatly missed – Patrick is a great loss to ourspecialty and his achievements and contributions should berecognised and celebrated.

Patrick leaves his wife Patricia and three sons Hugh, Cormac andRonan to whom we extend our deepest sympathies.

Tim Graham, Leslie Hamilton, Graham Cooper

I tried to think of different ways to startthis article, but having thought of somedifferent options, it is clear to me thatthere is only one appropriate way: andthat is to again thank each and every oneof you who participated in this year’sannual meeting.

Needless to say the meeting is a ‘peoplething’ and without enthusiasm fromdelegates, speakers and corporaterepresentatives none of it would beworthwhile, and hence the importance ofsaying thank you from all of us in theorganising committee.

Isabelle’s influence on worldly mattersworked wonders again, with warmweather and blue skies accompanying ourannual meeting. Some delegates for theSCTS University were initially drawntowards the body building congress, butthe lure of excellent postgraduateeducation proved too much for them.

University

This year we made sure that the whole ofthe Sunday programme was dedicated tothe university and avoided any of theparallel sessions that occurred inLiverpool. We will continue to makeimprovements year on year and for certainwe will make sure that there are moreeducational streams in thoracic surgery.

The University programme is reported inIan Wilson’s article –it is astounding theamount of thought and work that he puts

in to the project: this has gone fromconcept to reality in less than two

years and is a credit to hisdynamism.

We charge members £20 toreserve a place on the SCTSUniversity, which we hope isrecognised as exceptionalvalue for money and is atangible way that the societycontributes to itsmembership.

The programme is usuallyfinalised in early January,but this year was theexception. Only a fewweeks prior to the meetingthere were rumours that

the Health Secretary might be attending.Then with only a week to go an emergencyCabinet meeting was called andnecessitated a further change to theafternoon programme. I am grateful howunderstanding everyone was under thecircumstances.

Graham Cooper set the scene for AndrewLansley's address, summarising theachievements of the society encapsulatedin the society’s freshly released book onModern Medical Professionalism. The 700seat auditorium was packed, with excessdelegates having to stand at the back.

Health Secretary

Putting political persuasion to one side itwas a major coup for our society that theHealth Secretary should have chosen ourspeciality as the first to address. He wasslightly caught off guard by DavidTaggart’s introduction and reference to hisstand against the Iraq war, beforedelivering a robust address, which wasvery complimentary to all the qualityinitiatives that our society has achieved.

As an MP from Cambridge he clearly hadgood knowledge of the Papworth unit andhence our specialty, and as he had notreceived the prepared questions prior tothe meeting it was impressive how well heresponded.

Prior to the Health Secretary’s addressthere were several important parallelsessions;

The Database Managers had met for the6th consecutive year. Tracey Smailes,Middlesbrough, has been the lead since itwas first established and had organised avery relevant and interesting agenda. Therole of data has been pivotal in promotingour society and the care of our patientsand the database manager’s forum hasbeen vital in sharing good practice andachieving consensus. Understandably,but regrettably, Tracey has decided to stepdown from this role and we wish her wellconcentrating on ‘the day job’ in theknowledge she has made an outstandingcontribution to the national agenda.

The Trainees Meeting, organised by BetsyEvans, Papworth, had a comprehensiveagenda with presentations and discussion

on national selection, specialty exam,EWTD and service delivery. Another goodturnout from the trainees rewarded by thepresence of all the national leads intraining.

Eric Lim had kindly brought The ThoracicSurgical Research Collaborative to theAGM – this is a biannual forum to propose,review and coordinate national research,which must be the optimal way to makethe most out of the significant effort frompatients and clinicians.

A lot of hard work had gone into thepreparation of the Patients’ Forum by ourpatient representative David Geldard.There were papers presented onadmission and discharge, a presentationon cardiac rehabilitation by the nationalclinical lead, Jane Flint and the vision offuture care from Sir Bruce Keogh and TaraBartley.

ACSA (Association of Surgical CarePractitioners) held their annual meeting inconjunction with ours for the fourthsuccessive year. They are playing a largerand larger part in the care ofcardiothoracic patients, so much so that itis often difficult fro them to be able toleave their units and attend while so manysurgical staff are also in attendance. Theirpresident, Toby Rankin, has had a verysuccessful term in office but now has amore challenging role in Plymouth and ishaving to relinquish his post - it has beena pleasure to work with him and we arevery grateful for his continued support ofthe meeting.

There continues to be debate on the roleof surgeon specific results and theManagement of the High Risk Patient.Graham Cooper had carefully consideredthis sensitive session and we wererewarded with presentations from IrvingKron (the US perspective), Ian Wilson(what’s wrong with risk averse behaviour),Tim Jones (the Birmingham congenitalmodel) and Steve Griffin’s inspiredinsights into the personal and professionaleffect of ‘managing divergence’, the latterreceiving a standing ovation.

The Cardiothoracic Nurses Forum hadanother outstanding two day agenda. TaraBartley has consistently raised the bar

Annual Meeting 2011LONDON EXCEL – Sunday to Tuesday, MARCH 20th – 22nd 2011

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July 2011 9

Simon Kendall Meeting Secretary

London 2011

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year on year attracting national leaders topresent, as well as an increasing numberof abstracts and papers. The pastpresident of the RCN, Maura Buchananand the new president AndreaSpyropoulos were both present. Tara’scontribution to the Forum, the Executiveand the national agenda for cardiothoracicnursing is all done in her own time and hercommitment and delivery of excellencehas been recognised by the award of therare and prestigious RCN fellowship,presented in May at the RCN conference.

This was the second year we held amedical students’ poster competition.Expertly organised by David McCormack,there were an astonishing 42 submissionsand the presenters are all given freeregistration. The judges selected 10posters to be presented on the Tuesdaylunchtime. On the Monday night thestudents organised a social (with somesupport from the Society) whichapparently involved the bars includingKings’ Students union and UCL – but toomany others to list apparently.

The Thoracic Surgical Programmecontinues to expand. There were moreparallel sessions than ever, compiled byRajesh Shah, Sion Barnard and John Duffy:a total of 46 papers, two lectures, twosymposia and the research collaborative.We welcomed Professor Jean-Marie Wihlmwho presented on chest wallreconstruction and Professor RobMcKenna who gave the Tudor-Edwardslecture on lung volume reduction surgery.

In Cardiac Surgery we welcomed LarsSvensson, who gave his lecture on the roleof Aortic stenting, Michael Mack debatingthe technology on sutureless aortic valvesand Irvin Kron summarising contemporarymitral surgery.

Possibly the most contentious on goingdebate is the reconfiguration of paediatriccardiac surgical services. Dr Jeremy Glyde(project manager) and Dr Patricia Hamilton(chair of steering group) accompaniedRoger Boyle (Heart Tsar) in briefpresentations followed by discussion ofthe potential changes. Andrew Parry hadorganised a congenital programme thatwas stronger than ever: a corporatesymposium on RVOT to start the day;discussion on reconfiguration; symposium

on complex transposition; paperpresentations and finishing with a furthersymposium on bicuspid aortic valves.

Indeed the aortic valve was the focus ofseveral sessions on the Tuesday: VinnieBapat had coordinated the TAVIsymposium, Malcolm Dalrymple-Hay theMini-AVR symposium and finishing withthe session on the bicuspid aortic valvechaired by Sir Magdi.

Our President has been central to thedebate on strategies for revascularisation.He has been most influential in thecompilation of the ESC / EACTS guidelineswith a writing group more balanced thanever before. The symposium on thissubject was enriched by the presence oftwo of the major authors, Professor Kolhand Professor Wijns as well as thepresidents of the Cardiac Society,Professor Keith Fox and BCIS, Dr MarkDeBelder.

EWTD – has this become a four letter wordin surgery? It’s certainly an area ofcontentious debate and appears to beaffecting the amount of time for training,the continuity of care for patients as wellas the cost of that care. Marjan Jahangiricoordinated a lively symposium includingthe President of the College of Surgeons,John Black, and the head of HR from theQE at Birmingham, Ms Rona Miller, tomake sure we had the facts as well as theeffects.

Annual Dinner

The meeting concluded with the annualdinner on a Thames river cruise – but notquite as we intended. The food wasexcellent (just as we had tasted back inJanuary) the jazz music superb, the winejust right, but…….. did we have the nighttime views of London’s magnificent andhistoric landmarks? No! On boarding theSilver Sturgeon (not Surgeon) Isabelle andI were informed that the tides were goingto prevent any journey up river, so we hadto settle with a tour round the Isle of Dogsand multiple views of the MillenniumDome.

However we had a grand finale to enjoy:Professor John Pepper expertly presentedan entertaining account of Professor SirMagdi Yacoub’s outstanding career andpresented his Lifetime Achievement

Award. This is the fourth such award and,as with the previous three, there was areverent silence as Sir Magdi spoke, givingus further insight to the great man.

We are fortunate to have such strongcorporate support. Their continued focuson education is mutually beneficial toimprove the content of our meeting andthe opportunities for our patients. TillyMitchell had done a superb job attractingexhibitors and designing the exhibitionhall, which opened earlier than usual withthe Welcome Reception.

Last, but not least, and certainly thegreatest thanks goes to Isabelle Ferner –I’ve said it before but she is the hub of theentire affair. She has an extraordinaryability to manage and communicate themultiple facets of the meeting, and itshard to imagine the chaos if she wasn’tthere to guide us year on year.

What makes a successful meeting? I thinkit might be when the participants leaveand feel it has been worthwhile – worththe time, worth the expense. And this willbe measured in many different ways:good to deliver a paper or talk; met old ornew colleagues; learnt new practice orknowledge; met potential new customers;reinforced current practice; updated oncurrent topics; the feeling there has beenan opportunity to influence the agenda;new ideas for research or collaboration –the list goes on and we hope we candeliver to as many as we can.

Next year is a new era for the AGM - eventhough we are renamed the Society forCardiothoracic Surgery (AND we couldn’tpossibly work without each other) we haveyet to ‘meet’ with the Association ofCardiothoracic Anaesthetists ACTA.Therefore we are combining our meetingsfor the first time in Manchester, April 18th– 20th. The agenda will focus on commonareas for the two societies and it may bethat units will reduce their service toenable more colleagues to attend.

It should be a great meeting, and if so wemight consider repeating the ventureevery three to five years. We hope you willcome and take part.

Simon Kendall

Annual Meeting 2011 continued

London 2011

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Pre-registration was high; over 290delegates signing-up prior to the day, andwith on-site registration, members offaculty and corporate participation over450 attendees filled the Platinum Suite asthe Medical Director of the NHS launchedthe event for the second year. A fantasticturnout at 08:30 on a Sunday morning.

Participants reflected the constitution ofthe Society’s membership; 35% ofdelegates were consultant surgeons and55% trainee surgeons, whilst ACSAmembers, Perfusionists and Forummembers also enjoyed the vibranteducational environment created by theworld-class faculty.

As the SCTS University programme wasallowed to develop a full day’s activity, anexpansion from the first year’s course, thestamina of both delegates and faculty wastested by a programme committee notwilling to let an educational opportunitypass by.

The day included 6 parallel EducationalStreams, each of which analysedcontentious areas of current cardiothoracicclinical practice within an exhaustive 6hour interactive programme. Delegateswere encouraged to interrogate thenational and international faculty, resultingin an energetic cocktail of education andexperience.

The midday break was occupied by 7parallel “Lunch Box” sessions; 90 minuteseminars of topical analysis and debate,exploring some of the most controversialareas within cardiothoracic surgery.

The dynamic atmosphere generated bydelegates and faculty alike resulted in a

tremendously educational day, facilitatedby the use of “Hands-On” models ofcontemporary clinical practice, “State ofthe Art” simulators, and “Minds-On”exploration of contentious topics withincurrent day practice.

The Educational Streams in the SCTSUniversity 2011 were:

• Ischaemic Mitral valve Regurgitation:The Art of Balancing Forces

Professor Irving Kron, University ofVirginia, and Mr Frank Wells, led avastly experienced faculty ofinternational and national authoritiesin the field. The international facultyincluded Professor Jean-LouisVanoverschelde, Professor PatrizioLancellotti, Dr Patrick Perier, Mr AniAnyanwu and Professor MalcolmUnderwood; a national facultycomplimented this internationalexperience, resulting in a

comprehensive review of theknowledge-base of this complexarea of clinical practice,alongside a fascinating look intothe future. The wealth ofexperience within the assembledfaculty led to a mostauthoritative review of thesubject data, in a style thatallowed intense interaction withthe enthusiastic delegates.

Average Session score: 4.50/5

• Aortic Dissection: A Surgical MasterClass

Professor Lars Svensson, ClevelandClinic, and Professor Bob Bonser,chaired a highly dynamic educationalprogramme, supported by a hugelyexperienced international and nationalfaculty. This Educational Streamoffered the opportunity to gain acomprehensive “State of the Art”review of the many contentious topicswithin the clinical arena of AorticDissection surgery. Internationalperspectives on the nationalconfiguration of Aortic Dissection

surgery service delivery provedinsightful and may well assist inshaping the ongoing UK debate.


• Off-Pump Coronary artery BypassSurgery: Understanding its role in2011

Professor John Puskas, EmoryUniversity, Professor Gianni Angeliniand Professor David Taggartcollaborated in creating a highlyinteractive programme examining thefield of OPCAB surgery. Thecongregation of OPCAB enthusiastsand authorities in the field, alongside acollection of delegates hungry forknowledge, resulted in a vibrantatmosphere of exchanging data, tips,tricks and experience.


• Innovative Options in Aortic ValveSurgery

Dr Michael Mack, The Heart HospitalBaylor Plano, Texas, and Mr BenBridgewater developed an intriguingprogramme analysing the evolution ofaortic valve surgery, iterative changesin practice, risk prediction models, andhow these models interact withdecision-making in TAVI surgery.Professor Volkmar Falk, University ofZurich, Professor Thomas Walther,Kerchoff Heartcentre, Bad Naunheim,offered huge international experienceand complimented a highly thought-provoking national faculty. “Hands-On”simulation models allowed delegatesan ideal opportunity to reinforce theeducational content of the session,offering practical experience in TAVIsurgery.


• Contemporary Thoracic Surgery

Professor Robert McKenna, Cedars SinaiMC, Los Angeles, and Mr Rajesh Shahled a dynamic Thoracic Surgicalprogramme which proved so popularthat the delegates had standing roomonly within a venue capable of seatingover 90 attendees. This EducationalStream explored “State of the Art”minimally invasive thoracic surgical

SCTS UniversitySCTS University 2011 represented the second phase in the development of theSociety’s postgraduate education programme; staged on the 20th March 2011 at ExCel,London, immediately prior to the SCTS annual meeting.

July 2011 13

approaches alongside exploration ofspecific complex clinical scenarios,including Post PneumonectomyEmpyaema, Ruptured Oesophagus,Primary Malignant Chest Wall Tumoursand Mediastinal Tumours. This highlyinteractive session generated hugeinterest and vibrant discussion.


• The Small Aortic Root: Meeting theNeeds of Different Generations

Mr Asif Hasan and Mr Marcus Haw co-hosted an Educational Streamencompassing the clinical dilemma ofPatient-Prosthesis mismatch; itsclinical relevance and how it can bemanaged. “Hands-On” reconstructionof aortic root enlargement techniqueson human cadaveric hearts, courtesyof NHSBT – Speke, allowed detailedunderstanding of the relative merits ofthese procedures. The supervised“Wet Lab” experience, supported byProfessor Marjan Jahangiri, ProfessorMark Redmond, and Mr DavidAnderson, afforded an almost uniqueopportunity to gain increasedunderstanding of the complexities ofthese reconstructive procedures.


Although the change around at thelunch-break was a little hectic, overallthe quality of the food was good anddelegates settled into their chosensessions with a bite to eat, and a drinkat hand. Delegates assessed that theLunch Box sessions were a good use ofthe lunch-break 4.4/5; encouraged bythis we will look to replicate this formatnext year.

The 7 Lunch Box Sessions filled the lunch-break ensuring a lively interlude ofcontemporary discussion with the world

authorities gathered at ExCel within theSCTS University 2011.

These Lunch Box sessions included:

• Endoscopic Conduit Harvesting:Unravelling the Myths

Malcolm Dalrymple-Hay chaired adynamic session in which ProfessorJohn Puskas and Dr Michael Mackexplained how the PREVENT IV andROOBY Trials influenced the evidencebase, whilst Mr Tony De Souza and MrToufan Bahrami gave a robustresponse, detailing howendoscopically harvested conduit canbe utilized in a progressive UK practice.

Session score: 4.33/5

• Evaluation of Graft Patency:

Valuable Quality Assurance or anUnnecessary Expense

Mr Philip Hayward led a fascinatingsession in which Professor DavidTaggart, Professor Thierry Carrel,Berne, Switzerland, Dr Teresa Kieser,Calgary, Canada, and Dr Roger Bury,Consultant Radiologist explored therole of establishing quality assuranceafter coronary artery bypass surgeryand what this evaluation adds to thestandard of clinical practice.


• Postoperative Bleeding: More ThanJust a Lost Night’s Sleep

Professor Keyvan Karkouti, Universityof Toronto, and Mr Gavin Murphy,critically analysed the evidence-basewithin the clinical arena ofpostoperative bleeding withoutstandingly insightful detail, whilstdefining optimal peroperativemanagement strategies to facilitatehaemostasis in this field of rapidlychanging emphases.


• Minimal Extracorporeal Circulation(MECC)or Retrograde AutologousPrime (RAP):

What Role in Contemporary CardiacSurgical Practice?

Contemporary perfusion techniqueswere evaluated in a session chaired byMr Mo Bhabra and Mr Steve Robins

which explored the role, safety andefficacy of MECC and RAP, including adescription of how these noveltechniques can be incorporated intoclinical practice to optimise CPB safetyand augment patient protection.


• Guidelines in Lung CancerManagement and Resection: Utility ofFutility

Professor Alessandro Brunelli, Ancona,Italy, Mr Richard Page and Mr Eric Lim,explored the current national andinternational guidelines, debating howthe NICE Guidelines on Lung CancerManagement influence clinicalpractice, whilst analysing the Europeanand BTS / SCTS Guidelines in LungCancer Resection; evaluating howthese guidelines may be used toincrease UK resection rates.

Session score 4.29/5

• Emerging Technologies Workshop:

Mr Joe Zacharias chaired a franticsession exploring some of the mostprogressive areas of clinical practicewhich included; an Endobronchialapproach to Emphysema andprolonged air leaks (MohammedMunavvar), What every Mitral surgeonneeds to know of the Everest trials (IrvKron), Short and long term ventricularsupport in a non transplant setting(Christian Schlensak, Freiberg), Futuredirections for cardiac surgery: ACleveland Clinic perspective (LarsSvennson), State of the Art SternalClosure: Primary and Secondary ( JohnDunning). Joe did a great job holdingtogether such a diverse group of topicsdelivered by an assembly of worldauthorities.


• Hybrid Interventions are the Future ofCongenital Cardiac Surgery

Mr Tim Jones chaired a debateevaluating the future development ofcongenital cardiac surgery, as the roleof minimally invasive surgery andpercutaneous techniques evolve; DrShakeel Qureshi took the cardiologicalviewpoint, whilst Mr David Andersontook the surgical stand, outlining how

Ian Wilson

theBulletin14

current technologies can enhance thetherapeutic options available in themanagement of this potentiallycomplex group of patients.


All Educational Streams and Lunch Boxsessions were augmented by a LiteratureReview which was printed within theprogramme; this effort unquestionablyproved to emphasise the content of theindividual sessions. Many thanks to allcontributors; Neil Roberts, AaronRanasinghe, Neil Howell, Paul Modi, SteveWoolley, Ben Davies, Nigel Drury, VanessaRogers, Vassilios Avlonitis, Haris Bilal,Donna Eaton, Phil Botha and Tom Barker .

The SCTS University ended at 17:00, with apositive air generated and maintainedthroughout the day. The interactive formatof the programme undoubtedly affordedthe opportunity for delegates to get “closeand personal” to world authorities in theirfield and benefit from their knowledge andexperience.

On behalf of everyone involved in theprogramme I would like to express thanks

to all the faculty involved this year. Thequality of the international and nationalfaculty was extremely high, which resultedin a very high calibre and successfulmeeting this year.

The untiring support, both mentally andphysically, from Simon Kendall, RajeshShah, Tara Bartley and Christina Bannister,in delivering the educational programme isenormously appreciated and last but mostimportant Tilly Mitchell and IsabelleFerner’s unflinching execution of theproposals forwarded have beeninstrumental in the achievementsaccomplished this year.

We would also like to express enormousgratitude to all the corporate groups whosupported this initiative. Without suchsupport this venture could never have gotoff the ground, and we really appreciatethe ongoing assistance as the projectmatures.

Part of this maturing process has seen thelaunch of the SCTS University EthiconSurgical Scholarships this year, whichinclude potential educational

opportunities in New York, Hong Kong,Singapore, Atlanta, and Rennes, alongsideother national and international venues.These four, six month fully salariedScholarships, including travel expenses,will be awarded in June 2011 and will offeran amazing opportunity for senior traineesin the style of a “Finishing School” insubspecialty areas of clinical practice.Many thanks to Ethicon for making theseScholarships available to cardiothoracictrainees in 2011.

The construction of SCTS University 2012is underway. If members have ideas thatthey would like to explore for SCTSUniversity 2012 or 2013 please contact me:[email protected]. Recognisingthe demand for Thoracic Surgical contentwithin the project, SCTS University 2012will increase Thoracic EducationalStreams.

The SCTS University project is designed by,and delivered for, the SCT membership inits broadest definition, and we hope thatyou will want to participate as both facultyand delegates in the years to come.

SCTS University continued

The first 6 months of this year haveprobably been the busiest for theCardiothoracic Dean.

As well as my normal day to day work as aThoracic Surgeon I contributed to theThoracic forum in Glasgow, which was wellattended, including the President of theSociety who contributed to the debate ontraining for Thoracic Surgeons. In addition,late March was a busy time withpreparation for the Society meeting andthe University which was very successful.The Trainees day was very well attendedand as usual there were a number ofquestions regarding National Selection.The trainees who had been through orwere about to go through the selectionprocess, were invited to submit concernsand areas for improvement to the process.Two weeks later the 2011 selection processwas carried out on the 4th, 5th and 6th of

April. There were 46 candidatesinterviewed for what turned out to be 27posts. I had concerns that this 4th year wehave undertaken National Selection, therewas going to be problems in moving theadministrative side from Birmingham(West Midlands Deanery) where we havebeen well served in the first 3 years ofNational Selection, to the Wessex Deanery.However, these fears were unfounded. Itwas very well organised from all of thepaperwork onwards in January through tocompletion and beyond. Of the 19unsuccessful candidates I have givenformal feedback in writing to just over halfof them to date.

In addition I have been involved in theEthicon fellowships which were announcedat the Society meeting, and these shouldbe interviewed in late June. This is anexciting opportunity for Senior Trainees in

C a r d i a c ,Thoracic andC o n g e n i t a lSurgery to finetune theirspecialist skillsbefore makingthe leap intoConsultancy. One area of weakness hasbeen the establishment of a database ofoverseas Doctors who may wish to trainhere for short periods. Although I havebeen able to facilitate this locally, my planwould be that centres could submittraining opportunities they may have forshort term training periods of 1-2 years,similar to the previous FTTA posts and tryto match these with people who write infrom abroad enquiring about a period oftraining in the UK. Any further suggestionsor notification of potential posts would bewelcomed.

Cardiothoracic Dean’sReport

Sion Barnard Cardiothoracic Dean

15July 2011

Tara BartleyNurse Representative

This year’s Annual meeting was held at ExCEL,overlooking the river Thames. With the theme ‘21stCentury Care’ the Cardiothoracic Forum was openedby Ms Andrea Spyropoulos, the newly electedPresident of the RCN. Don’t be fooled by the Greeksurname, Andrea is very proud of her Liverpuddlianaccent and to represent the RCN.

She opened by suggesting that with a substantialproportion of the Cardiothoracic workforce attendingthe meeting this was not the week to needcardiothoracic surgery! Her speech highlighted thechallenge of providing Quality Care in the face of thecurrent NHS efficiency drives and praised the successof the multidisciplinary working which takes place inthe Cardiothoracic speciality, examples of which couldbe seen throughout the programme. She stressed theimpact of patient lifestyle choices and healthinequalities against the challenges the healthprofessions are facing. Highlighting data from the‘Frontline first’ campaign she gave specific examplesof planned cuts in the workforce over the next twoyears and the impact of this upon staffing levels andmoral. Her message was about putting patients firstand in a climate that demands more for less the needfor expertise and skill was paramount.

Andrea’s opening remarks were followed by Sir BruceKeogh who developed the theme with a presentationabout the implications of change in the current NHSchanges. He shared the blunt realities of deliveringquality care in the face of fiscal demise and the truereality of the savings that had to be made in thecoming years.

Thoracic Session

During our Thoracic session the plenary speaker wasMr Richard Steyn who talked about Trauma in the prehospital setting. In an era when there is centralisationof Trauma centres with an increasing demand upon theCardiothoracic team, Mr Steyn shared case histories ofhow patients treated at the scene had favourableoutcomes in what could have been tragiccircumstances.

We have all had to accommodate the introduction ofthe WHO Check list so it was topical for Mr StephenClark to deliver a plenary presentation on the WHOChecklist - Surgical safety checklists; it is worth theeffort! While the logic of this process is easy tounderstand many of us are struggling to embed itwithin the theatre routine. The conclusions from boththe presentation and the audience would suggest itsadoption is driven by leadership and mostsuccessfully completed where it has been surgeonlead.

Mr. G Bolger, formerly of the DOH spoke on hisextensive involvement on Quality Indicators and theway we can measure the care we delivery. Clearly, theethos of empowering patients with choice has focusedour delivery of care on quality. The NHS is now strivesto recognise how we give quality care, how wedemonstrate this to the public, thus how we measureit and then to satisfy the financial constraints howefficient the service is.

Dr Stephen Green from the National CardiacBenchmarking Collaborative shared the work they andthe trusts involved are undertaking around thecountry. The remarkable set of data is a major resourcethat can be used to inform the speciality on excellentservice delivery. The extensive work was clearlyappreciated by delegates some of who were unawareof the organisations work.

The session given over to workforce issues and thedevelopment of Advanced roles was led by JennyAston, President of the Advanced Nurse PractitionerForum. Jenny updated us on the progress of theStandardisation and Regulation of Advanced Practiceby the NMC. Disappointingly it would seem they are nofurther forward in resolving the issue of registration,despite the logistical barriers surely it is time toformally recognise the expertise these roles bring tothe profession and patients.

Eighteen abstracts were selected from the thirty-threesubmitted for the Forum. Congratulations to allpresenters whose work went towards creating anexcellent two days. A special mention goes to thewinners of the £200 Best Paper award as chosen bythe audience, which this year wasshared between;

Reflection on the Implementation of aNurse Practitioner Training Programmein a Large Cardiothoracic Surgical Unit

Sandra Laidler1; F. Thompson2; L.Clarke1; R. MacFarlane1; S. Naden1; G.Newberry1; S.A. Stamenkovic1

1 Newcastle-upon-Tyne Hospitals NHSFoundation Trust, United Kingdom; 2 Newcastle-upon-Tyne Hospitals NHSFoundation Trust, United Kingdom

and Minimising Patient Morbidity – TheNext Challenge for CardiothoracicSurgery.

C. Tennyson; D.J. McCormack; S.Ibrahim; P. Lohrmann; A.R. Shipolini TheLondon Chest Hospital, United Kingdom

SCTS Cardiothoracic ForumAnnual Meeting 2011

Sir Bruce Keogh

shared the blunt

realities of delivering

quality care in the

face of fiscal demise

and the true reality of

the savings that have

to be made in the

coming years

theBulletin16

SCTS Forum continued

The £25 Wisepress token awarded to the Best poster wasselected by members of the abstract selection committee and wasgoes to;

Developing a Multidisciplinary Complex Pre and Post OperativeIntervention to Reduce Complications and Enhance Recoveryafter Lung Resection Surgery.

M.Z. Abdelaziz; A. Bradley; P. Agostini; K. Nagarajan; E. Bishay;M.S. Kalkat; R.S. Steyn; P.B. Rajesh; B. Naidu.

Birmingham Heartland Hospital, Heart of England NHS FoundationTrust, United Kingdom

Forum delegate numbers were slightly less than last year which isa sad reflection of the difficulties that nurses and the allied healthprofessional have in procuring time away from work and thefinancial outlay for professional development. Having recentlyattended the American Association Critical Care nurses to deliverthe CALS course, I was astounded to know that 7000 delegateshad registered with the support of their institutions to ensuremaintenance of their registered accreditation. Clearly, in the USAthere is recognition of the value of professional development andits impact on the delivery of care beyond the individual.

The social scene at the meeting added to the value for delegates.Our thanks go to Joel Dunning and CALS for sponsoring theNurses and allied health professionals Caribbean night and toChristina Bannister who attended on my behalf. The Annualdinner was held on the magnificent Silver Sturgeon where thechef and team produced the finest meal we have had the pleasureto sample during our many meetings.

Plans are already underway for next years’ meeting in Manchesterand we will call for Abstracts to be submitted between Octoberand December, so I would encourage you share any projects orwork in progress.

Other news from the Speciality;Deputy Nursing Representative;

I have invited Christina Bannister, Deputy Nursing Representativeto introduce herself. Her piece is attached and I am delighted thatshe has joined me in my final year as the Nursing Representative.

Fellowship of the RCN;

At the recent RCN Congress I was delighted to be awarded theprestigious RCN Fellowship. I would like to express my gratitudefor the nomination and those that provided the references. Inaddition I would like to thank former and current members of theSCTS Executive for providing me with the opportunity and supportto undertake my role without which the award would not havebeen possible.

RCN Research scholarships for nurses and midwives;

This years RCN Congress announced a number of FoundationBursaries awarded to nurses for professional development. Foranyone interested in viewing the winners or applying in the futuredetails can be found at;

www.rcnfoundation.org.uk/bursary_scheme/bursary_winners_2011

The SCTS Cardiothoracic Advanced Course;

This year’s course will be held on December 4th & 5th atHeartlands hospital and places will be advertised shortly. We arevery grateful to SORIN and Kevin Austin from Wet Labs for theircontinued sponsorship and support. If you are interested at thistime please contact me directly at [email protected]

Update on current issues;

During this year’s RCN Congress in Liverpool the currentGovernment published its response to the consultation ‘Front LineCare’, the report on the future of Nursing and Midwifery inEngland. Since its publication in March 2010, the Principles ofNursing Practice have been launched. The CNO Bulletin April 2011states;

‘The eight core principles set the direction for nursing and

midwifery, in the context of Equity and Excellence: Liberating

the NHS, and form the basis of the DH’s response to the

Commission’s recommendations. The principles set out clearly

that dignity, responsibility, patient involvement and safety

awareness should form the solid foundation for good nursing

practice. The response to the 20 recommendations made by the

Commission include support for the pledge to deliver high

quality care, addressing the contribution of nurses and

midwives and their freedom to manage, commission and run

their own services..’

Clearly the recent publicity about input from the all sectors of thehealth professions to the proposed NHS changes, not leastnursing should feature to a greater degree than the currentprocess is supported by the RCN.

There is now a listening exercise scheduled to take place involvingpatient representatives, doctors, nurses and other healthprofessionals to listen and report back to the Government on theModernisation of the NHS. An exercise that, in the words ofAndrew Lansley will be the chance to ‘pause, listen, reflect andimprove’.

With this in mind it is important to remember that the NationalQuality Board, who has recently published the first of its tworeports restates that as professionals we have a duty to deliverquality care and highlight sub-standard care.

To finish I would like to highlight that Nurses throughout thecountry took part in events for International Nurses Day on 12 May2011 and Maura Buchanan, previous President of the RCNattended the ceremony held at Westminster Abbey to celebrate allthat is excellent about nursing.

If any of your colleagues would like to add their names to theSCTS Allied Health Professionals database so they can receive theemails that are sent out then please forward there name, addressand title to me at [email protected] or direct to TillyMitchell at [email protected]

Tara Bartley

Nurse Representative

17July 2011

I would like to introduce myself in mynew role as Deputy NursingRepresentative for the SCTS. It is a greathonour to join Tara in promoting the worknurses and allied health professionals dowithin the realm of cardiothoracicsurgery.

Currently I work at Southampton GeneralHospital as a Nurse Case Manager inCardiac Surgery, a role I set up atSouthampton which encompasses theatreco-ordination, list planning for a specifiedcaseload and one-stop pre-assessmentclinics for all cardiac surgical patients. Iwork alongside a new team of 5 NurseCase Managers and 4 Advanced NursePractitioners in cardiac surgery, andtogether we ensure all patients coming forcardiac surgery at Southampton have assmooth a patient journey as possible,reduced length of stay and positive patientexperience. Within our team we have aThoracic Surgery Nurse Case Manager andare looking to expand that role also.

At Southampton I work with six cardiacsurgeons, who have a love of homemadecake, peanuts, Haribo and good coffee, allwhich is available in our office which weshare with the cardiothoracic SpR’s, whichas you can imagine has its ups and downs.When I’m not at work I’m normally chasinground after my 2 children who are nearly 7and 3, doing the usual soccer mom role oftaxiing them to and from school, nurseryand any other activity they can lay theirhands on. On Sundays in the summer youcan find us all on Granddad’s yacht fightingthe rest of the south coast of England for asmall stretch of water. As I am originallyfrom Manchester water is something thatfalls from the sky, so sailing has been anew challenge.

I have been working within the area ofCardiac Surgery and Cardiology for thepast 17 years, after completing my nursetraining at the University Of Wales CollegeOf Medicine in Cardiff. Post qualification, Ispecialised in Cardiac Nursing and haveworked at both St George’s Hospital and StThomas’ Hospital in London. I have workedon Cardiac Surgery and Cardiology wards,

and have cared for patients’ both pre andpost cardiac transplantation. During mycareer I have completed an ENB CardiacNursing Course and ENB GeneralPrinciples of Transplantation Course; Ihave also obtained an MSc in Cardiology atthe University of Brighton.

During my current role I have been amember of both the Pan-Dorset CardiacSurgery & Inter-Hospitals Sub-Group forDorset Cardiac and Stroke Network andthe South Central Cardiovascular Network

Cardiac Surgery Project Group. I havedeveloped outreach one-stop pre-assessment clinics at the RoyalBournemouth Hospital and Frimley ParkHospital, and at Southampton I am theclinical co-ordinator for the joint CardiacMulti-disciplinary Team Meeting.

I hope that throughout my term as DeputyNursing Representative for the SCTS I willbe able to develop the role by continuingthe good work already started by previousNursing Representatives in creating acollaborative approach to cardiothoracicsurgery, through promoting multi-disciplinary working. I would like tocontinue to increase the profile of nursesand allied health professionals within theSociety and beyond. As a Nurse CaseManager I work alongside Advanced Nurse

Practitioners and Surgical CarePractitioners and would like to developboth roles within the changing face ofnursing. The reduction in junior doctorsworking hours with the European workingtime directive has created an enormousopportunity to develop the scope ofnursing practice and with my experienceand enthusiasm I would like to work withnurses and allied health professionalsacross the country to support their workand continue to develop guidelines andstructure for emerging nursing roles.

Through my experience in working withinthe South Central Cardiac Network I wouldlike to promote nursing networks acrossthe country, not just with experienced andspecialist nurses but within the junior staffworking on cardiothoracic wards andoutpatient departments. Especially intodays difficult and challenging nursingenvironment I feel that all nurses incardiothoracic surgery should linktogether to support each other withineveryday nursing practice. We all face thesame daily challenges and more time onthe wards is spent away from actual handson caring for the patients undergoingcardiothoracic surgery. I believe thatthrough better networking across thecountry we, as nurses and allied healthprofessionals, can increase the time andquality of care we provide for our patientsby sharing excellent practice and not tryingto re-invent the wheel.

Finally I would like to build on the linksalready forged throughout the nursing andsurgical communities to enhance theeducational opportunities available forcardiothoracic nurses and allied healthprofessionals, throughout the year, andespecially at the annual joint SCTS andACTA conference.

Christina Bannister

Deputy Nursing Representative

SCTS

Christina BannisterDeputy Nurse Representative

Deputy Nursing Representative’sReport

Currently I work as a NurseCase Manager in CardiacSurgery, a role I set up atSouthampton whichencompasses theatre co-ordination, list planningfor a specified caseloadand one-stop pre-assessment clinics for allcardiac surgical patients.

theBulletin18

David H Geldard, MBE

Patient RepresentativeIt is interesting to note that theinvolvement of patient representation intothe proceedings of the Society does notinhibit discussion and decision making,but rather it seems to enhance it. A goodexample was at the British OncologyThoracic Group's Conference in Dublin inJanuary, where a lunch-time breakawaymeeting on Addressing Risk AverseBehaviour, attracted a standing- roomonly group of participants who wanted totackle the disparities in treating acutely illpatients across surgical centres.

The debate was open and honest, andthere was genuine recognition that somepatients who were otherwise doomed,were being denied surgery. It was alsorecognised that the involvement of thepatients in the discussions around theirprospects was also necessary.

Similarly, at the Society's Annual meetingin London in March, SCTS is deservingpraise for arranging its third Patients'Forum, and it is likely that this is the onlyForum for a cadre of patientrepresentatives at any other medical orsurgical conference. It is a precedent thatothers are bound to emulate. This yearpresentations of special interest to patientrepresentatives were received on SurgicalSite infection Surveillance, from St James'sHospital, Ireland; In-house UrgentPatient's Experience Waiting for CardiacSurgery, from the Morriston Hospital;Same day admission for Cardiac Surgery?,from Leeds; Thoracic Surgery PatientExperience Day, from Leicester; and alsofrom Leeds, Can Patients be SafelyDischarged Home on the 4th PostoperativeDay? An interactive session with Sir BruceKeogh and our own Ms Tara Bartley, on“Improving the Experience and theOutcomes for Patients and their Carer”,was well received and provoked livelydiscussion. On more familiar ground, DrJane Flint, National Clinical Adviser forCardiac Rehabilitation gave the KeynoteAddress on The Current and Future Statusof Cardiac Rehabilitation and the Role ofthe New Commissioning Guide, thesession was chairs by Graham Venn andProfessor Marjan Jahangiri, who is one ofour strongest advocates for CR. Allattendees received the recently publishedNational Audit for Cardiac Rehabilitation

Annual Statistical Report 2010. Ourdelegates came principally through theirinvolvement with their Cardiac Networks,but also from local self help groups and asmall group from the thoracic side. We hadno representatives from Scotland, Irelandor Wales, and none from Northumberlandor the East side of England right down tothe South Coast. However we had strongteams from the London area, Merseyside,Greater Manchester and Cheshire, and theBlack Country. The Society covers theMeeting side of the patient costs butdelegates are expected to arrange theirtravel and accommodation coststhemselves, and several patients weresupported in this respect by their ownhospital's Cardiac Surgery BenevolentFunds. As these Funds are invariablydonated by grateful former patients, thisseems to be an eminently sensible andcooperative development.

The majority of cardiac patientrepresentatives come to their new foundrole through their own involvement inCardiac Rehabilitation, and they are askeen as mustard to promote its value. The2010 Statistical Report mentioned above,is only of cheer to surgery patientrepresentatives, as the improvement intake-up of CR was only 3% in 2008-2009 to41% of all patients from the target groupsof heart attack, bypass surgery andangioplasty. As there was no improvementin the numbers of angioplasty and heartfailure patients taking up CR, this marginalimprovement derives from the continuingimprovement in the numbers of bypasspatients participating in CR that has risenagain to 76%. This is good news, but not

great news. Please remember when youare discharging your patients home, lookthem in the eye, and tell them straight,"your chances of survival are greatlyimproved if you join your local CR scheme.So, please, make sure you enrol!" It wouldbe a good idea if each surgical centre couldcheck out the arrangements for your in-hospital first phase of CR, and what formalarrangements are made for referringpatients to their local schemes ondischarge. Please keep up this good work.

This summer, the National Clinical Directorfor Heart Disease, Professor Roger Boyle isretiring. We first met at a ModernisationAgency (Heart) conference in 2001, andthen I was asked to become a Trustee onthe pilot project "Patient Choice in CardiacSurgery" in 2002, and later on the CardiacTask Force, and then the NationalProgramme Board. Roger Boyle has been agreat support to cardiac surgery and tocardiac surgeons and their clinicalcolleagues over these years, the resourcesto move forward in terms ofaccommodation, staffing, and facilities ofall description owe much to his efforts.Professor Boyle has always been a keenadvocate of the role of patient involvementin clinical practice in its widest terms, andhe has always seen the patient as thefocus of all we do. Members of the SCTSand their patients have benefittedenormously from his efforts.

It was pleasing to be asked to contribute aForeword to the Society's publication"Maintaining patients' trust: modernmedical professionalism 2011". Thisdocument is a demonstration of opennessand confidence that will inspire yourpatients, their carers, and the public atlarge. It was an opportunity for me, onbehalf of all of your patients, to express awarm message of thanks and appreciationto our surgeons and their teams for thelives that we now lead.

Warmest Regards,

David H Geldard MBE,

Patient Representative and ExecutiveBoard Member, SCTS, National PatientRepresentative for People with HeartDisease.

SCTS deserves praise for

arranging its third Patients'

Forum, and it is likely that this

is the only Forum for a cadre of

patient representatives at any

other medical or surgical

conference.

July 2011 19

In 2010, I was invited to write an articlefor the Association of Anaesthetists ofGreat Britain and Ireland (AAGBI) Group ofAnaesthetists in Training on how todevelop one’s CV for a career incardiothoracic anaesthesia. Writing thearticle gave me pause for thought. HereI was with single digit years betweennow and my retirement, so I could bepretty confident that it will be possible tocontinue working in cardiothoracicanaesthesia until then.

However, for someone entering the sub-speciality with maybe 30 odd years beforeretirement, is there actually a future forcardiothoracic anaesthesia and, if so, whatmight it look like and, moreover, should itbe recommended to trainee anaesthetistsas a lifetime career? When I was invited towrite an article for the Bulletin, I thoughtthat it might be valuable to develop thistrain of thought, given that cardiothoracicsurgeons may share some of the sameconcerns for the future, or at the very least,may wish some insight into themotivations of their anaestheticcolleagues who choose to stand on thecerebral side of the blood-brain barrier.Therefore, the aim of this article is toattempt to divine the future ofcardiothoracic surgery and anaesthesia, atleast in the UK.

Over the last two decades, there has beena burgeoning of cardiac surgery in the UKand this has generated jobs for surgeonsand anaesthetists. When I was appointedas a consultant in the early 1990s, it was asone of five anaesthetists undertakingcardiothoracic anaesthesia in the RoyalInfirmary of Edinburgh. Although not allare full-time in cardiothoracic anaesthesia,there are now thirteen consultants on therota. However, surgical activity peaked lastyear and our unit is contracted toundertake 10% fewer patients this year.Given this downward trend in surgicalactivity, combined with the worst recessionin living memory, the chances that postsarising from retirements will be re-appointed might seem slim and,potentially, cardiothoracic anaesthetistsmay even be seconded to work elsewherein the hospital.

Reduction in trainee servicecommitment

However, because of other currentpressures on the system, the prospects forfuture consultant appointments incardiothoracic anaesthesia may not be asgloomy as might first appear. TheEuropean Working Directive (EWD),combined with the decrease in anaesthetictraining posts, has made a big impact onthe work of consultant cardiothoracicanaesthetists. Anaesthetic trainees whowere once present at every cardiothoracicsurgery list are now often absent, as theyare on rest periods having done a night-shift or been working over the weekend.Therefore, consultant anaesthetists arenow usually working single-handed andthis has a major impact on turnover ofcases, never mind being not being able togo out for coffee, lunch or the rest room.Furthermore, at least in our unit, traineesare not available for critical care work suchas intra- and inter-hospital patienttransfers.

New ways of working

We are trialling a possible solution to thisproblem by scheduling a consultant on therota as the, euphemistically named,logistic consultant (also known as tea-boy)to do all the critical care scut work, letsingle-handed consultant out for coffee,lunch or rest room breaks and to help withthe turnover of cases. In addition,dedicated sessions for patients requiringgeneral anaesthesia for interventionalcardiology and electrophysiology havebeen created. These innovations have

ensured that optimum patient care hasbeen preserved, our consultant group hasmaintained its overall working hours andthere is no immediate threat to ournumbers. However, it remains to be seenwhether or not management will supportthis re-organisation in the future.

This may provide a potential template forsurgeons, although it is hard to envisionhow consultant cardiothoracic surgeonscould effectively cover for colleaguesduring surgery. Nevertheless, in Swedensome consultant cardiothoracic surgeonsactually work in pairs to overcome the lackof trainees to assist during surgery, somaybe a similar system will becomeroutine practice in the UK in the future.

As for the prospects for thoracic surgeryand anaesthesia, there appears to be noreduction in patients presenting forthoracic surgery. If anything, we aretackling more sicker and older patientsthan ever before and there is a steadyincrease in the number of patients withoperable secondary lung tumours. Itwould, therefore, seem unlikely thatthoracic surgery will decrease in theforeseeable future and the need forthoracic surgeons and anaesthetists willcontinue, or even increase.

Outside the world of cardiothoracicanaesthesia, I have recently proved that Ican still safely provide anaesthesia forlaparoscopic cholecystectomies, hippinning, varicose veins, etc, although, tome, it seemed very dull by comparison. Inaddition, most cardiothoracicanaesthetists have the knowledge andskills to move into general intensive caremedicine. For the, rightly, highlyspecialised cardiothoracic surgeons, it ishard to imagine them walking down thecorridor to work in a general, orthopaedicor vascular theatre without some majorinvestment in training in the respectivespeciality. For anaesthetists, theknowledge that, should the numbers ofpatients undergoing cardiothoracicsurgery fade away, one could always workin other areas of the hospital is a big safetynet for trainees entering the sub-specialityof cardiothoracic anaesthesia, and, sadly,one that cardiothoracic surgeons do notshare.

Quo vadis cardiothoracic anaesthesia?

Peter Alston,Edinburgh

is there actually a future for

cardiothoracic anaesthesia

and, if so, what might it

look like and, moreover,

should it be recommended

to trainee anaesthetists as

a lifetime career?

theBulletin20

Echocardiography

In the past, to be successful at aconsultant cardiothoracic anaesthetistappointment committee, evidence ofresearch in the form of published papers,or at the very least scientific presentationsat relevant meetings, would have beenessential criteria. The combination of“run-through” training and the paucity ofresearch now undertaken in cardiothoracicanaesthesia means that publishedresearch on trainee CVs are now onlydesirable. Echocardiography has nowreplaced research as an essential on anapplicant’s CV. Currently, one would behard pushed to appoint a trainee to aconsultant cardiothoracic anaesthetistpost without evidence of experience intrans-oesophageal echocardiography(TOE).

TOE is now such an essential tool for manycardiac operations, such as mitral valve

repair and for diagnosing failure to weanfrom cardiopulmonary bypass (CPB), thatfuture consultant cardiothoracicanaesthetists must be able to use TOE andinterpret the images they generate. Thiswill require formal training and thenaccreditation such as offered by the BritishSociety of Echocardiography or by theEuropean or US equivalents. The researchaspect of cardiothoracic anaesthesia wasone of the reasons that I was attracted tothe sub-speciality and I mourn itsdiminishment. However, I can onlyimagine that surgeons recognise theimmediate benefits to patient care ofhaving an anaesthetist who is skilled inTOE at the end of their table. In addition, Ithink there needs to be, and will be,greater development of echocardiographyin postoperative care, as it is such apowerful diagnostic tool for complicationsfollowing cardiac surgery. Furthermore, ifonly in the area of postoperative care, I

think that cardiac surgeons will also needto up their game and learn the practicalaspects of basic trans-thoracicechocardiography.

Intensive care medicine

Intensive care medicine (ICM) is anelephant in the room for bothcardiothoracic anaesthetists andsurgeons. Postoperative critical care isessential for cardiothoracic surgery and,although different models exist across theUK, historically, both anaesthetists andsurgeons have been integrally involved itsdelivery. When I trained in cardiothoracicanaesthesia, the cardiothoracic surgerytrainees spent many, many hoursmanaging patients after surgery andexperientially, gained a good knowledge ofICM. In recent years, the number ofsurgical trainees has been decimated andthey have been replaced by staff grade andassociate specialist (SAS) doctors. The

Quo vadis cardiothoracic anaesthesia? continued

July 2011 21

knowledge of ICM held by these SASdoctors is highly variable. Whilst some areexcellent, this is sadly not always the caseand, as a result, there are times when thestandard of patient presentations at wardrounds is less than optimum and there aresome nights on call when I sleep lesssoundly. However, without these SASdoctors many ICUs and HDUs would not bemedically staffed out-of-hours.

So is there an alternative to staffing thepost-operative critical care areas withSASs? Some units have managed to gettheir cardiothoracic critical care unitsstaffed with trainee anaesthetists.Personally, I do no see this as a good andsustainable model. To do this wouldrequire a large increase in the number ofanaesthetic trainees and this is notpragmatic as there is currently anoverproduction of anaesthetists with theirCertificates of Completion of Training (CCT)and many have no prospect of obtaining a

consultant post in the near future. I workwith many excellent nurses who have asuperb knowledge and experience ofcardiothoracic critical care and I wouldrather see an enhanced nurse-basedmodel of critical care for out-of-hours.

Whilst I believe nurses should have anenhanced role in the postoperative care ofpatients undergoing cardiothoracicsurgery, I have no doubt that it should bemedically led. However, should it be theanaesthetists or surgeons that providethat lead? As much as my surgicalcolleagues, at least the older ones, mighthave knowledge and experience of ICM forcardiothoracic surgery, unlikeanaesthetists, they have never beenformally trained in ICM. Whilst I am firmlyof the opinion that cardiothoracic criticalcare should be anaesthetically led, ICM isproblematic for future cardiothoracicanaesthetists as well. ICM has become aspeciality in its own right and obtaining

duel qualification and sufficient clinicalexperience in both cardiothoracicanaesthesia and ICM will be arduous anddifficult to achieve.

However, I would not wish futurecardiothoracic critical care units to be runby intensivists who have no experience incardiothoracic anaesthesia, asunderstanding what happens duringsurgery is fundamental to managingpostoperative care. For this very samereason, the input of surgeons intopostoperative critical care is essential foroptimal patient recovery. Over recentyears, the Association of CardiothoracicAnaesthetists (ACTA) has increasinglyrecognised the importance anduniqueness of critical care for patientsundergoing cardiothoracic surgery and hasset-up a Cardiothoracic Intensivists Group.In addition, it has, and will, run meetings

continued overleaf

July 2011 23

focusing on cardiothoracic critical care towhich all surgeons are most welcome toattend. Hopefully, anaesthetists andsurgeons will also have the opportunity toexplore ICM next spring at the first JointMeeting of ACTA and the SCTS inManchester.

Paediatric cardiac anaesthesia

The delivery of paediatrics cardiac surgeryis about to undergo major change inEngland as a result of the Safe andSustainable Review of Children’sCongenital Heart Services. In Scotland, weunderwent this process over a decade agoand Edinburgh lost out to Glasgow, whichbecame, sensibly, the single nationalcentre for paediatric cardiac surgery. Theproposals of the Safe and SustainableReview are out for public consultation butit seems clear that the number of centresundertaking paediatric cardiac surgery willshrink from 11 to seven or even six. Clearly,this is going to have a major impact on thelives of surgeons and anaesthetistsworking in the centres that close. If theywish to continue working in paediatriccardiac surgery or anaesthesia, they willhave to move to a centre that will remainopen. This may be extremely hard to do forthose with family ties and a developednetwork of friends. Some may choose notto move for these reasons and, asdiscussed earlier, this may be an easieroption for anaesthetists than for surgeonsbecause of their more readily transferableskills. Nor will it be easy for those thatwork in the six or seven centres thatremain. These will require major changesin infrastructure and organisation andamalgamation of personnel is unlikely tocome together completely smoothly.

Training

The final point I wish to address is thetraining of future cardiothoracicanaesthetists. In August 2010, the RoyalCollege of Anaesthetists (RCA) publishedthe new Curriculum for CCT inAnaesthetics. Cardiothoracic anaesthesiais one of the seven essential units forintermediate level training in SpecialityTraining (ST) years 3-4 and one of the fivefor higher training in ST years 5-7.However, in each case, the minimumrequirement is for four weeks and isdefined as 20 sessions. Potentially, this isfar less exposure to cardiothoracic

anaesthesia than current consultants incardiothoracic anaesthesia will haveexperienced in the equivalent periods oftheir training. However, in compensationthe Curriculum has cardiothoracicanaesthesia as one of the eight advancedunits of training in ST years 5-7 and atrainee can spend a maximum of one yearin a single unit or six months in each of twounits. One year in cardiothoracicanaesthesia might barely be enoughtraining for a consultant who does onlyanaesthesia. In our unit, the currentcombined impact of the EWD andreduction of trainee numbers meanstrainees are infrequently and erraticallypresent on elective lists and as a resulthave difficulty developing the skills andknowledge required to become aconsultant cardiothoracic anaesthetist,never mind being proficient in TOE orhaving advanced training in ICM. To methis points to the concept of a post-CCTfellowship or a junior consultant post togain sufficient clinical exposure to be asafe cardiothoracic anaesthetist. For thefew cardiothoracic trainees that remain, Ican see that they have the same problemof getting sufficient continuity of exposureto elective clinical surgery.

If the training of cardiothoracicanaesthetists is problematic, then it isdoubly so for paediatric cardiacanaesthetists. Indeed, this exact pointwas highlighted during the Safe andSustainable Review. Traditionally,paediatric cardiac anaesthetists came fromtwo different backgrounds depending onthe type of centre in which they weretrained. One group came from the majorpaediatric hospitals that undertookcardiac surgery and so came from thebackground of paediatric anaesthesia. Theother group came from cardiac centres thatundertook paediatric as well adult cardiacsurgery and so came from the backgroundof cardiothoracic anaesthesia. Clearly,both routes have their merits and demeritsbut there has not been a clear definition ofwhat curriculum is required to train apaediatric cardiac anaesthetist. TheAssociation of Cardio-ThoracicAnaesthetists (ACTA) has maderecommendations to the Royal College ofAnaesthetists (RCA) who will decide on thetraining requirements. However, it willclearly take post-CCT training, if not

mentorship of newly appointedconsultants. As a result of successfulpaediatric cardiac surgery, there will be anincreasing number of grown-ups withcongenital heart disease (GUCH) that willrequire revision of their heart surgery aswell as non-cardiac surgery and obstetricanaesthesia. Therefore, it is important thatfuture training produces cardiothoracicanaesthetists that are capable ofmanaging GUCH as well as paediatricsurgery. Indeed, this will also be true forsurgeons and the increasing number ofGUCH patients is also another reason to beoptimistic for the futures of bothcardiothoracic anaesthetists andsurgeons.

Conclusion

In medicine, one can never tell when thenext magic bullets will be found. Theremay be a cure for coronary artery disease,and even for lung malignancies, and thenthere would be no requirement forcardiothoracic surgeons andcardiothoracic anaesthetists. However, mydivinations into the foreseeable futurewould suggest that there will be enoughcardiac and thoracic surgery work to meanthat there will be a future forcardiothoracic surgeons andanaesthetists. Notwithstanding thatfuture, we share major challenges thatmust be addressed, most notably trainingthe future cardiothoracic anaesthetistsand surgeons, training anaesthetists andsurgeons in echocardiography and how tostaff and run cardiothoracic critical careunits. Finally, it is fitting to end with aquote from Niels Bohr (1885 – 1962) “Prediction is very difficult, especially if it’sabout the future”.

R Peter Alston,

Consultant Anaesthetist,

Royal Infirmary of Edinburgh.

Quo vadis cardiothoracic anaesthesia? continued

theBulletin24

There has been a steady increase in usageof bioprosthetic valves in UK and acrossthe globe. The cut-off age for implantationof a bioprosthetic valve has also beenlowered from 70 yrs to 60 yrs in NorthAmerica. We have seen a similar trendacross cardiac centres in UK withincreasing number of patients preferring abioprosthetic valve over a mechanicalvalve due to issues with anticoagulation.With time, a bioprosthetic valve isexpected to degenerate and eventually fail.Thus, patients who are undergoing abioprosthetic valve implantation today willpresent in their 80’s for a reoperation. Untilnow, reoperation has been the onlypossible treatment though it carries asignificant risk. The STS risk calculatorpredicts that an 80-year old man with nocomorbidities has an approximatemortality risk of 5%, while his EUROSCOREis 14%. These risks increase dramatically inpresence of comorbidities which are notuncommon at this age.

Transcatheter aortic valve implantation(TAVI) has recently been established as afeasible alternative to conventional valvesurgery for the management of high-riskelderly patients with aortic stenosis. TAVImight also present an attractive option forpatients with failing bioprosthesis as a‘Valve-in-Valve’ procedure.

‘Valve-in-Valve’

Success of TAVI is dependent on

1. Choosing the correct size of theprosthesis in relation to the native aorticannulus diameter and,

2. Correct positioning across the nativeaortic annulus.

Edwards Sapien valve is currently availablein 3 sizes (23, 26 and 29mm). Correctchoice is dependent on the aortic annulusdiameter. Sizing is generally performed onTOE. Recommended sizes for a Sapienvalve are as follows:

Sapien Valve Size Annulus size on TOE (mm)

23 18 to 2126 22 to 2429 25 to 27

Sizing is operator dependent; experienceguides choice in cases with borderlineannulus diameters. This is important aschoosing a smaller device can lead toembolisation or significant paravalvularleak and a bigger valve can lead to annularrupture. Similarly, correct positioning ofthe device is of paramount importance toavoid coronary obstruction or embolisationin the aorta if it is placed too high orembolisation in the ventricle if it is placedtoo low. Positioning can be especiallytricky in patients with poor calcification asvisualisation of the hinge points is difficult.

However, in a stented bioprosthesis, theseanxieties are taken away as one knows theinternal diameter of the bioprosthesis andthe radio-opaque stents provide excellentmarkers for perfect positioning of the TAVIdevice.

Sizing:

Prosthetic heart valves are labelled by theirexternal diameter but their internaldiameter varies by manufacturer, modeland size (Table)

Size Type Stent Internal dia.(mm)

21 Perimount 20

Mitraflow 17.3

Mosaic 18.5

23 Perimount 22

Mitraflow 19

Mosaic 20.5

Thus it is of paramount importance toconfirm the internal diameter and thenchoose the appropriate device; eg. a 21mmbioprosthetic valve with an internaldiameter of 17.3 mm may not be an idealcase to be treated with a 23mm TAVI deviceas it will lead to under expansion of theTAVI device and also leave the patient withhigh residual gradients (Russian dolleffect). Future availability of a 20mmdevice will allow us to treat such patients.

We also recommend confirming theinternal diameter with TOE as bulkyleaflets and pannus can further narrow theinternal diameter. For example, we recentlyimplanted a 23mm valve in a patient with a25 Mosaic valve with an internal diameterof 23 mm, which on TOE was 21.5 mm dueto pannus.

Positioning:

Majority commercially availablebioprostheses have radio-opaque markers.It is important to achieve fixation withinthe annular ring of the bioprosthetic valveas stent posts can be easily displaced byradial force applied during implantation ofthe device. We recommend at least 10% ofthe device to be below the annular ring(Figure). Rapid ventricular pacing andslower deployment is the key to achievinga satisfactory position.

Advances in TAVI:‘Valve-in-Valve’ Implantation for failed Bioprosthetic valves

Mr. Vinnie (Vinayak) BapatConsultant Cardiothoracic Surgeon

Guy’s and St. Thomas’ Hospital, London

A - Fluoroscopy image of a 29Perimount and a 29 Sapien valve

B - Fluoroscopy image of 29 Sapieninside a 29 Perimount valve

July 2011 25

Stentless valves:

This also includes homografts and variousstentless valves, which have beenimplanted in the last decade. Valve-in-valve in a stentless valve is challenging andshould be undertaken by an experiencedteam. The majority present with aorticregurgitation, have minimal calcificationand have no radio opaque markers. Thusadequate fixation of the TAVI device reliesentirely on over-sizing of the device andpositioning needs to be aided by TOE and adistal marker, such as a guidewire in theleft main. Coronary obstruction is a

possibility as the suture lines may be veryclose to the coronary ostia and/or due toover-sized device required in these cases.

Guys and St. Thomas’experience:

We have performed 15 cases of ‘Valve-in-valve’ with no mortality and satisfactoryresults in all. Of these, 10 patients had astented bioprosthesis and 5 patients werestentless valves (2 homografts). One ofthese patients is a 29 year old with a 29Perimount valve who has had 4reoperations from the age of 8 months on

his aortic root. He underwent a 29mm valve-in-valve procedure using a Sapien valve andwas discharged home on the 4th day.

Cases have also been performed fordegenerated bioprosthesis in mitral,tricuspid and pulmonary positions. Withincreasing experience we are likely to see agrowth in ‘Valve-in-valve’ usage in ourclinical practice.

Mr. Vinnie (Vinayak) BapatConsultant Cardiothoracic SurgeonGuy’s and St. Thomas’ Hospital, London

C - Bench test of 29 Sapien within a 29Perimount ‘side view’

D - Bench test of 29 Sapien withina 29 Perimount ‘top view’

E - Valve in valve ‘Mitraflow’.

Prize Winners

Society Thoracic Medal for bestthoracic presentation:

Operative Surgical Training in GeneralThoracic Surgery: Transitions in TraineeStructures and Training Models

Presenter: Kirsten Morgan Bates Co-Authors: O.A. Jarral, Z. Sarang, G.Ladas, M. Dusmet, S. Jordan, E. Lim

The Royal Brompton Hospital and ImperialCollege London

Ronald Edwards Medal for best cardiacclinical presentation:

Intracellular Calcium Handling in DonorHeart: Comparison of DCD andBrainstem Dead Donor Hearts

Presenter: Fouad. J. Taghavi Co-Authors: A. Ali, C. Woods, S.R. Large, E.Ashley

Stanford University Hospital, USA andPapworth Hospital, United Kingdom

John Parker Medal for best scientificpresentation:

Effect of NormothermicCardiopulmonary Bypass on RenalInjury in Paediatric Cardiac Surgery: aRandomized Controlled Trial

Presenter: Nishith PatelCo-Authors: S. Bays; A. Pawade A.Parry; S. Suleiman; G.D. Angelini; M.Caputo

Bristol Heart Institute, University of Bristol

Society Cardiothoracic ForumMedal, Joint Winners for best forumpresentation:

Reflection on the Implementation of aNurse Practitioner Training Programmein a Large Cardiothoracic Surgical Unit

Presenter: Sandra LaidlerCo-Authors: F. Thompson; L. Clarke; R.MacFarlane; S. Naden; G. Newberry; S.Stamenkovic; S. Clark

The Freeman Hospital, United Kingdom

and

Minimising Patient Morbidity – TheNext Challenge for CardiothoracicSurgery

Presenter: Charlene Tennyson Co-Authors: D.J. McCormack; S. Ibrahim;P. Lohrmann; A.R. Shipolini

The London Chest Hospital, UnitedKingdom

Winner of the Student PosterPresentation

Should double lung transplant beperformed with or withoutcardiopulmonary bypass?

Presenter: Myura Nagendran

University of Oxford, Supervised by DTaggart, John Radcliffe Hospital.

Winner of the CT Forum prize:

Developing a Multidisciplinary ComplexPre and Post Operative Intervention toReduce Complications and EnhanceRecovery after Lung Resection Surgery.

M.Z. Abdelaziz; A. Bradley; P. Agostini;K. Nagarajan; E. Bishay; M.S. Kalkat;R.S. Steyn; P.B. Rajesh; B. Naidu

Birmingham Heartland Hospital, Heart ofEngland NHS Foundation Trust, UnitedKingdom

The CALS Course goes international

theBulletin26

It’s been a busy year for the CALS(Cardiac Surgery Advanced Life Support)course. Last year saw us help theEuropean Resuscitation Council rewritethe official recommendations forresuscitation of patients after cardiacsurgery to the way that we teach it andto conform to the official EACTSguidelines on this subject that we helpedpublish in 2009.

Admittedly it was not given very highprominence in the ERC guidelines, beingon page 1417 of the special circumstanceschapter, but nevertheless our course nowteaches the official way to resuscitatesomeone who arrests after cardiac surgery.But following the publication of theseguidelines and our live demonstration atthe EACTS conference, interest hasexploded this year.

We were invited to Geilo in Norwaywhere we sent a team of 4 peopleto demonstrate the protocol totheir national conference. Thenonly 3 weeks later we sent another5 people to Hungary to performtheir first course too. St. James' inDublin is now running its owncourses and we just sent a singleperson and a dummy there to helpout. This was in addition to

national courses in Wolverhampton and StGeorges this year and two overseasinvitations at the end of last year to Syriaand Iran of all places ! Then 3 of us went tothe USA to America's National Conferencefor Critical Care nurses in Chicago while therest of you were watching the RoyalWedding. This was a real eye opener. Thisis a conference of 7,000 critical carenurses. We ran 2 one day courses with 32people booked onto each day. Butthroughout both days people kept comingalong saying they couldn't get booked inas it was full so quickly and could theywatch.

Two things really struck us in the USA.Firstly the nurses were outstandinglycompetent and had the knowledge of post-operative management of a patientequivalent to a competent 3rd or 4th yearregistrar here. The second thing that stood

Editors:

Duthie D and Swanevelder JThe lecture series are packaged into two DVDs.

One DVD covers the accreditation course. It consists of18 lectures and an abstract book. The other DVDcovers the advanced course. It consists also of 18lectures, an abstract book and mock exam. Eachlecture lasts 20 minutes.

The accreditation lectures are comprehensive incovering all aspects of transoesophagealechocardiography examination. It starts with basicphysics and standard views; and end with prostheticvalves and congenital heart disease.

The advanced course dealt with a number of clinicalscenarios, offering useful practical tips; and newimaging techniques and technology. I particularlyenjoyed the lectures on diastolic dysfunction and

tissue doppler imaging. The talk on emergencyechocardiography in ICU is both informative andentertaining. The mock exam will be of interest to anyprospective candidate.

The lectures are delivered by a number of speakers.Therefore there are variation in style and somerepetition. The DVDs are in Macromedia format. Thisprogram does not allow full screen viewing on thecomputer. As a result, the labels/numbers on someslides were difficult to read.

Overall the DVDs are excellent resource material eitheras standalone or to complement other textbooks. I canrecommend them to both novice and intermediatetransoesophageal echocardiography practitioners.

Julian Wang

Edinburgh Royal Infirmary

The EACTA Lecture Series ofPerioperative Echocardiography

July 2011 27

out was the reason that they were so good.They were mostly very senior nurses whoran their units, but in contrast to the hugeAmerican units that we hear about at theconferences, many of them worked in oneof the 1,250 units in the USA that weremuch smaller. Many had only 2 or 3 fulltime surgeons and no resident surgeonsovernight. They managed all the post-operative care with the surgeon on the endof the phone. There were also, in mostcases, no resident cardiothoracicanaesthetists. Thus the nurses had tomake most of the bigger decisionsovernight themselves and were routinelyused to starting inotropes, bringing incardiologists to do echos, and even puttingin balloon pumps if they were nursepractitioners.

The horrifying thing was that most of themhad a story or two of arrests due totamponade where they just massaged forhalf an hour or longer while the surgeon

came in, uniformly with theexpected outcome. It doesseem like a scandal waiting tohappen out there. I was in factsurprised that no savvylawyers have got a hold of thisfact and asked the question'what would have happenedto my client's father had thetamponade been relieved in 3minutes rather than 30minutes'. But it seems thatthe expense of residentsurgeons for this rare eventmeans that they will never be

able tochange theirsystem tor e s i d e n ts u r g e o n s ,hence the verylarge interestin our coursethat trains thepeople by thebedside torespond fullyto the arrestand ifn e c e s s a r yreopen thechest.

So all of us involved in CALS are looking tothe future wondering how we are going tomanage getting to all these trainingvenues. We are in active discussions withthe ERC to come under their umbrella as anofficial ERC course which will remove our

current 'back of theenvelope' status wherewe deliver the course asa group of enthusiasticsurgeons, anaesthetistsand nurses. Instead thiswill be replaced byofficial ERC CALSTrainers and will comewith all the benefits of

being under this organisation. We hopethat this will be a reality by the end of theyear or early next year. Thus if you arereading this article and you fancybecoming a trainer then please get intouch. We always need more people toteach. We have now performed 31 coursesincluding 13 in-house courses, having been

invited into units who want to performbetter in this emergency situation. Weneed lots of good people who can spreadthe word and who hopefully will becomethe first group of ERC CALS Trainers. If youare more junior and want to come on acourse then we do have several courses foryou too this year.

To find out more, visitwww.csu-als.com or look for us on facebook atwww.facebook.com/group.php?gid=115765272129&ref=mf

Joel Dunning

www.ctsnet.org/home/joeldunning

Joel Dunning

Dear SCTS Member

RE: VATS Lobectomy Training Proctorship at St George’s Hospital London

It is with great pleasure that we announce the first Vats Lobectomy Proctorship

at St George’s Hospital London, the aim of this programme is to provide support

and assistance to thoracic surgeons who wish to undertake VATS lobectomy.

We are delighted that Mr Ian Hunt and Ms Carol Tan have agreed to facilitate this

training.

Briefly the training plan will encompass onsite sessions for surgeons and theatre

personel at St George’s Hospital and then offsite training when the surgeon

returns to begin operations at their own centre.

This training will be supported through the professional education department at

Ethicon Endo-Surgery.

For further information please contact Mr Ian Hunt at [email protected]

or for an application please contact myself on any of the details below.

Kind Regards

Ross Campbell

Product Manager - Stapling

Ethicon Endo-SurgeryPart of the Johnson & Johnson Family of CompaniesJohnson & Johnson Medical LtdPinewood Campus, Nine Mile RideWokingham, Berkshire RG40 [email protected]: +44 (0) 1344 864165Mobile: +44 (0) 7770 333878

29July 2011

Although all the surgeons involved inpaediatric cardiac surgery are very awareof the current review, we realised thatadult cardiac and thoracic surgeonswould not necessarily know what washappening.

Background

In the late 1970s, when the specialty wasexpanding, there were discussions aboutthe need to limit the number of units tomaintain a critical throughput of cases. Inthe 1980s we had “supra-regional” fundingfor neonates and infants – to try and limitthe number of centres undertaking cardiacsurgery. However, no politician had thecourage to use this tool to achieve the aimof larger centres. It is sobering to reflectthat had they done so, “Bristol” wouldprobably not have happened.

In 2001, in the final “Inquiry” Report, SirIan Kennedy’s panel made 198recommendations, only 7 of which werespecific to paediatric cardiac surgery.Three of these related to the need forlarger centres / bigger throughput. Thesewere ignored.

In 2003, Jim Monro (then President ofSCTS) chaired “Paediatric and CongenitalCardiac Services Review” – the Minister“was not minded” to accept the mainrecommendation to have larger (andtherefore fewer) centres.

In 2006, Roger Boyle convened a meetingof representatives of all the units at theDepartment of Health. The unanimousconclusion was that something had to bedone – maintaining the current number ofunits was not a viable option.

Meanwhile things were occurring in unitsaround the country which createdinstability in the surgical service – illness,emigration and retirements. The ExecutiveCommittee of SCTS asked the thenPresident (Bruce Keogh) to write to theMinister to highlight the problem. As youknow, Bruce was subsequently appointedto the post of NHS Medical Director and hisfirst task (the Minister gave Bruce theletter he had written from SCTS!) was topersuade the NHS Management Executivethat change was necessary.

So was born the “Safe and Sustainable”review.

The Review Process

Paediatric cardiac surgery is currentlycommissioned at regional level - eachStrategic Health Authority has a specialistcommissioning panel. The chairs of each ofthese 10 panels became the JCPCT (JointCommittee of Primary Care Trusts) – this isthe body with the legal responsibility tomake the decision on the futureconfiguration of the service. An advisory“Steering Group” was established, chairedby Patricia Hamilton, past President of theRCPCH and comprising parents andprofessional representatives: thePresidents of SCTS, BCCA (BritishCongenital Cardiac Association – thePresident elect was also included) andPICS (Paediatric Intensive Care Society)

and nominees from ACTA, the RoyalCollege of Nursing, the RCPCH (RoyalCollege of Paediatrics and Child Health).There was no question of individual unitsbeing represented. Additionally a surgicalBCCA member was co-opted in view of hisexperience in three nationallycommissioned services includingtransplantation and ECMO.

Although the review was asked to focus onpaediatric cardiac surgery, the SteeringGroup were aware of the need for aconsistent approach with the standardsfor adults with congenital heart disease(ACHD / GUCH) that were published in2009 by a separate working group, and soan ACHD representative was co-opted.

The Standards

The first task wasto set the proposedstandards for theservice in thefuture – a“ S t a n d a r d s ”working group wasestablished withwide representation and chaired by BillBrawn. The aim was to achieve the highestquality care. See: www.specialisedservices.nhs.uk/document/paediatric-cardiac-surgery-standards The key infuture will be that care will be provided by“managed clinical networks” with thesurgical centres being responsible for thequality of care within their network.

It will not surprise you that the mostchallenging standards on which to agree aconsensus were the number of surgeons ina unit and the minimum number ofpaediatric cases. The number of surgeonswas relatively easy – to allow for leave, 7day working for urgent cases, mentoring ofnew appointees and succession planning,4 are necessary.

The number of cases was morechallenging. Looking at a number per weekto maintain skills, three was the magicnumber. Over a 43 week working year, thisequates to 129 – remarkably similar to the125 recommended by EACTS some yearsago. Thus 500 per unit. However this couldhave meant about 5 units in the country,thus reducing access for many families. Inrecognition of this a minimum of 400paediatric cases was set, accepting that inmost centres the same surgeons wouldalso be doing some adult congenitalsurgery. Another influencing factor was tolook at the units around the world that weregard as “centres of excellence” – theones to which we send our trainees. Alldoing at least 500 and most in fact doingmuch more. There is also increasingevidence in the literature (an independentliterature review was commissioned) inmany surgical specialties (includingpaediatric cardiac surgery) of a positiverelationship between volume andoutcome. In our field this is especially thecase in neonatal cardiac surgery.

The “Safe and Sustainable” Review of Paediatric Congenital Cardiac Services in England

Leslie Hamilton

continued overleaf

The number of cases

was more

challenging. Looking

at a number per week

to maintain skills,

three is the magic

number.

theBulletin30

Accepting that there is no cut-off numberfor improved outcomes in paediatriccardiac surgery, most authors concludethat volume is a surrogate marker forquality of care. A major advantage ofbigger centres is that they would have asimilar case mix and this would allow amore robust statistical comparison ofoutcomes (we do not currently have anaccepted method of risk scoring equivalentto EuroSCORE).

Sir Ian Kennedy then led a panel of clinicalrepresentatives to visit and assess everyunit against these standards - both howthey fare now and how they could achievethem in future (NB: surgical outcomeswere not part of the assessment). Thepanel gave each unit a composite score.Not surprisingly some have interpretedthis as a league table with this novel,subjective score being an absolute markerof quality.

External Review

Any major change in the NHS comes underscrutiny by a number of bodies – all havebeen supportive of the process. Inparticular the National Clinical AdvisoryTeam (NCAT) said: “it is not acceptable todo nothing”. Also: “using a figure of aminimum of 4 surgeons per unit as anabsolute minimum does make sense..”They concluded: “NCAT can support the

case for reconfiguration of paediatriccardiac surgery, reducing the number ofcardiac surgery centres.”

Possible Configurations

After prolonged deliberation and takinginto account a wide range of issues, theJCPCT came out with 4 possibleconfigurations for public consultation– twowith six centres and two with seven. All ofthe centres currently undertakingpaediatric cardiac surgery are in at leastone of the options. All of the configurationswere based on the proposal to have 2centres in London: at Evelina (St Thomas’)and Great Ormond Street (supporting theindependent proposal to merge the currentunits at GOSH and the Royal Brompton).

Monitoring outcomes

Although we have the best monitoringprocess in the world for congenital heartservices, commissioners have (quiterightly) really pushed the steering group tothink about how the current system can beimproved. This is not an easy task, butthere is agreement on the need toimplement real-time alert systems insurgical units and a need to collect,analyse and report on meaningfulmorbidity data. This would be trulyground-breaking, and easier to achievewith larger units.

Summary

By the time you read this, the publicconsultation will have ended on 1 July,coinciding with the 10th anniversary of thepublication of Sir Ian Kennedy’s reportfollowing the Bristol inquiry.

Public events have been held in all parts ofthe country, both to listen to the views ofparents, patients and staff and to explainthe process. Clinical members of theSteering Group have fronted these events.The results of the consultation process willbe collated by Ipsos Mori and presented tothe JCPCT in the autumn. A decision willthen be made with implementationplanned by 2013.

But then the really difficult work begins! In2009 Bruce Keogh called upon surgeonsand others to set aside their personalinterests for the greater good of thechildren of this country. He suggested thatfailure to reconfigure children’s heartsurgery this time around would be a ‘stainon the soul of the specialty’.

Some countries have already gone throughthis process. Others know they need to doso and are watching! Further details of theReview can be found at:w w w. s p e c i a l i s e d s e r v i c e s . n h s . u k /safeandsustainable

Leslie Hamilton

Review of Paediatric Congenital Cardiac Services in England continued

Save the Date

Joint Meeting

ACTA - SCTS

Manchester Central

18 -20 April2012

A D V A N C E N O T I C E

Association forCardiothoracicAnaesthetists

Society for Cardiothoracic Surgeryin Great Britain and Ireland

July 2010 31

SCTS welcomes the opportunity tocomment on the proposed NICEGuidelines for stable angina. From theoutset SCTS would emphasise that itstrongly supports the NICE principles andprocess. While the guidelines areextensive, covering 456 electronic pages,SCTS will confine its remarks to thosesections dealing with recommendationsfor revascularisation interventions.

The most striking feature of the proposedNICE recommendations are that theirrecommendations for revascularization arein almost direct opposition to those of themost definitive contemporary guidelineson revascularization from Europe, whichexamined the same evidence base as NICE.Furthermore, and as detailed in theaccompanying document, the Europeanguidelines were recently strongly endorsedin a Heart editorial from the respectivePresidents of the British Cardiac Society,the British Cardiovascular InterventionSociety, SCTS and the National Director forHeart Disease and Stroke.

On review of the proposed NICErecommendations SCTS have a number ofconcerns, including omission,misinterpretation and misrepresentation

of crucial data at odds with NICEconclusions. Of greatest concern,however, is the NICE proposal, statedunder ‘Key Priorities for Implementation’that in effect an individual cardiologist canconsider PCI even for any three vessel andleft main disease if they, alone, considerthe ‘anatomy suitable’. This is not only atodds with the best available evidence(while simultaneously undermining theprinciple of the multidisciplinary team) butSCTS also believes that this is a potentiallydangerous recommendation.

Accordingly SCTS does not support theproposed NICE guidelines in their currentformat but would propose a complete re-writing of the revascularizationrecommendations and preferably in a moreobjective fashion.

In view of our concerns we have copied thisletter to Sir Andrew Dillon (ChiefExecutive), Sir Michael Rawlins (Chair ofNon-Executives Directors), Prof RogerBoyle (National Director for Heart Diseaseand Stroke,) Dame Sally Davies (ChiefMedical Officer NHS) and Professor SirBruce Keogh (Medical Director NHS).

Kind regards

SCTS RESPONSE To Proposed Nice Guidelines

NICE Stable Angina

Guideline Committee

SCTS does not supportthe proposed NICE

guidelines in their currentformat, but would

propose a complete re-writing of the

revascularizationrecommendations and

preferably in a moreobjective fashion.

New AppointmentsName Hospital Specialty Starting Date

Kandadai Rammohan Wythenshawe Hospital, Manchester Thoracic February 2011

Choo Ng Papworth Hospital, Cambridge Adult Cardiothoracic 2011

Haralabos Parissis Victoria Hospital, Belfast Cardiothoracic May 2011

Narain Moorjani Papworth Hospital, Cambridge Adult Cardiothoracic June 2011

Eveline Internullo Nottingham City Hospital, Nottingham Thoracic July 2011

Other AppointmentsRam Dhannapuneni Alderhey Hospital, Liverpool Locum Consultant November 2010

Paediatric Cardiac

Ajay Moza Harefield Hospital Locum January 2011 Cardiac Transplant

Natasha Khan Birmingham Children’s Hospital February 2011 Locum ConsultantPaediatric Cardiac

DP Taggart

J Roxburgh

G Cooper

M Dalrymple-Hay

C Bannister

T Bartley

B Bridgewater

J Duffy

B Evans

D Geldard

M Jahangiri

S Kendall

S Livesey

N Moat

S Ohri

J Pepper

R Shah

S Westaby

I Wilson

At an ‘open day’ held by the Guy’s and St Thomas’ thoracic unita visiting physician asked why the peripheral minor thoracicsurgical service at her hospital had ceased. As I think I was thelast thoracic surgeon in England to have provided such a serviceso I thought it appropriate to set out the history of theseperipheral lists and explain why they no longer exist.

For decades it had been possible for chest physicians to put theirpatients on a thoracic surgical list and have minor investigative ortherapeutic procedures carried out at their local chest hospital.The patients benefited in that they did not have to travel to amajor hospital. Also they had continuity of care as they remainedin the same chest physician’s bed after their procedure that theywere in beforehand. The physicians benefited because they knewimmediately what had happened to their patients. Thepathologists enjoyed seeing material otherwise the province of ateaching hospital and the anaesthetists benefited because theycould practice and teach in an attractive specialist field. So whatwent wrong? Why cannot the modern NHS offer such a service?Let us look at the history.

Until the discovery of effective antituberculous chemotherapy inthe late 1940s TB made up a large component of a thoracicsurgeon’s workload, lung cancer then being relatively uncommonand there were a large number of TB sanatoria throughout thecountry. The mainstay of treatment of pulmonary TB then was to‘rest’ the lung, usually by collapsing it in one way or another. Thesimplest was to induce an artificial pneumothorax, the mostcomplex was to perform a five rib thoracoplasty. This wasperformed under local anaesthesia! Thoracic surgeons would visitthese outlying sanatoria and perform a wide range of surgicalprocedures, including thoracoplasties. Nowadays thoracoplasty,rarely performed, is considered a major procedure andanaesthetists often stipulate that an intensive care bed beavailable.

As TB declined in incidence so the sanatoria closed or becamegeneral hospitals. The peripheral minor thoracic lists with theirvisiting surgeons continued though much of the work wasassociated with investigating lung cancer and treating morecommon chest problems such as empyema or pleural effusion.From the mid 1950s Robert Brain, consultant thoracic surgeon at

Guy’s, used to go down to Bevendean Hospital in Brighton once aweek and carry out up to twenty operations in a morning, albeitmany were rigid bronchoscopies under general anaesthesia.When he retired in 1980 I was appointed as his successor andcontinued his practice of a Tuesday morning operating list, a lunchtime chest conference and an afternoon out-patients. Thepatients from the Brighton, Worthing and Haywards Heath areaswere thus spared from coming up to London for relatively minorprocedures. Furthermore they remained under the care of theirchest physicians who had looked after them up to the operationand would continue to look after them following surgery, truecontinuity of care. Bevendean Hospital eventually closed and in1986 the chest unit moved to Hove General Hospital but this tooclosed in 1997 and finally the thoracic list ended up at BrightonGeneral Hospital where it ceased in October 2003. For historicalreasons the operating list was always referred to as ‘thebronchoscopy list’ even though thoracotomies were notinfrequent and bronchoscopies became the province of the chestphysicians. Biopsies using image intensification and of courseVideo Assisted Thoracic Surgery (VATS) were all embraced as theybecame available. Oesophageal procedures included balloondilatation for achalasia and feeding gastrostomies. Major surgicalcomplications were very rare.

Why did this apparently successful system end? As always thecauses were multifactorial, though changes in doctors’ workingpractices were probably the most important. For many yearsthere had been a clinical assistant, later associate specialist, whowas an excellent doctor, and he appeared to be there all the time,partly because he lived with his family in hospital residentialaccommodation, now also a thing of the past. Thus when thesurgeon went down to do the list he would take him round andshow him all the patients. His clinical acumen was astoundingand we respected his judgement about suitability for surgeryalmost unquestioningly. He had been there a long time and hadseen a lot. Inevitably and deservedly the chest physiciansacquired two SHOs which meant that it was possible that the SHOon duty on the day the surgeon came may not have been the onewho admitted the patient the day before.

For most of the history of the thoracic surgical service it was tacitlyunderstood that patients for that list would be given priority of

admission over other non urgentpatients. This seemed sensible, thesurgeon only came once a week andthe conditions needed promptinvestigation or treatment. Howeverthe pressure on beds in Brightonworsened progressively with the resultthat patients’ admissions werefrequently cancelled or they may beadmitted late in the evening when abed did finally become available. As aconsequence of the further reduction in

The demiseof a thoracic surgical service

theBulletin32

Bevendean Hospital, 1963

July 2011 33

junior doctors’ hoursthey would thenprobably be admittedby a doctor from acompletely differentdiscipline.

Furthermore, theadmitting SHO couldnot obtain informedconsent from thepatients as thedoctor obtainingconsent has to befully conversant withthe procedure and inparticular the risks.This meant thatinstead of goingdown to Brighton and

finding fully clerked, consented and informed patients with alltheir investigations I would have first to find the patients, thentake a history, examine them, assess their CT scans etc. andobtain consent. Additionally they could not be given a premedbefore all this had happened. The pressure on the surgeon, andparticularly the anaesthetist was enormous especially bearing inmind that the patients by definition had chest disease and manywere frail and some extremely sick.

As already mentioned, this was an ‘open access’ list, i.e. referringconsultants could send in patients unseen by the surgeon whowould take these patients on trust. This worked well when thepatients were referred by experienced chest physicians butpatients were also sent in from other sources. Despite a rule thatall patients should be discussed ‘consultant to consultant’ thesystem was abused and with the absence of dedicated junior staffthere was no gatekeeper. Critical information was oftenconcealed, in particular the fact that a patient had ClostridiumDifficile or MRSA. The arrival of such patients on the chest wardplaced an intolerable burden on the staff, let alone the clinicalrisks they engendered. Patients would also arrive without vitalinformation such as their X rays or CT scans. Sometimes thepatients were given totally erroneous information by theirreferring doctor, for example a patient being sent for a VATSpleurodesis for a complex pneumothorax being told that theywould be out of hospital the same day! It would have been easyto turn many of these patients away but they had often waiteddays or weeks in their referring hospital prior to transfer and for

many their future woulddepend on the outcome of theinvestigations or procedureswe performed.

Given all these problems it isamazing that the servicecontinued for as long as it didand the only reason it was ableto do so was because the staffinvolved had worked togetheras a team for many years. Allwere very experienced. I hadbeen a consultant thoracicsurgeon for twenty years, andthe consultant anaesthetist was exceptional, not only inanaesthetizing some desperately sick patients but in his clinicalacumen and preoperative assessment. I had great respect for hisopinions, especially on the advisability of anaesthesia and thesurgery. The theatre nurses had worked as a team for manyyears, so as long as the key personnel were present we felt it safeto continue and in fact we had no major mishaps. But it was withrelief that I performed my last operating list in Brighton notsadness.

During this period the facilities and expertise at Guy’s hadincreased enormously so that parallel with the justifiabledevelopment of a risk averse culture in medicine it becameinevitable that the list should cease in Brighton and the patientstreated at Guy’s. This trend of closing small units and movingpatient care to large centres is of course occurring throughout theNHS though it is not universally popular with the public.

Last, the unsung heroes of this story of peripheral thoracicsurgical lists are the chest physicians who have looked after thepatients before and in particular after surgery. Their expertiseand commitment to the care of these patients combined with awillingness to sacrifice their beds has been fundamental. I knowthat they are saddened to have lost their surgical service but inthe end the patients, given the changing circumstances ofspecialist surgery, while being inconvenienced should benefitfrom the improved facilities of a major thoracic centre.

Jules Dussek

Robert Brain, Alan Yates, Donald Ross

The SCTS Serves who first?

theBulletin34

The patient is at the center of ourattention as doctors and surgeons but dowe involve them in the design anddecision of their patient specific pathway.Web based information reflecting theSafety and Efficacy of our work isempowering and enabling our patients tomake choices.

Very soon sites likewww.iwantgreatrcare.org will enablepatients to rate their Experience. They willbe able to comment on how you deliveredyour service - that will include elementslike meet and greet and how well youconveyed information. This will challengeour thinking and ask us to re evaluate ourrole and relationship with the patient. Thissame applies to the Cardiologist who todate has been perceived as the gatekeeper and to the GP who is very likely tobe commissioning our services in thefuture (no firm decisions are made as yet).We need to, as individuals, teams and as aSociety, working with the Cardiologist andthe GP, help our patient through atransparent and evidence based decisionprocess without the biases and heuristicsintrinsic in a one to one consultation.Decision theory and consent guidelinesadvocate the best way to meet theseobjectives is to include the patient in aMDT process.

The 2011 Annual General Meeting Societyof Cardiothoracic Surgeons of Great Britainand Ireland, held at the Excel Centre inLondon was a triumph. The Society yetagain, demonstrated its ability to lead inmany areas and received an unqualifiedendorsement from the Secretary of Statefor Health. Our Society is nationally andinternationally recognised for ourpublications and patient involvement. Ourleadership has to be applauded. However,there are going to be many challengesahead as outlined by our ex-President andour MD of the NHS, Professor Sir BruceKeogh. Many of the presentations at theSociety, demonstrated that units andindividuals are tackling many of thesechallenges in creative ways through

various innovative practices.

The National Health Service is now over 60years old. However, the way we havedelivered our practice over that time hasnot changed and the plant in which weoperate is the same. The NHS suffers from“Structuration” - a consultant of 1948would not feel out of place in a hospital in2011. We continue to tinker and fix thenoun “health” but we have not focused onthe operative word “service”.

Service is summarized in the 6 E’s’

• Efficacy

- Do the Means work?

• Efficiency

- Amount of work divided by theresources

• Effectiveness

- Is it meeting the long term aim?

- What is our failure rate over time?

• Experience

- Is the patient delighted?

• Ethical

• Elegant

The surgery we offer is Effective, Ethicaland in many cases Elegant but are weEfficient, Effective and do we really monitorpatient Experience.

There are two essential pillars of a goodservice industry. The first is based oncomprehensive real time data. Our data isgood but does it inform the process andflow and experience of the patient? Thesecond is defined by values. Thepublication of the Professionalism bookthis year, again leads the way.

We can andshould go further.We need tob e n c h m a r kourselves with theservice sector ingeneral. We areall customers inour every day life.We understandwhat is good andbad service. The

customer value equation is easily adaptedfor health care. It is defined as Qualitydivided by Cost (figure 1).

Quality is not what we put into the healthservice, but what the patient gets out of it.It is defined by both short and long termoutcomes as well as the quality of theprocess. Few within our Society arelooking at long term outcomes. Yes, we canplot Kaplan Myer curves but do wedocument what has happened to ourpatient after discharge? Have we improvedtheir quality of life? The Health Secretary isnow focused on re-admissions - are theseavoidable or unavoidable or do we acceptreadmissions as part of patient centriccare? We would do well to use thedatabase again at follow-up clinic todetermine these factors and ask aboutexperience.

The Pathway

The process factors include the flow(Patient Care Pathway) and Quality ofdelivery of a service - delivery and timingthat does not directly improve the flow ofthe patient through the system is referredto as non - value added waste. Instituteslike Virginia Mason Medical Centre inSeattle USA have mastered process foreach and every medical condition andremoved non value added waste. Theresult is a hospital that maximizes patientcontact time and provides all the facilitiesnecessary for the doctor to do their job.The patients are happy and the consultantsurgeons get home earlier because theirclinics and theatres operate efficiently.

The cost to the patient is invisible. It is the

Figure 1 Patient Value Equation - value is defined by Qualitydivided by Cost

cost of inconvenience, the cost of time,waits, delays and distress caused by aservice that is not necessarily designedwith them in mind. The flow of the servicewill be improved with one stop shops andproper discharge planning - papers to thiseffect were presented at the 2011 SCSmeeting.

The highlighted areas of the patient valueequation are within our remit and notthose of managers. Change will not comefrom top down control but from within oursociety and ourselves. We have to want todo it - a realisation by all members that wecan and should design a better service byputting our patients at the centre of ourendeavors and design services that meetthe challenges of the future. If we expectsupermarkets and other service sectors tobe open when we finish work, it is notunreasonable to foresee in the future thatour patients, our customers, will expectthe same from us. Would it not be moreuseful and more agreeable if we start tothink of this ourselves? Indeed, evidencetells us that systems designed andinspected by the people who do the workare more successful.

The fundamental principle in the serviceindustry is to front load with the expert.

The expert in our specialty is theconsultant, and yes, we do deliver andhave embraced the principle of aconsultant led and delivered service, butdoes this principle encompass all activitiesto ensure that our patients receive expertdecision making at all times throughouttheir pathway. Putting the consultant onthe front line reinforces this principle. Itwill not only improve the delivery of ourservice and remove waste but improvetraining opportunities. How many clinics

are run by trainees alone - past researchhas determined that if in doubt bring thepatient back - this is a waste of resourceand a waste for the patient. Is it notpossible to say - no consultant no clinic?

The interdependency of the Consultant,Patient and the Society is represented in aservice triangle with Trust Assurance andReassurance being interdependent asdepicted in figure 2.

The cardiologist must also be regarded asa customer rather than a partner (figure 3).This paradigm brings new thinking to theirrole and reinforces the concept of multidisciplinary clinics. Our President is to becongratulated in championing the effortsof establishing rigorous guidelines thatshould direct our practice and those of thecardiologists. Creating value can only beachieved by rigorous application ofevidence based practice and collection andsharing of knowledge of conditions wherethat evidence is not so clear. Our nationaland international networks and society goa long way in sharing that knowledge -figure 3.

July 2011 35

David O’Regan

Figure 2 The Patient Service Triangle

Figure 3 The Cardiologist Service Triangle

continued overleaf

theBulletin36

The SCTS serves who first? continued

But as we enter a new era there is a thirdcustomer on the horizon. GPcommissioning means that a generalpractitioner is now to be regarded as animportant customer (figure 4). Using thisparadigm, it is easy to see how we can helpGPs and GPs can help us. A home-to-homeapproach will realise and create value foreach and every medical condition. Theobvious area of synergy is to be found inbuilding the medical record. This has to bebetter than the often brief referralencapsulating a description of anangiogram without any mention of othersystems or social circumstances. Thelatter we are all aware is as an importantdimension in the decision making processof whether to operate or not – would it notbe better that the notes are started by theGP completed by the cardiologist and thenpresented for consideration for surgery,This would constitute a comprehensivewell documented consultation.

Another GP-surgeon collaboration is thepractice of prevention. Primary andsecondary prevention for heart diseasemeans that together we need to focus onoptimal treatment for high blood pressure,high cholesterol and diabetes. We canrealise savings and create value by sharingbest evidence of treatment of theseconditions and ensuring that patientsarriving in hospital are optimally treatedfor these conditions. Likewise ondischarge our recommendations arecontinued and followed up. A partnershipwith the general practitioners will alsomean that we will be able to find out whathappens after discharge. Longer termoutcomes such as re-admission rates andcomplications will become a reality. More

importantly we can then begin to get abetter picture of the patient’s experience,outcomes, functional status and quality oflife. This data needs to inform the processthrough established feedback loops -figure 4.

The new era is presenting fantasticchallenges. The Society, however, iseffectively meeting many of thesechallenges whether it realises it or not.Business thinking and adopting thinkingfrom the service industry will bringcoherence to our endeavours. We need toreflect on own service encounters andapply them to our specialty. Above all weneed to start thinking ‘Who is ourcustomer?’ The SCTS can and shouldcontinue to serve first.

Addendum - The Satellite meeting at theSCTS was attended by 20 businessthinking cardiac surgeons. Many haveMBAs and many more are consideringdoing an MBA. The UK Association of NHSMedical Executives (www.UKAN.me)pronounced [you can] has beenestablished because together we willshape the business of health care is. Ibelieve the SCTS - can!

David J. O’Regan

MBA MD FRCS C-Th

Twitter:@David_ukan

Figure 4 The GP Service Triangle

Other Interests1) Sam Nashef has begun compiling Crosswords for the Guardian newspaper, starting May 2011. Look out for his crosswords

on Thursdays.

2) Shyam Kolvekar has been a medical advisor for over 300 episodes of “Holby City” (televised every Tuesday 8 pm, BBC)

3) Rob Lamb’s team has been selected to run a course at the Olympics 2012 in Weymouth. (More details next time).

July 2011 37

Setting up and running research can be difficult. The ideas forstudies are in the main relatively simple. However, after thepower calculation that tells you that you need to recruit animpossible number of patients for your "hard endpoint", youthen compromise so that you can get a workable number. You arenext faced with a number of hurdles including writing (andrewriting) the protocol, coming up with a statistical analysis plan,obtaining funding, ethics and research and developmentapproval. By the time you have been through all of this, you maybe 12 months down the line and not even got close to recruitingyour first patient. Wouldn't it be a good idea if there were somepeople who could help? This is where the United KingdomCardiothoracic Research Collaboration (UKCRC) comes in.

The idea for the UKCRC was based on an idea set up by thegeneral surgical trainees in the West Midlands for two primaryreasons: Trainees were interested in finding the answer toquestions, but the studies had not been done because of thesample size required. And many had not undertaken a formalperiod of research and found that they were short of publicationsand presentations when it came to the consultant job interview.

With these aims in mind, they constructed the West MidlandsResearch Collaborative a trainee-led research network within theWest Midlands set up by the trainees themselves with the activesupport of their consultants). The collaboration has support fromthe University of Birmingham Clinical Trials Unit and the PrimaryCare Clinical Research and Trials Unit. It capitalises on the naturalnetwork formed by surgical trainees rotating between hospitals inthe West Midlands and since its inception it has allowed them toset up eight research projects. These include retrospectivedatabase studies in association with the West Midlands CancerIntelligence Unit (CANOES and CANOES II), a study on the impactof shift work on Foundation Year trainees (SWIFT) and aprospective randomised multi centre observer-blinded trial toreduce surgical site infection (ROSSINI). Note that it's not onlythe Cardiologists that can come up with fancy acronyms.

The concept of research collaboration within their specialty hasbeen successful and there is no reason why a similar model albeiton a national scale could not work (with the correct support) forcardiothoracic trainees.

There are a number of questions that spring to mind immediately:

Who will run the collaborative?

There are a number of administrative positions within thecollaborative (chairperson, treasurer etc). These are open to alltrainees and be for a fixed term to allow rotation of theadministrative committee.

Who will supervise the collaborative?

All consultants who participate with trainees in UKCTRC projectswill naturally retain a supervisory role over their own trainees. Allprojects would be undertaken under both national and localresearch governance legislation with appropriate ethicalcommittee and R&D approval prior to starting a project.

Who is supporting this group?

We hope that all consultant cardiothoracic surgeons within the UKand Ireland will support this initiative. Specifically, Professor Tom

Treasure has kindly agreed to act as a steward to the group andthe President of the SCTS has given backing to the collaborative.With multi-centre trials we will engage the support and expertiseof clinical trials units.

What about the Thoracic Research Collaborative?

This is a separate group to the Thoracic Research Collaborative.Whilst these collaboratives are separate bodies, there is a clearpotential for overlap of ideas and for collaboration between thetwo groups.

What do the trainees get from this?

Trainees would gain:

1 A share in better research, bigger "N", more representativepractice.

2 Shared experience with project proposals, grant writing, ethicssubmission, presentation skills and manuscript writing(defined groups would work on each of these areas)

3 Strengthening of CVs with both presentations and publications

4 Networking with trainees from other regions

5 A share in projects that can run over more than one year and inmore than one unit.

What do Consultants get from this?

1. Bringing research into local units which want to participate butdo not at present have the infrastructure or appropriatesupport to have dedicated research teams

2. A chance to scale up individual or unit level research projects

3. Publications

4. Networking

How will proposals be chosen?

An annual call for proposals will be announced; followingsubmission all proposals will be anonymously assessed and oneor two projects chosen per year. This would allow for a number ofactive projects to be running whilst others are being set up,hopefully allowing for a constant stream of projects.

Who will present the data?

Each project will have a lead. It is envisaged that the lead for thatproject would become the lead presenter of the work but if thereare more outings others can take their turn to present. All workwould be presented on behalf of the UKCTRC.

Who will be listed as authors on manuscripts?

Authorship will be from the UKCTRC with all collaborators andtheir Units credited (as is the norm for multi-centre trials). Criteriafor authorship will be agreed in principle at the outset so thatthere is transparency as to how authorship is credited.

We hope that both consultants and trainees reading this articlewill support such an endeavour and will contact us with any directquestions/suggestions.

UKCRC currently consists of Joel Dunning, Neil Howell, AaronRanasinghe and Neil Roberts

Aaron Ranasingheon behalf of the UKCRC

The UK Cardiothoracic Research

Collaboration

Hunaid A VohraCardiothoracic Representative for the Wessex ShadowSchool of Surgery

theBulletin38

Purpose

The participation of trainees in thedevelopment and evaluation of curriculumenhances delivery of training and thequality of milieu in which learningobjectives need to be accomplished.Encouraging trainees to give objective andpractical view-points can however, bedifficult, perhaps due to the lack of aformal body to which trainees areaccountable to and because trainees mayfeel that their comments are ignored.Cardiothoracic trainees may also feel thatproviding ’negative feedback’ may impactfuture training opportunities. Hence astructure which enables trainees to feelconfident to provide feedback as well asone which encourages their involvementwith the development of trainingenvironments at a regional level would bewelcome.

The recent introduction of the WessexDeanery School of Surgery promises toprovide an excellent prospect ofdeveloping a pioneering way of ensuringtrainee participation into deanery andspecialty affairs. A Shadow School ofSurgery which mirrors the main SurgicalSchool has been developed to provide aforum for surgical trainees to discussmatters intrinsic to being a surgical traineein Wessex. The elected members of theShadow School board endeavour to ensurepro-active trainee involvement with bothsurgical specialty and deanery issues andfacilitating the delivery of trainee’sopinions to the main Deanery School ofsurgery. The Shadow School isaccountable to the Head of the School ofsurgery and the postgraduate dean.

The Board

The board of the Shadow School of Surgeryhas a similar composition to the mainSchool of Surgery board. Each of the tensurgical sub-specialties is represented byan elected trainee who is interested intraining and educational matters. Theappointment is supported by the training

programme director (WessexCardiothoracic TPD: Mr Sunil K Ohri). Thereis also an academic training representativeand a Core Training Representative on theboard. The board has an external layrepresentative appointed by the dean anda member of the deanery. Finally, there is adeanery appointed ‘Chair’ who is directlyaccountable to the head of the main schooland who is also the trainee representativeon the main School of Surgery board.

Terms of Reference

The Shadow School of Surgery provides apoint of reference for all surgical traineeswithin Wessex from each of thesubspecialty areas. The Shadow School:

• ensures high quality training within thedeanery

• is responsible for the propagation ofinformation from the School of Surgeryand regional STCs

• ensures representation on localtraining committees

• ensures there is a point of contact foreach hospital

• develops a trainees’ website inconjunction with NESC School ofSurgery site

• maintains a trainee database

• produces a newsletter for surgicaltrainees

• is involved with regional teaching thatfacilitates training and logbookcompletion

The sphere of activity of the shadow schoolof surgery board is to discuss the themesthat the main school deals with. It seeks toachieve this by incorporating the deaneryfunctions of:

• Teaching and learning

• Managing training programmes andposts

• Curriculum implementation

• Trainee selection

• Assessment of progress (RITA / ARCP)

• Workplace based assessment

• Quality assurance and evaluation

• Educational research

My Role

Being appointed as the Cardiothoracicrepresentative on the Shadow School ofSurgery board, I have a committement toensure high standards of cardiothoraciceducation and training at programme andhospital level are met. This exciting newventure enables me to influencecardiothoracic workforce needs andchampion patient safety by contributing tothe development of training programmesthat ensure the training of fit for purposecardiac and thoracic surgeons. Thefostering and development of trainee-trainer relationship is another crucial issuewhich is generally poorly handled in ourspeciality and needs to be addressed. Forthose trainees interested in pursuingacademia, a fertile soil tailored to theirrequirements, needs to be cultivated. Theprovision of high-quality regularconsultant-led didactic/interactiveteaching should be the aim to ensure ahigh pass rate at the Inter-collegiate FRCS(CTh)

Appraisal

The Shadow School of Surgery undergoesregular evaluation as part of the Deanery’sQuality Assurance process to determinewhether its establishment has brought achange. The evaluation process involvesHead of the Surgical School, Main SchoolBoard, members of Shadow School Boardand the Wessex surgical trainees. Thisaims to identify whether there has been animprovement in the opportunities toprovide feedback and influence training asa result of the development of the ShadowSchool.

by Sam Nashef

Across 1/9 Fruit as 8 the 19 of 17 21 (7,3,6)

5 Birds in smart disguise (7)

9 See 1

10 17 feature, type I disorder (5)

11 So many grapes are not picked (8)

12 See 28 Down

15 Remote object of which you owe 5 as 8 the 19 of 17 5ac (8)

17 Stain-free character (5)

19 Inventor's clangers (5)

21 After 17, church where a hundred replaced drug in fire andwater (8)

24 Take in Arabs, or Brits admitted (6)

25 Playing Moon River right away for no picky eater... (8)

28 ... starts to overeat big entrees, sweets, etc and ends so (5)

29 Suggestive comments send union round the bend (9)

30 Legendary hairdresser somehow allied with Hungariancapital (7)

31 Stitches torn trouser suit having left riot (7)

Down1 Pop a question that's partly unclear (6)

2 Assistants with funny ideas (5)

3 Most dull eyes for compiler in grit (7)

4 Waterside dump in London (10)

5 How King Edward may be served with sausages (4)

6 Salesman swallows and regurgitates (7)

7 Get laid if drunk (present perfect) (5,4)

8 State for example (3)

13 Snowman rising in white yuletide scene (4)

14 Deals with meat and greens? (10)

16 Compiler waves after a 50-50 general reassurance (3,2,4)

18 In Sweden they rock up and down (4)

20 Fantastic as ruler (7)

22 Famous compiler's in part of hospital (7)

23 Count the poles in misleading cues (6)

26 Organisation command (5)

27 Loaded what I need to grow before settling, 8 the 19 of 4(4)

28/12 Court whose 19 demand payment date (3,6)

crosswordthe

Send your solution to:

Sam Nashef, PapworthHospital, CambridgeCB23 3RE or fax to01480 364744 by 31 December 2011.

Solutions from areasover 10 miles fromCambridge will begiven priority.

Last issue’s winner:

The winner forDecember 2010 isTed Brackenbury,Edinburgh.

annual meeting london 2011 - society for cardiothoracic surgery

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