ACTA Echo 2008 was organised by StGeorges Hospital in London. It followedlast year’s September meeting on the themeof the ischaemic mitral valve held inManchester.This year’s meeting took place inJune and immediately preceded the ACTAspring meeting at the Zoo.The theme of themeeting was ‘new and emerging technology’and its challenge was to look beyond thecomfort zone of our sub-speciality and todiscuss how we may embrace developmentsin the fast moving field of modernechocardiography. Following our theme, I triedto design a good-looking modern websitewith facilities to register and pay on-line. Oneof the important benefits of this approach wasthat it attracted a number of our colleaguesfrom Portugal, Spain, the Netherlands andBelgium to attend the meeting.

The event took place at the Royal Societyof Medicine in the newly refurbished MaxRayne auditorium.The day started with anovel registrar case presentation prize chairedby Hanif Meeran and Donna Greenhalgh.Thequality of the submitted presentations wasvery high and with some difficulty seven hadbeen selected for presentation on the day.Each presenter had 12 minutes in total to

impress the audience and the judges withtheir wit, knowledge and image files. On theevidence of subsequent discussions theyachieved this and then some.The ‘celebrityjudges’ chose Caroline Evans from Cardiff asthe winner with her tale of a coronary arterytear.They commented on the consistent highstandard attained. It is my hope that the casepresentation section will continue in futureecho meetings to encourage our youngechocardiographers.

Two lectures that were chaired by Dr PaulQuinton, preceded the lunch break.The speakers were both from GlenfieldHospital in Leicester demonstrating itscredentials as a centre of excellence. DerekChin, a cardiologist, shared the mysteries ofpercutaneous aortic valve technology with us.He explained their successful programme ofover 30 patients and illustrated his talk withremarkable echo images including some 3DTOE clips. Justiaan Swanevelder, well known toall of us, gave us a tour de force ofechocardiography and its surgicalconsequences in a lecture entitled ‘thethoracic aorta – the old and the new’.Returning from lunch and a tour of theexhibitors, there was a mini-symposium on

the subject of screening the ascending aorta.A poll taken prior to the lectures revealedover 90% of the audience considered thatthey should be screening the ascending aortain cases selected for coronary artery grafting.Arno Nierich from Zwolle in the Netherlandstold us about his invention, the A-viewcatheter and how it can give us window onthe aorta for TOE. Dr Daniel Bainbridge fromLondon, Ontario in Canada followed him.Dan told us about his work with 3-D surfaceultrasound to image aortic atheroma andreduce stroke rates. Mr V Chandrasekarancompleted the talks with a surgicalperspective and demonstrated some veryinteresting devices to enable proximalcoronary anastamoses without the use of across clamp.A short panel discussion chairedby Dr Frank Schroeder wrapped up thesession.

Following coffee Mr Graham Leech who ispast-president of the BSE and a physicistchaired the final afternoon session by training.Dr Jan Hultman from the Karolinska clinic inStockholm presented us with real-time 3DTOE imaging and he expertly drew out theadvantages and the pitfalls of this newtechnology developed by Phillips. Our finalspeaker was George Sutherland, Professor ofCardiac Imaging at St George’s Hospital. Hegave us a tour de force of assessingventricular function. He reminded us of theproblems of the ejection fraction and pointedout the value of such indices as tissueDoppler and strain.After some interestingdiscussion, it only remained for Dr vanBesouw the chairman of ACTA, to present thewinners prize to Dr Caroline Evans and drawthe meeting to a close.As the sun continuedto shine, the bars across the road filled upquickly. People digested what they had heardover the day accompanied by a chilled glassand pondered about the start time of thenext days ACTA session.

I would like to thank all those who assistedme in the organisation of this meeting andthe sponsors for their generous support.We can now pass the torch to Cambridgewho will organise the ACTA Echo meeting for2009.

Dr Nick Fletcher

NewsNEWSLETTER OF THE ASSOCIATION OF CARDIOTHORACIC ANAESTHETISTS

No.2

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ACTA

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ACTA Echo 2008 Meeting

Exhibition are.

BeforeThe stakes were high - we had taken the spotfor the ACTA Spring meeting traditionallyhosted by Papworth in Cambridge.We knewwe could not compete with the beautifulcolleges, historical dining halls or punting onthe Cam, so it had to be different whichmeant The Zoo.As one of the newest, stand-alone cardiac departments in the country wealso had something to prove; we desperatelyneeded to shake off our reputation forcappuccino drinking, shopping and partying,and bolster our position as serious players inthe world of cardiac anaesthesia.With this inmind, we went round the corner to Starbucksin Marylebone to make plans.

DuringThe Heart Hospital’s top fashion modelsmanned reception and male delegates fromnorthern climes were fighting to part withtheir registration fees.The flowers too, simplearrangements of white hydrangeas in tall blackvases, were the most stylish ever seen at anACTA meeting. Male anaesthetists weremuttering Jane Packer or Paula Pryke (?) andmaking mental notes never to buy flowersfrom the garage again.We played our trump card first, the mostfamously absent member of the departmentDr Judith Hulf, President of the College ofAnaesthetists, opening the meeting with a

sobering view on re-accreditation andrecertification and the roles of specialistsocieties, such as ACTA, in these processes.Dr Hulf ’s lecture was followed by astimulating free-paper session. First prize forthe oral presentations was awarded to DrsWharton and Linter from Bristol.Their dataon a significantly higher perioperative risk forcardiac surgery in the over eighties struck acord with many in the audience, who felt onlytoo familiar dealing with this age group. DrLakshminarayan and colleagues fromMonklands Hospital won the best posterpresentation, which demonstrated how somesimple audit recommendations, could impacton clinical outcomes such as infection rates.

Coffee was followed by the return ofProfessor Sir Bruce Keogh, former director ofsurgery at the Heart Hospital, and nowMedical Director of the NHS. He was flankedby two officious PA’s in sensible shoes andwas palpably anxious about what Dr Ashleymay refer to, by way of introduction. Howevershe was uncharacteristically discreet, Sir Brucewas visibly relieved, and then gave anoptimistic speech on the state of health careand the NHS in England and Wales, withparticular reference to cardiovascular disease.He was whisked off by his minders to avoidbeing subjected to questions from such adiscerning audience. One wistful glance backsuggested he was missing the convivialatmosphere of The Heart Hospital.

Heather Cooper summarised the NCEPODCABG Study that included a positive appraisalof cardiac anaesthesia.The report highlighteda sub-speciality with a consultant delivered,high quality service to cardiac surgical patientsin the UK. Justly proud, on this positive andoptimistic note, it was off for a packed lunchin order that delegates could walk around the

Zoo and visit the trade exhibition.This wasthe highlight of the day for some, with a fewreported sightings of more troublesomecardiac surgeons in their cages.

The afternoon lectures were given by adistinguished group of people from the worldsof surgery, anaesthesia and cardiology. Marc deLeval from Great Ormond Street gave anopen and honest talk on human factors andtheir influence on cardiac outcomes. Heshowed the strength of admitting problemsearly, taking rapid action and if necessary re-training.This is a laudable way of preventingdisaster and promoting a no-blame culturewithin surgical teams. He also underlined what

2

Dr Liz Ashley with Dr Wynne Aveling (aspiringcontender for the new Manners of Southampton)together with the most expensive flowers ever shown atan ACTA meeting.

Professor Sir Bruce Keogh, Medical Director of theNHS, looking for one of his minders.

Professor George Shorten, talking about uncertainty inmedical treatments (or was he?)

The organisers invite readers to submit captions forthis photograph to the editor.

ACTA @ The Zoo June 6th 2008

3

teams could learn from unrelated disciplinessuch as Formula 1 pit-lane crews. Cardiacanaesthetists were dreaming of red Ferrariswith girls draped over their bonnets andmagnums of Champagne, when they wererudely awakened by a fascinating talk fromProfessor Philipp Bonhoeffer about hispioneering developments in percutaneousvalve technology.The rapid rise in the rate ofpercutaneous coronary interventions may befollowed by a rise in percutaneous valvesinsertion. Professor Bonhoeffer from GreatOrmond Street and the Heart Hospitalcurrently inserts one percutaneous pulmonaryvalve every week. Hybrid techniques are alsobeing developed whereby devices areimplanted through minimally-invasive surgicalapproaches.This may herald changes intraditional valve surgery and suddenly the

Ferarris seemed a long way away. Indeed oursurgical colleagues may be an increasinglyendangered-species.The meeting venuesuddenly seemed all the more appropriate.

Professor George Shorten from Cork, gave aphilosophical talk entitled ‘Primum nonnocere’ meaning ‘First, do no harm,’emphasising the role of anaesthesia in riskbenefit analysis, risk- management, andmonitoring and reporting of adverse events.He related this particularly to painmanagement in thoracic surgery, so that wecould try to understand some practicalimplications of this complex subject.

Tea was followed by the final sessions, whichmade us truly proud to be a part ofUniversity College London. Dr Mike Grocottgave an inspirational lecture about theexpedition, which he led to the summit ofMount Everest.Apparently this was to studyan individual’s adaptive response to hypoxia,

which may also predict survival of criticalillness and intensive care. (We secretlythought they just wanted to climb Everest!!)Many in the audience had participated in theEverest Expedition, and were not toosurprised to learn that one of their colleagueshad a measured arterial pO2 of 2.4 kPa justbelow the summit! This was a truly aweinspiring achievement, which will produce(some world-first) data for many years tocome and may give new insights into thepathogenesis of critical illness.

Finally, Dr Sue Wright described her four-yearproject to develop a virtual heart and TOEsimulator. Sue, Bruce Martin and AndrewSmith from The Heart Hospital, haveproduced a teaching tool that correlates 2Decho images with 3D cardiac structures.Thissoftware has been developed in conjunctionwith a computer graphics company from thefilm industry and has been incorporated into amannequin TOE simulator.This lecture

generated a great deal of discussion at thedinner, where ACTA colleagues acknowledgedtheir significant achievement.

Dr Wynne Aveling, who has recently retiredfrom cardiac anaesthetic duties at The HeartHospital, was a fitting choice for thepresentation of the prizes and closure of themeeting.We may have witnessed the next‘Manners Southampton,’ only time will tell!

AfterThe Champagne reception was held in theBUGS! house, before everyone was led pastthe lions and tigers around the Zoo to abeautiful Orangery for dinner.The meal wasexcellent, with a surprising lack of bananas onthe menu.We were entertained by magiciansand a charming young musical trio, andbehaviour slowly and predictably deterioratedas the evening progressed.The ACTA 2008committee were reassured that the day hadbeen a success and The Heart Hospital washeld in new regard amongst UK cardiacanaesthetists.The party was continued in abar in Soho into the early hours, by the usual(suspects) monkeys.

We wish to thank all our sponsors whosupported the meeting, especially Enoximone.The local organising committee would like tothank the ACTA committee for their help andguidance, particularly Dr Alston for hisarduous organisation of the abstract process.

Particular thanks are also due to Dr MatthewBarnard who instigated the meeting, lead theorganising committee and did the majority ofthe work. His wife Corinna provided valuablesupport and managed the online registrationand web site.

Dr Elizabeth Ashley

Two Italian delegates, just after they were asked which lecture they enjoyed the most.

Travelling magician impresses the dinner guests.

4

Many of you attended the second ACTAEcho meeting, which preceded theACTA Spring meeting at the London Zoo.

The Echo meeting was held at the RSM and

hosted by Nick Fletcher who put together an

interesting and informative programme.

The theme was ‘Innovations in Echo’, with 3D

and percutaneous aortic valve (AV)

replacement, which relies on echo, being

current topics.

There were case presentations byregistrars where echo had made adifference to outcome.The standard of

presentations was very high and it was

difficult to choose one as winner. I know how

difficult it was, as I was one of the judges.

The prize was eventually awarded to Caroline

Evans from Cardiff.

The Society of CardiovascularAnaesthesiologists meeting was inVancouver this year and had a strong echo

component as well as covering a range of

current topics such as aprotinin and sugars.

Again, 3D and percutaneous AV replacement

featured. One highlight was ‘Echo Jeopardy’

with three teams of two and a variety of

categories covering echo topics. Jack

Shanewise teamed with Sol Aronson ran away

with the prize but it was good testing ones

knowledge against the experts. Roger Hall and

I thought we did well.

By the time you are reading this,Blackpool will have hosted a meetingfrom September 11th –12th on “Managing

Aortic Valve Disease. Jack Shanewise is coming

over to speak at the meeting and he is always

worth hearing as is Justiaan Swanevelder. In

addition, there is also an echo lab.

The BSE’ annual meeting is in Harrogatein October.Again this should be a goodmeeting with a different perspective and CME

points available for re-accreditation in

echocardiography.The programme has a TOE

session on ”When to use it and what to look

for” including endocarditic, strokes and mitral

regurgitation, stress echo and TOE in

emergencies.

The Perioperative ACTA /BSE TOE examthis year will be held prior to the ACTAmeeting on Thursday the 13th November in

Harrogate.There has been a lot of discussion

regarding accreditation in Emergency Medicine

and General Intensive Care.A working party

has been set up to look at this.At present the

feeling is that there will be two levels

available.The FEEL/ FATE level will be basic

and have a focused assessment with specific

goals e.g.“is the heart working or not”.The

training numbers and who will provide the

training as well as other details are still in the

process of being decided.There will be a

second level of accreditation which will

probably be part of the perioperative exam

with modifications to the logbook case mix

and may include transthoracic images to

enable the case numbers and mix to be more

appropriate to the work in general intensive

care, as well as haemodynamic assessment.

This will just focus on the heart at present

and is still in the early stages of development.

The current syllabus is also being updated to

accommodate some of these changes.

Asub-group of the ACTA TOE sub-committee, including Agneiska Crear-Gilbert, Henry Skinner, Mark Patrick and I

have put together guidelines as to what the

TOE requirements are for logbook markers.

This is to assist both those who are putting

their logbooks together as well as the

markers.A tick box doesn’t provide enough

information for a logbook as methods of

quantification are rarely mentioned.This can

be found on the new guidelines page on the

ACTA website along with other links to

relevant and interesting sites. Please check out

the new Guidelines page of the ACTA site.

Hope you all had a good summer!

Best wishes,

Donna Greenhalghdonna.greenhalgh@btopenworld.com

ECHO ReportPerfusionUpdate

As reported in the last edition of ACTANews, the Department of Health (DoH)set up a Working Group in November2007 to review national practice inperfusion science and to develop a GoodPractice Guide.The intention is topublish the Good Practice Guide thisyear, although the draft document hasundergone numerous revisions and thefinal text has still to be agreed within theWorking Group.The professionalrepresentatives on the Working Groupwould like the Guide to be approved andendorsed by their respective executivecommittees, though it is not yet clearwhether this will be allowed by theDoH.

The DoH still has no plan for earlyregulation of perfusion science, andwants to include them with a variety ofother professions following theirintegration into the ModernisingScientific Careers (MSC) reorganisation.Regulation is therefore unlikely tohappen before 2011.Although theperfusionists are enthusiastic about theirintegration into the structure of MSC,the dirt is in the detail of what willhappen to their existing excellenttraining structure.

The recent ballot of ACTA membersindicated that the majority of you (70%of those who replied) do not want to beresponsible for signing prescriptions forthe perfusionists, and the surgeons haveindicated that they are not in a positionto take responsibility for drugs and fluidsgiven during bypass.We are thereforerecommending that, until professionalregulation of perfusion science occurs,current practice should accepted asstandard as it is supported by asignificant body of reasonableprofessional opinion.There is bound tobe some robust discussion over thispoint, with the DoH unkeen to agree toanything that does not have a legal basisin spite of the years of incredibly safeperfusion practice under the currentarrangements.

Donna Greenhalgh donna.greenhalgh@btopenworld.com

David Smith david.smith@suht.swest.nhs.uk

5

Last year her Majesty, Queen Elizabeth II,visited the Commonwealth of Virginia, forthe 400th anniversary of the Jamestownsettlement. She was warmly greeted by thedescendents of the revolution, in a thrivingmodernizing State.What a contrast from thegaunt, emaciated, remnant of English settlerswho met the supply ships, after the harsh“Starving Time”, back in the 1600s. In 2003, Ireturned to Virginia CommonwealthUniversity Medical Center in Richmond, andfound life here had changed too, also for thebetter. I was excited but a little apprehensive.How would I adapt after 13 years as aConsultant Cardiac Anaesthetist in GlasgowRoyal Infirmary?

During my absence, the historic MedicalCollege had been re-branded.TheAnesthesiology Department had grown, andtechnology proliferated.We now hadelectronic anaesthesia records, in all 30operating rooms and most external sites (seehttp://www.anesthesiology.vcu.edu/department.html). In some operating rooms there wasultra-sound machines for cardiac evaluation,vascular access and nerve blocks, as well asnumerous devices to help manage the difficultairways. Morbid obesity had abounded andnon-English speaking, Hispanic patients hadbecome common in our obstetric service.Thepeople may now be malnourished but theyare certainly not underfed! Despite all thetechnology, a simple bougie, hidden beside thetie cord in my scrub pants, occasionallyprovides a quick, low-tech solution to airwaydifficulties. I’m sure my mentors would haveapproved.

Language andworking practice

While my Scots tongue often bringsstories of Scottish or Irish relatives, the

relapse into mentioning “theatre”,“trolley” or“recovery room” brings a vacant expression.“Why do you folks make spelling difficult?”“Anyway, an anesthesiologist is a doctor, andan anesthetist is a nurse.” We have as manyCertified Registered Nurse Anesthetists(CRNAs) as there are residents acting as first-line anaesthesia providers. No moreconsultant fixed lists, for the AnesthesiologyDirector assigns the daily workload; patientsare seen at the Pre-operative AssessmentClinic.The anaesthesia room that was the safehaven for many a soul, has disappeared but sotoo has the quick turnaround of patients.Early starts, commencing work at 6.45 a.m.prevail and I regularly supervise twoconcurrent operating rooms, one with aresident, the other with a CRNA. Boredomwatching the bellows rise and fall, has gone,with multiple rooms you have to be on yourtoes.A routine day lasts until 4 p.m.There is alittle in-hospital “call” 7 pm till 7 a.m. andsome specialty call from home. My teachingcommitment has expanded, as have the clinicalchallenges. I now have a rolling one-yearcontract, but a bigger salary. Faculty vacanciesare common in the Teaching Hospitals, socontinuation of employment is not a problem.In all, quite a number of changes, some maybeyond the pale for many, but in reality all iswell.

Licensure andcredentialing

In the USA State Authorities hold aphysician’s licensure, while hospital’scredential practitioners by granting privilegesto practice in certain areas. In Virginia,physicians must complete 60 hours ofapproved Continuing Medical Education withineach two-year cycle. Nationally, there aremany excellent anesthesiology options, whereparticipants are encouraged to work and play,so complying with their CME regulations. I’vereluctantly accumulated educational credits inColorado, San Francisco, San Diego,Atlanta,Houston, Boston, Florida, Banff Canada, andSydney Australia!

Education andtraining

Having missed the recent debacle ofManaging Medical Careers, I read withinterest of the five years of SpR Anaesthesiatraining. I’m glad it still commences someyears after graduation, for most people needtime to decide what they want to do. In the“land of the free”, final-year medical students,

choose a specialty, then visit departmentsbetween November and January each year.Like most programs we interview manycandidates, approximately 10 for everyresident position.Anesthesiology has becomepopular again. On “Match Day” in March wewill discover who our 12 new starts will bethat July. Over the next four years, theseyoung doctors will progress through a generalinternship year (PGY-1) to three clinical yearsof Anesthesiology (CA1-foundation, CA2-specialties, CA3-advanced), becoming BoardEligible (BE) by the end. Residency hours haverecently been reduced by the nationalauthorities, to a maximum of 80 per week, stillconsiderably excessive by European WorkingHours Directive.All residents havecompulsory multiple choice tests annually, inwhich their academic knowledge is comparedwith peers in their own program andnationally. In the tradition of US educationsome of the questions may reappear whenthey take their “Boards” for real! Residentsare also required to satisfy local competencyassessments.At the end of the Residency,many disappear into the rich pastures of theprivate hospitals, while others, as many as 50%of our graduating residents in recent years,have decided complete additional Fellowshipyears: cardiothoracic, pediatric, regional andpain medicine are the most popular. Cardiacfellowships provide training in TOE and havebecome a must for all aspiring cardiacanesthesiologists. Finally, many medicalstudents pass through our ranks, tipping theirtoes in the waters of anesthesiology for a fewweeks of “elective” study.This has alsoincluded a number of UK medical studentsjoining for summer funhttp://www.adcolquhoun.wikispaces.com. Ourdepartment has proven to be popular andoccasionally these experiences have solidifiedcareer choices.

A physician onlyservice

In contrast to anesthesiologists, CRNAs canbe ready for clinical practice after only 20months having competed a diploma courseand passed a national multiple-choiceexamination.Tick the box and go! MostCRNAs are recruited from nurses with someICU experience.Working conditions andsalaries make these graduates the envy of thenursing profession.Their quest forindependent practice and nursing PhDsinforming patients that they are doctors,provides interesting political challenges for thefuture.

A Letter from the Old DominionAugust 2008

Capital Colonial Williamsburg,Virginia, USA.

Continued overleaf

6

Beyond Crownindemnity

Medical practice in the US is often seenas big bucks but big risks, particularlysince the public is perceived to be litigious.Our patients now sign an Anesthesia ConsentForm carefully crafted by legal experts, butalso with individualized information including arisk statement added by the attending. In ourHealth System, physicians have beencollectively insured for many years, withexcellent results, both in limiting costs andallowing innovation in managing claims.TheHealth System favours a pro-active approachwith mediation, rather than protractedadversarial legal activity. Fortunately, largeclaims have been rare, and I have no personalknowledge of major claims within the pastfive-years.

Nationalised healthcare

While our State forefather ThomasJefferson, the “pen” of the Constitutioncould declare in the preamble to theDeclaration of Independence that “that allmen are endowed with certain unalienableRights”, namely “Life, Liberty and the pursuitof Happiness”, it fell far short of universalhealth care. In the wake of World War 2, theBritish National Health Service was borndelivering free health care for all.This isconsiderably more comprehensive than thecurrent combined American Veterans Affairs,Medicare and Medicaid programs. In thiselection year, healthcare is firmly on thepolitical agenda.Too many Americans have nohealth insurance; costs are too great; ill healthabounds.The free-market is creaking.Wherewill all the political promises lead? Willaffordable healthcare and improvement instandards come? Time will tell.

The last five years has brought diversityand opportunity.While I remain gratefulfor my formative British training and years ofConsultant practice, I believe anaesthesia canbe safely delivered and administered in amanner quite distinct from British practice.My life-style has improved and technology hashelped bridge the geographical divideseparating family and friends. I continue toenjoy new challenges, and affirm the VCUHealth System motto “every day a newdiscovery”. If you are feeling stuck in the rut,why not take a walk on the wild side!

Alex D ColquhounAssociate Professor of AnesthesiologyVirginia Commonwealth UniversityMedical CenterRichmondVA 23298-0695adcolquhoun@vcu.edu

Alex Colquhoun.

Editorial

Yet again it has been a pleasure to briefly

escape from a world in financial crisis

and edit another issue of ACTA News.

The regular reports from committee

members keep us all up-to-date with

what is happening in the different areas

of cardiothoracic anaesthesia.These are

supplemented with four reports from

the organisers of ACTA and ACTA

sponsored meetings and these fill in the

gaps for those that have not been able

to attend. Our representative, David

Smith, has provided an update on what is

happening in EACTA.Alex Colquhoun,

who was a former ACTA committee

member, has provided an excellent piece

on life as anesthesiologist in the US of A.

If there are any other expatriate

members out there, I would also

welcome reports about anaesthesia in

your part of the world. Finally, we have

the obituary of Parry Brown who was a

pioneer of thoracic anaesthesia, from

some of his former colleagues. I thank all

you that have contributed to this issue

and encourage you all to consider

submitting an article that is newsworthy

or simply of interest to cardiothoracic

anaesthetists.

Peter Alstonpeter.alston@ed.ac.uk

ACTA Membership Subscriptions Update

All Annual ACTA subscriptions are unchangedas follows:

Full Membership £40

Associate Membership £25

Retired Membership £10

The annual EACTA subscription for 2009 is100 Euros (£80) which includes the bimonthlyJournal of Cardiothoracic and VascularAnaesthesia.

ACTA recently changed its main collectiondate from May to November to synchronisesubscriptions with EACTA. ACTA intends tocollect ACTA & linked EACTA subscriptionson 3rd November 2008.

It has come to my attention that Banker'sAutomated Clearing Services (BACS)automatically cancel some direct debits thatare not used for 13 months or more.

The following members do not need tocomplete a new direct debit mandate

i) Members with Royal Bank of Scotland or National Westminster bank accounts

ii) New members who paid their initial subscriptions in November 2007 or later

iii) Overseas members who pay by cheque

BACS have advised me that I need new directdebit mandates from the remaining ACTAmembers whose last collection was before

November 2007. New mandates were mailedto the members concerned in earlySeptember with a stamped addressedenvelope. I would be grateful if these couldbe returned as soon as possible and apologisefor the inconvenience.

Please do not hesitate to get in touch if youhave any queries.

Yours sincerely

Jon MackayMembership SecretaryJon.mackay@papworth.nhs.uk

7

Following on from the highly successfulSpring meetings held in London – thanksto my colleague at St George’s Nick Fletcher

for organising ACTA Echo and Mathew

Barnard at the Heart Hospital for the 25th

Spring ACTA Meeting at the London Zoo –

one can usually relax a little and wind down

into the Summer months which are

traditionally considered to be quiet ones in

the academic year. Unfortunately this has not

been the case for the ACTA Committee who

had been tasked with a number of projects to

complete before the autumn round of

meetings.We have now refined and redrafted

our Articles of Memorandum in line with new

legislation introduced in April 2008.We have

been granted charitable status in Scotland –

an important factor in regard of meetings

organised north of the border.Annual

accounts have been completed, audited and

lodged with the appropriate authorities and

we have reviewed our investment strategy to

optimise our capital return.

June saw the launch of the NCEPODreport into deaths following first-timeCABG surgery, the principle

recommendations of the report focused on

the need for enhanced multi-disciplinary team

working throughout the patient pathway as

being the solution to further reducing the

mortality for this group of patients.Although

supportive of the recommendations as a

whole,ACTA and the SCTS were unhappy

with the tone of the press statement which

accompanied the launch and made our

disquiet known through our own joint press

release – I appreciate that dialogue with

surgeons might be considered a step too far

by some!

The national cardiothoracic benchmarkingcollaborative review meeting took placeat the end of June; Jon MacKay formed part of

the faculty and facilitated a workshop, looking

at improved ways of working in cardiac

theatres and critical care.The NCBC steering

group will be meeting in the autumn to

discuss the future direction of this project.

In July the DoH launched its developmentdocument on Medical Revalidation-Principles and next steps1: the document

outlines the direction and requirements of the

proposed re-licensing and re-certification

process.The re-certification process will be

based upon standards for specialist practice as

determined by Royal Colleges working with

specialty associations and approved by the

GMC. Over the summer months we have

been working with the RCoA to establish a

set of standards applicable to cardiothoracic

anaesthesia which meet with the principles as

outlined in the CMO’s discussion document.

I hope to publish these on our website in the

late autumn after further discussion and input

from the committee, linkmen and the RCoA.

ACTA continues to support those of itsmembers seeking ACCEA nationalawards at levels 9-11, the timeline for the

2009 process has been foreshortened to

allow an earlier notification of successful

applicants.The national on-line application

process will close on 19th December 2008;

I have already requested individuals seeking

ACTA support to send a copy of their CVQ

to me for consideration by the ACTA ACCEA

committee. I look forward to hearing from

you.

The DoH have announced their intentionto review paediatric cardiac services inthe UK and requested assistance from ACTA

in nominating members of the working party.

Thanks to all of you who expressed an

interest in this post. I forwarded CV

summaries to the DH in August and await

their deliberations both on the terms of

reference of the working party and its

constituent members.The vexed issue of

perfusionist prescribing remains unresolved

and there has been little movement over the

last few months.ACTA members voted not to

support the use of patient specific directives

as a quick fix solution to the problem, but

strongly favoured early regulation by the

DoH.We have not been persuaded to alter

this position and await further developments.

On the research front ACTA are nowrepresented on the board of theNational Institute for Academic Anaesthesia,

this coupled with our own in house initiative

to establish a cardiothoracic research

collaborative are important steps in

maintaining the research profile of

cardiothoracic anaesthesia.

We approach the autumn round ofmeetings. Our next meeting takesplace in Harrogate on the 14th November

and is organised by Mike Cross and the Leeds

group of cardiothoracic anaesthetists.The

Autumn Meeting will be preceded on the

Thursday by an ACTA sponsored ICM

refresher course.We continue with our aim

to co-host a meeting with the SCTS and have

identified a timeline to its development.

Plans for EACTA 2010 in Edinburgh remain on

track and I am sure that Pete Alston will be

seeking help and support from the

membership to make it a memorable

occasion.

Finally I should like to express mypersonal thanks to the ACTA committeeJon, Pete, Ravi,Alistair and Donna who have

supported me throughout what has been a

very busy year for the Association.All have

contributed in a major way. Should you wish

to comment upon any of the topics or issues

raised in this piece or any other ACTA related

issues please e-mail your comments to our

ACTA administrator at the RCoA. I look

forward to seeing you in Leeds.

J-P van BesouwACTA Chairman

1.Available atwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086430

CHAIRMAN’S Report

8

David Sharpe Memorial Symposium

Membership andJournal

The EACTA membership fee now includes a

complimentary (but not free!) copy of the

Journal of Cardiothoracic and Vascular

Anesthesia instead of the European Journal of

Anaesthesia.The membership subscription has

increased to offset the cost, and the discounted

three-year rate is now only available by direct

subscription rather than through joint

ACTA/EACTA membership. Those members

who pay a joint membership fee through ACTA

will get their current membership for 18

months instead of the usual 12 to compensate

them for the failure of EACTA to ensure

delivery of the EJA under the previous

arrangement.The database of UK members of

EACTA held by MCI/Ovation is pitiful and I

have been trying to update the UK

membership information (where have I heard

that one before...?). If you are an EACTA

member and do not receive your copy of

JCTVA could you please let me know, together

with mailing and email addresses.

On 11th & 12th September the 2nd DavidSharpe Memorial Symposium – Managingaortic valve disease – took place in theLancashire Cardiac Centre,Victoria HospitalBlackpool.This followed last year’s successwith – Managing mitral valve disease.Anaesthetists, cardiologists and surgeonsattended a 10 CPD approved interactivemeeting with faculty from UK, Europe, USAand Canada. Local faculty contribution andindustry sponsorship was invaluable to theorganisers Mr Joseph Zacharias and DrChristopher Rozario.

Dr Bury (VHB) began a multidisciplinarysession with CT and MRI assessment of theaortic valve followed by Prof Shanewise (N.Y.)with TOE aortic valve assessment. Dr Lansac(Paris) progressed from dynamic anatomy ofthe aortic root to conservative aortic valvesurgery.

After coffee Professors El Khoury (Brussels)and Shaefers (Homberg) outlined their aorticvalve conservation techniques. In theafternoon their operations were synchronisedfor live broadcasting. Prof Shanewise facilitated

TOE assessment while Prof Dreyfus (RoyalBrompton) chaired lively questioning from theauditorium.

Operations were completed in time fordinner in the neighbouring De Vere Hotel.Delegates dined to music from members ofthe Royal Northern College of Music andProfessor Raj Persaud talked on Motivationand Stress in the NHS. He was well receivedand afterwards specially commissionedglassware was presented to speakers.

Day two began as an Echo-lab on aortic valvedisease led by Prof Shanewise and DrSwanevelder (Leicester). Dr Swanevelder thenengaged all with early postoperativeassessment in aortic valve surgery.A timelyupdate by Dr Knowles (LCC) of the previousday’s surgery confirmed its success.Afterwards Dr Saravanan (LCC) revieweddata from Bristol Royal Infirmary, theLancashire Cardiac Centre and PapworthHospital to underline the value of routineTOE in aortic valve surgery. In a subsequentvideo session Dr Lansac illustrated hisapproach to fixing the aortic annulus while

Prof Gersak (Ljubljana) discussed beatingheart aortic valve surgery.

After lunch the Ross Procedure – Mr Hassan(Newcastle), percutaneous aortic valveReplacement – Dr Jilaihawi (Leicester) andtrans-apical aortic valve replacement – ProfLichtenstein (Vancouver) were explored indetail. Before conclusion a wet-lab allowed allto get ‘close and personal’ with aortic valvesurgery.Anaesthetic operative enthusiasm wasgenerously recognised by surgical colleagues.

It remains now for the Lancashire CardiacCentre to extend a further invitation to the3rd David Sharpe Memorial Symposium –Managing Coronary Artery Disease – inNovember 2009.

Peter Martinovsky

Christopher J Rozario dr.rozario@bfwhospitals.nhs.uk

EACTA News

EACTA Echo

The EACTA Echo course was held in Rome at

the end of September 2008. This year, for the

first time, the preparation for the TOE exam

has been organised jointly with the EAE. This

meeting is on-track to be one of the most

successful EACTA echo courses yet.

Trevi Fountain, Rome

FellowshipAccreditation

An important achievement this year is the

activation of the first EACTA-accredited

training program, in Leipzig, following the

EACTA-ESA agreement a couple of years ago.

EACTA is ready to evaluate applications from

other European centres (see the dedicated

page in the Members Only section of the

website). The Representative Council decided

in June 2008 to also allow the accreditation of

“limited” cardiac programs, with the exclusion

of the vascular and/or thoracic parts of the

program.

Understanding withEACTS

EACTA is establishing relationships with other

scientific associations with similar aims, and a

co-operation with the EACTS has been

established, based on an exchange of expertise

and probably joint sessions within each

meeting.Watch this space.

9

Dr Parry Brown who was always knownto friends and senior colleagues simplyas “Parry”, died in Cambridge in November2007 aged 99 years. He had worked at theLondon Hospital from 1933 to 1973 and as ayoung man, he also worked the NationalHeart and Brompton Hospitals.

Parry was recognised as a versatile andpioneering anaesthetist during his career.He was always very calm in the operatingtheatre and his surgical colleagues reliedheavily on his expertise and judgment. He wasvery well liked and is remembered very fondlyby all those he worked. However, under thepolite exterior lurked an inner steel. He likedto do things his way and woe betide a traineewho displeased him by using some maverickvariation on his technique. For instance, heparticularly disliked the use of carbon dioxideto stimulate breathing at the end of ananaesthetic and its unauthorised use wouldinduce a polite but personally devastatingrebuke.

At the beginning of his career anaesthesiawas still practised with ether and aSchimmelbusch mask and Parry was still ableto demonstrate this technique at his lastanaesthetic before his retirement in 1973. Heis also remembered as an exponent ofinduction of anaesthesia with a rectal infusionof Bromethol.This technique, which seemsperversely eccentric to us today, almostachieved the status of a religious ceremony asthe Bromethol was brought to theatre in andadministered through a tube from a silvercanister. Parry strongly believed that it wasthe safest induction for patients withthyrotoxicosis undergoing thyroidectomy.Parry also maintained anaesthesia forthyroidectomies was by holding on a specially

adapted mask with the patient breathingspontaneously.This technique was particularlystressful for a trainee with small hands.

His main interest was thoracic anaesthesiaand the bulk of his career was beforethe advent of cardiopulmonary bypass. Heworked with Mr Vernon Thompson(Thompson bronchus blocker) and MrGeoffrey Flavell at the London and Sir ThomasHolmes Sellors at the Brompton.At that timeone-lung anaesthesia was achieved by the useof the fearsome Carlen tube of which he wasa master. Parry believed in the “educated hand“for thoracic anaesthesia and at that timeventilators in theatre were in short supply.Monitoring even into the mid 1960s consistedof a blood pressure cuff or oscillotonometerand Parry always had a finger on the temporalpulse. For a long time there was only oneECG monitor in the London Hospital theatresand whether you used or not depended onhow early you arrived in the morning.

Parry was most famous for the ParryBrown “prone” position used for patientshaving pulmonary resections first described inThorax1 in 1948. (See picture) This alloweddrainage of excessive secretions particularlywith bronchiectasis and tuberculosis.Theposition prevented spill over of secretions to

the contra lateral lung and depended thesurgeon being familiar with a posteriorapproach to the thorax.The only disadvantageascribed to this position was the suddencardiovascular collapse that occurred in somepatients with limited cardiovascular reservewhen they were turned face down. (Nosaturation probe, no arterial line, no ECG, afinger on the pulse and hand ventilation!)

The patient lies prone with flexed hips andpillows under the chest and pelvis,allowing the abdomen to hang free.Theipsilateral arm hangs over the edge of theoperating table (drawing the scapula away

from the incision site) with the contralateralarm lying at the side.The head is extended onthe atlanto-occipital joint and rotated to theipsilateral side so straightening the line of thetrachea and contralateral bronchus.When theoperating table is tilted, secretions willgravitate along the tracheal tube to the mouthand can be easily suctioned.This is in directcontrast to the Overholt position wheresecretions tended to remain in the lung untilthe bronchus was divided.This position hadthe advantages of continual drainage of thelungs, together with greater mediastinalstability, albeit at the expense of a morelimited incision as compared to a lateralthoracotomy. It represented a significantadvance in thoracic anaesthesia and wasinitially described using a single lumen trachealtube.

Cardio-thoracic anaesthesia has come along way since then but it is well topause occasionally and remember men likeParry Brown who had the skills and clinicalacumen to develop the techniques that haveeventually led to where we are today.At thesame time we should also remember thepatients who had the courage to subjectthemselves to anaesthesia and surgery at atime when both were so hazardous.

(1) Parry Brown,A.I. Posture in ThoracicSurgery.Thorax, 3:161-5 (1948)

Kate Wark

(with thanks to Jerome Cotter, Peter Colvinand John Simpson)

Dr Arthur Ivor Parry Brown (1908-2007)A pioneer of thoracic anaesthesia

Parry Brown

Parry Brown position.

10

The 2008 scientific meeting was held atthe Topkapi Palace Hotel in the TurkishMediterranean resort of Antalya.The hotel

buildings are modelled on the Topkapi palace

in Istanbul, but complete with swimming pools

and conference facilities. It was a curious

choice of venue which delegates shared with a

predominantly Eastern European clientele; the

adjacent hotel being a model of the Kremlin

accentuated the surreal climate.There was a

good turnout, with almost 400 delegates, but

only a small UK contingent.The Welcome

Reception was held in the Antalya Museum,

where there is a fascinating collection of

historical artefacts, followed by Turkish folk

dancing and rather meagre catering.The

scientific program was wide-ranging, covering

new developments in both cardiothoracic

anaesthesia and intensive care, and the

meeting was rounded off by an Ottoman-

style Gala Dinner in the grounds of the hotel.

The next annual scientific meeting is inAthens 27-30 May 2009, details arestarting to appear on the website

(www.eacta.org) now and the abstract

deadline is 4th December 2008.The following

year the meeting will be in Edinburgh,

coordinated by Peter Alston; the dates have

not been finalized but will probably be in June

and held at the Edinburgh International

Conference Centre. I would urge you to make

every effort to submit abstracts and attend

the meeting.

David Smithdavid.smith@suht.swest.nhs.uk

Annual Scientific Meetings

Tokapi Palace Hotel

Ottoman-style Gala EACTA Dinner in Antalya,Turkey

2008 ACTA CommitteeElection Results

Jon MacKay and Peter Alston were re-elected for a secondthree-year term on the ACTA Committee.

26th Spring Meeting of ACTAin Cambridge

Friday 19th June 2009

For further details contact Kamen Valchanov, Department ofAnaesthetics, Papworth Hospital.Tel: 01480 364406

ACTA Echo 2009Thursday 18th June 2009, Cambridge

For more details contact Roger Hall, Dept Anaesthesia PapworthHospital Papworth Everard CB23 3RE

Email: roger.hall@papworth.nhs.uk

EACTA 200927th-30th May 2009

Athens, Greece

http://www.eacta.org/page-11-01.shtml