Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

Background COVID‐19 is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS) and circulatory shock. Although the symptoms of the disease are predominantly respiratory, involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID‐19. Aim of the Review To examine the challenges faced by healthcare organisations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID-19 pandemic. Results Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID-19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short-term mortality. LVAD as a bridge to transplant may be a viable strategy to get at-risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19, and impaired social and psychological well‐being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm. Conclusions HF incidence, prevalence, and undertreatment will grow as a result of new COVID-19-related heart disease. ECMO should be reserved for highly selected cases of COVID-19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs.

Severe Aortic stenosis: Is urgent transcatheter aortic valve replacement better than Balloon aortic valvuloplasty better than?Wael Awad FRCS(C/Th)1, Mohammed Idhrees MS, MCh, FAIS2, Mohamad Bashir MD, PhD, MRCS 31. Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew’s Hospital,West Smithfield, London, UK2. Institute of Cardiac and Aortic disorders, SRM Institues for Medical Science (SIMS Hospital), India3. Department of Vascular Surgery, Royal Blackburn Teaching Hospital, Haslingden Road,Blackburn, UK

Background Same-day cancellation of cardiac surgeries is a disheartening experience for patients. The primary aims of this study were to determine the frequency and reasons for same-day cancellations, and associated patients’ outcomes. The secondary aims were to evaluate patients’ reactions to cancellations and to propose measures to reduce cancellations. Methods We prospectively reviewed all elective and urgent in-patient adult cardiac surgeries performed from August 2017 to March 2018. Procedures were divided into cancelled (C) and not cancelled (NC) groups. A qualitative patient satisfaction survey was undertaken. Results Overall, 1388 patients were scheduled for cardiac surgery during this period. Elective surgeries constituted 70.7% (981/1388) and urgent 29.3% (407/1388). 231/1388 (16.7%) procedures were cancelled for the following reasons: 30.5% lack of ITU beds, 20.1% patient medically unfit, 8.2% ITU staff shortage, 6.9% emergency case intervention and 34.2% other. There was no significant difference in mortality between groups (2.6% in C vs 1.6% in NC, p=0.62). In group C, 36% (84/231) of patients underwent surgery within 72 hours of cancellation, 47% (110/231) of procedures were rescheduled, and 6.9% (16/231) were not performed. 30.7% (71/231) were potentially preventable. All cancelled patients were asked to complete the survey; 43.7% (101/231) responded, with 22.8% (23/101) describing feeling upset. However, 92.1% (93/101) felt the cancellation was justified. Conclusion This single institutional study suggests a relatively high number of planned same-day surgeries are being cancelled. A third of these may be preventable. Despite this, patients were understanding. Actions to decrease cancellations should be identified to improve efficiency.

A 60-year-old lady with a past history of rheumatic mitral stenosis (MS), percutaneous valvuloplasty and persistent atrial fibrillation represented with heart failure. Cardiac ECHO confirmed severe MS, moderate tricuspid and aortic valve regurgitation and pulmonary hypertension. She underwent mitral and aortic valve replacements, a tricuspid valve repair and left atrial appendage clip. She developed a LV wall rupture and underwent repair of defect. Cardiogenic shock persisted despite IABP counter-pulsation and escalating inotropic support. Central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 9 days later, a percutaneous Protek Duo right ventricular assist device (RVAD) for RV failure afforded a successful outcome.

Background: During this SARS-CoV-2 pandemic, there has been unprecedented stress on health care systems, resulting in a change to how services are carried out. The most prominent question for healthcare professionals specialising in cardiac surgery is, should we operate during this pandemic, and to what extent ? Methods: As one of the biggest, specialised cardiac surgery centres in the UK, we researched the available published evidence surrounding this question, to formulate an answer. During this process we considered the potential risks of cardiac surgery during a pandemic on the patients, staff, the healthcare system, and the community. We also considered the immunological aspect of cardiac surgery patients and the risk it entails on them. Results We have discussed the available evidence and consequences of our findings, and we found Patients are subjected to greater risk of catching Covid-19 whilst being in hospital. Patient’s immunity is disrupted for up to 3 months post CPB, which makes them more vulnerable to catch the Covid-19 infection during admission and after discharge. Plus the burden on the whole healthcare system, by using the precious resources and occupying the necessary staff and hospital beds needed during the pandemic surge. Conclusion: Try and minimise cardiac surgery operations down to emergencies or unstable patients who have no other options apart from surgery, particularly during the surge stage of the pandemic. Strictly following structured pathways and protocols, updating relevant protocols with emerging new evidence.