AimsDescribe differences in changes in cardiopulmonary exercise testing after surgery for severe primary mitral regurgitation between class I and class II indications for surgery. Methods Prospective observational study of patients who underwent transthoracic echocardiogram and cardiopulmonary exercise testing pre-operatively and six months after surgery. Results Forty three of the fifty patients recruited between February 2017 and October 2018 were included in per protocol analysis. Seven patients were excluded-two patients did not meet inclusion criteria after further investigation, two patients were unable to perform pre-operative cardiopulmonary exercise testing, two patients had post-operative mortality, one patient declined post-operative cardiopulmonary exercise testing. Median age was 64 years and 15 patients (34.9%) were female. Thirty five patients had impaired post-operative functional capacity defined as post-operative left ventricular ejection fraction on echocardiogram <50% and/or post-operative percentage predicted peak VO2 ≤ 84%). In patients with class I indication for surgery (n = 30), there was no significant change post-operatively in ppVO2 (81 (69-88) % vs. 79 (60-87) %, p = 0.09). In patients with class II indication for surgery (n = 13), there was a significant fall post-operatively in ppVO2 (82 (79-92) % vs. (74 (68-86) %, p < 0.01). In the univariate analysis, pre-operative ppVO2 ≤ 84% (p < 0.01) was a predictor for impaired post-operative functional capacity. Conclusions Patients with class I indication have persistently abnormal exercise performance six months after surgery. Patients with class II indication for surgery have worse exercise performance parameters six months after surgery. Pre-operative ppVO2 ≤84% is an independent predictor of impaired post-operative functional capacity at six months.

BACKGROUND:Optimum timing for surgery in asymptomatic/mildly symptomatic adult patients with Ebstein anomaly remains uncertain. This study assessed the association between preoperative cardiopulmonary exercise testing (CPET) and mortality, and longitudinal changes in CPET. METHODS:A retrospective review was conducted of consecutive adult patients with Ebstein anomaly who had tricuspid surgery between 2007 and 2018 with preoperative CPET. Primary outcome was all-cause mortality and secondary outcomes included changes in CPET. RESULTS:The cohort included 116 patient, of whom 94 (81.1%) were New York Heart Association Functional Class I/II. Median age was 39.6 years, and 75 (64.7%) were women. There were 44 (37.9%) with ≥1 prior sternotomies, 58 (50%) underwent Cone repair, and 55 (47.5%) had tricuspid replacement. Median percentage predicted peak oxygen consumption (Vo2) was 62%, and ventilatory efficiency was 30 L/min/min. Fifteen (12.9%) had severe right ventricle dysfunction, and median left ventricular ejection fraction was 58%. At a median follow-up of 9.8 years, there were 8 deaths. Ventilatory efficiency trended to be associated with mortality (P = .075) on univariate analysis and was the largest contributor to prediction of mortality in machine learning random forest models. Thirty-three patients had CPET at a median of 2.9 years after surgery. There was significant improvement in ventilatory efficiency (30 L/min/L/min preoperatively vs 27 L/min/L/min postoperatively, P = .015). CONCLUSIONS:In those with minimal or no symptoms, ventilatory efficiency is one of the most important variables in predicting mortality after surgery. Patients may have improved ventilatory efficiency after tricuspid surgery for Ebstein anomaly. These findings highlight the role of CPET in optimizing timing of surgery.

Transatrial transcatheter mitral valve replacement is a hybrid strategy involving placing the patient on cardiopulmonary bypass and direct implantation of a transcatheter valve in a calcified annulus for mitral annular calcification. We report a rare phenomenon of systolic anterior motion of the leaflets of a transcatheter heart valve prosthesis used for mitral valve replacement causing left ventricular outflow tract obstruction. Although reported in transcatheter mitral valve replacement, we believe this is the first report of left ventricular outflow tract obstruction after transatrial mitral valve replacement and discuss the pre-disposing risk factors.

The preclinical study of atherosclerosis has traditionally centred around the use of small animal models, translating to large animal models, prior to first-in-man studies. We propose to disrupt this paradigm by designing an ex vivo pump perfused human limb model. The novel model consists of taking a freshly amputated limb and incorporating it into an ex situ pump-perfused bypass system (akin to extracorporeal membrane oxygenation), circulating warmed, oxygenated blood. The circuit incorporates an introducer sheath and guiding catheter for intravascular imaging and X-ray angiography. Regular monitoring is performed using blood gas analysis, aiming for physiological parameters. The model maintains oxygen saturations > 99% for the length of perfusion (up to 6-h). Clinical grade X-ray angiography, intravascular ultrasound and optical coherence tomography have been successfully performed. Indocyanine green, a near-infrared fluorescent dye that localises to atherosclerotic plaque, has been injected into the system and left to circulate for 90-min. Fluorescence reflectance imaging of the dissected arterial bed confirmed uptake in areas of calcific atherosclerotic plaque on intravascular imaging. This is the first demonstration of an ex vivo pump-perfused "living" limb experimental model of atherosclerosis, which shows promise for future studies in translational interventional imaging and molecular targeting.

Background Given the variety in mitral valve (MV) pathology and associated surgical techniques, extended reality (XR) holds great potential to assist MV surgeons. This review aims to systematically evaluate the currently available evidence investigating the use of XR and associated technologies in MV surgery. Methods A systematic database search was conducted of original articles and case reports that explored the use of XR and MV surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to February 2022. Results Our search yielded 171 articles, of which 15 studies were included in this review, featuring 328 patients. Two main areas of application were identified: (i) pre-operative planning and (ii) predicting post-operative outcomes. The articles reporting outcomes relating to pre-operative planning were further categorised as exploring themes relevant to (i) mitral annular assessment; (ii) training; (iii) evaluation of surgical technique; (iv) surgical approach or plan and (v) selecting ring size or type. Preoperatively, XR has been shown to evaluate mitral annular pathology more accurately than echocardiography, informing the surgeon about the optimal surgical technique, approach and plan for a particular patient’s MV pathology. Furthermore, XR could simulate and aid ring size/type selection for MV annuloplasty, creating a personalized surgical plan. Additionally, XR could estimate the postoperative MV biomechanical and physiological characteristics, predicting and pre-empting post-operative complications. Conclusion XR demonstrated promising applications for assisting MV surgery, enhancing outcomes and patient-centred care, nevertheless, there remain the need for randomized studies to ascertain its feasibility, safety, and validity in clinical practice.

Introduction: In recent years, major findings on concomitant procedures and anticoagulation management have occurred in Mitral Valve (MV) surgery. Therefore, we sought to evaluate the current practices in MV interventions across Europe. Methods: In October 2021, all national cardio-thoracic societies in the European region were identified following an electronic search and sent an online survey of 14 questions to distribute among their member consultant/attending cardiac surgeons. Results: The survey was completed by 91 consultant/attending cardiac surgeons across 12 European countries, with 78% indicating MV repair as their specialty area. 57.1% performed >150 operations/year and 71.4% had 10+ years of experience.Concomitant tricuspid valve repair is performed for moderate tricuspid regurgitation (TR) by 69% of surgeons and for mild TR by 26.3%, both with annular diameter >40 mm. 50.6% indicated ischaemic MV surgery in patients undergoing CABG if moderate mitral regurgitation with ERO >20 mm(2) and regurgitant volume >30 mL, and 45.1% perform it if severe MR with ERO >40 mm(2) and regurgitant volume >60 mL. For these patients the preferred management was: MVR if predictors of repair failure identified (47.2%) and downsizing annuloplasty ring only (34.1%).For atrial fibrillation (AF) in cardiac surgery, 34.1% perform ablation with biatrial lesion and 20% with left sided only. 62.6% perform concomitant Left Atrial Appendage (LAA) Occlusion irrespective of AF ablation with a left atrial clip. A wide variability in anticoagulation strategies for MV repair and bioprosthetic MV valve was reported both for patients in sinus rhythm and AF. Conclusion: These results demonstrate a variable practice for MV surgery, and a degree of lack of compliance with surgical intervention guidelines and anticoagulation strategy.

Background: Optimum timing of surgery for severe primary mitral regurgitation (MR) particularly in the absence of significant symptoms or echo evidence of LV impairment remains unclear. Other modalities of assessment include cardiopulmonary exercise testing (CPET) and novel echo measurements, such as LV global longitudinal strain (LVGLS). We sought to evaluate whether pre-op CPET or LVGLS are associated with survival after surgery. Methods: We identified consecutive patients who had surgery for severe primary MR between 2007 and 2017 and had pre-op CPET. Clinical and mortality data were collected from chart review and our institutional database. LVGLS was retrospectively collected by a single person blinded to patient outcomes. Primary outcome was post surgery all cause death, and we used univariable analysis to identify variables associated with all cause death. Results: We included 176 patients with median age 63 (IQR 51, 71) years, 63 patients (35.8%) were female and 31 patients (14.8%) had a history of atrial fibrillation. 165 patients (93.8%) had mitral repair, 18 (10.2%) had concomitant CABG, 22 (12.5%) had concomitant ablation procedure and 14 (8.0%) had concomitant tricuspid procedure. 114 patients (64.8%) were in NYHA Class I and 56 (31.8%) were in NYHA Class II. There was no operative mortality. Median % predicted peak VO2 (ppVO2) was 89 (74, 101), median ventilatory equivalent of carbon dioxide (VE/VCO2) was 28.0 (25.7, 31.0) l/min/l/min and median respiratory exchange ratio was 1.2 (1.1, 1.2). 73 patients (41.5%) had abnormal CPET (defined as ppVO2<85%). Median LVEF was 65 (60, 68) %, median LVESD was 35 (32, 38) mm and median LVGLS was 18.5 (16.6, 20.3) %. 45 patients (25.9%) had abnormal LVEF (defined as ≤ 60%), 11 patients (6.7%) had abnormal LVESD (defined as ≥45mm) and 35 patients (20.8%) had abnormal LVGLS (defined as <16%). At a median follow up of 10.2 (6.8, 13.2) years, there were 19 (10.8%) deaths. In the univariate analysis, age at surgery (HR 1.12, p<0.001), LVESD (HR 1.11, p=0.009), LVGLS (HR 1.11, p=0.013) and VE/VCO2 (HR 1.08, p=0.044) were associated with all cause mortality. Conclusion: A significant proportion of patients with no or mild symptoms exhibit echocardiographic evidence of LV impairment when having surgery for severe primary MR. CPET parameters such as VE/VCO2 and novel echocardiographic measurements such as LVGLS may predict risk of long term mortality and potentially inform timing of surgery in these patients.

CLINICAL INTRODUCTION A patient in their 60s previously underwent transcatheter aortic valve implantation for severe aortic stenosis with a postprocedural dual chamber pacemaker for complete heart block. They subsequently had prosthetic valve endocarditis which was treated with antibiotics, but developed valvular degeneration and aortic root pseudoaneurysm. As a result, the patient underwent mechanical aortic root replacement, mitral valve repair and coronary artery bypass grafting. The operation was unremarkable and intraoperative transoesophageal echocardiogram showed a wellfunctioning aortic valve prosthesis, mild mitral regurgitation and good biventricular function with no regional wall motion abnormalities. The pacemaker was reprogrammed on VVI mode at 80 beats per minute with underlying complete heart block. The patient was successfully extubated 3 hours after surgery with minimal inotropic support, good cardiac index and urine output and low drain output. However, they developed recurrent ventricular fibrillation requiring several defibrillations in spite of electrolyte optimisation and an amiodarone infusion. The postoperative chest radiograph is shown in figure 1.

Introduction: Our aim is to describe the use of cardiopulmonary exercise testing in watchful waiting for asymptomatic severe primary mitral regurgitation.Methods: Between October 2016 and October 2017, ten patients with asymptomatic severe primary mitral regurgitation underwent watchful waiting in a single centre. Baseline assessment included history, physical examination, transthoracic echocardiogram and cardiopulmonary exercise testing. Patients were re-evaluated every 6 months with history, physical examination and transthoracic echocardiogram; and at 12 months with cardiopulmonary exercise testing.Results: At 1 year follow up, five patients remained asymptomatic with no significant change in left ventricular ejection fraction (p = 0.18). This was associated with no significant change in cardiopulmonary exercise testing parameters. However, five patients developed early new symptoms or changes in echocardiographic parameters with a significant fall in left ventricular ejection fraction (p < 0.01). This was associated with a significant fall in anaerobic threshold (p = 0.04) and four of the five patients having an abnormal percentage predicted peak VO2 at 1 year follow up.Conclusions: Changes in symptomatic status or echocardiographic parameters during a watchful waiting approach for asymptomatic severe primary mitral regurgitation is associated with a significant reduction in cardiopulmonary exercise testing parameters.

•Stroke is a significant complication of transcatheter aortic valve replacement.•Computed tomography can quantify aortic valve calcification prior to intervention.•Aortic valve calcium on CT was associated with post-TAVR stroke.•This could inform discussions of individual patient stroke risk prior to TAVR.

The late 18th and early 19th century ushered an era of innovative ways to perfuse and aerate the heart, lungs, and various other organs in the body. Lillehei and colleagues presented their creative cross-circulation technique and reported successful outcomes in 32 surgical interventions. The real impetus happened later in mid 1950s by John Gibbon who pioneered modern-day open heart surgery using the IBM-Gibbon heart-lung machine. In spite of early disappointment, persistence by John Kirklin and colleagues popularized the cardiopulmonary bypass (CPB) machine which has now become a standard. The CPB machine however presents its own challenges, and the primary and secondary effects of the interaction between the blood and the artificial CPB apparatus remain a challenge. Many techniques and procedures, for example, off-pump surgery, minimally invasive extracorporeal technology, and minimally invasive surgical procedures are being refined and adopted to eliminate and/or minimize the deleterious of CPB which initiated systemic inflammatory response syndrome. Together with pharmacological interventions, the aim is to ameliorate these effects and successfully rehabilitate the patient to recover fully and benefit from the treatment of the underlying cardiac pathology. This chapter outlines the progress in cardiovascular perfusion and technology by outlining advancements in each component providing an overview of current evidence and literature.

Introduction Translational modelling for the study of atherosclerosis has been traditionally centred around the use of small animal models, translating to large animal models prior to first in man studies. We propose to disrupt this paradigm by designing an ex vivo pump perfused ‘live’ limb model, to enable researchers to study molecular targeting of atherosclerosis. Purpose To develop and test a novel experimental model of atherosclerosis, based on perfusion of an amputated human limb, to reduce time spent in translational pipelines and reliance on animal preclinical atherosclerotic research. Methods The novel model consists of taking a freshly amputated limb and incorporating it into an ex-situ ECMO system. A custom-made operating table was designed that facilitates the flow of venous blood back into the circuit. The outflow of the table is connected to an oxygenator and then a pulsatile pump in series. The oxygenator is supplied with a sweep gas of 40% oxygen: air mixture. A parallel circuit warms the system to 37°C using a thermocirculator. The circuit outflow is connected to a cannula that is sutured into the proximal end of an amputated limb artery, which permits the passage of an introducer sheath and guiding catheter for intravascular imaging and x-ray angiography (Figure 1A). The pump is set to provide an output of 15ml per stroke (to represent approximately 10% of clinical stroke volume), with an average pump rate of 70 per minute (equating to a heart rate of 70 beats per minute). Thus, total pump output, or ‘cardiac output’ to the limb is estimated at 1,050ml/min. Regular monitoring is performed using arterial blood gas analysis, with correction of pH, oxygenation, haemoglobin, lactate and electrolytes. All participants provided written informed consent, and ethical permission was granted by the Imperial College Healthcare Tissue Bank (REC Wales 17/WA/0161; subcollection CAR_RK_17_070) Results The model has been successfully performed (n=3), maintaining oxygen saturations >99% for the length of perfusion (up to 6 hours). X-ray angiography (Figure 1B), intravascular ultrasound (Volcano, Phillips) (Figure 1C) and optical coherence tomography (Dragonfly Optis, Abbott) (Figure 1D) was performed. In one limb, indocyanine green, a near-infrared fluorescent probe that localises to atherosclerotic plaque, was injected into the system (2mg/kg) and left to circulate for 90 minutes. The arterial tissue was then dissected (Figure1E), and fluorescence reflectance imaging performed (790nm) on the extracted tissue (Figure 1F). This confirmed indocyanine green uptake in areas of calcific atherosclerotic plaque on intravascular ultrasound and optical coherence tomography. Conclusions This is the first demonstration of this novel ex vivo on ECMO ‘living’ limb experimental model of atherosclerosis, showing promise for future use in translational interventional imaging and targeting studies.

Abstract Introduction The preclinical study of atherosclerosis has been traditionally centred around the use of small animal models, translating to large animal models prior to first-in-man studies. We propose to disrupt this paradigm by designing an ex vivo pump perfused “live” limb model, to enable the molecular targeting of atherosclerosis. Purpose To develop and test a novel experimental model of atherosclerosis, based on perfusion of an amputated human limb, to reduce time spent in translational pipelines and reliance on animal preclinical atherosclerotic research. Methods The novel model consists of taking a freshly amputated limb and incorporating it into an ex-situ pump-perfused bypass system (akin to ECMO) circulating warmed, oxygenated blood. A custom-made operating table was designed to allow the flow of venous blood back into the circuit. The outflow of the table was connected to an oxygenator followed by a pulsatile pump in series. A parallel circuit warms the system to 37°C using a thermocirculator. The circuit was connected to an outflow cannula sutured into the proximal end of the amputated limb artery, permitting the passage of an introducer sheath and guiding catheter for intravascular imaging and x-ray angiography (Figure 1A). The pump was set to provide an output of 15ml per stroke (to represent approximately 20% of clinical stroke volume), with an average pump rate of 70 strokes per minute (estimating a heart rate of 70 beats per minute). Thus, total pump output, or “cardiac output” to the limb was ∼1,050 ml/min. Regular monitoring was performed using arterial blood gas analysis, with correction of pH, oxygenation, haemoglobin, lactate and electrolytes. All participants provided written informed consent, and ethical permission was granted by the Imperial College Healthcare Tissue Bank (REC Wales 17/WA/0161; subcollection CAR_RK_17_070). Results The model has been successfully performed (n=3), maintaining oxygen saturations >99% for the length of perfusion (up to 6 hours). X-ray angiography (Figure 1B), intravascular ultrasound (Eagle Eye, Volcano, Philips; Figure 1C) and optical coherence tomography (Dragonfly Optis, Abbott Cardiovascular; Figure 1D) was performed. In one limb, indocyanine green, a near-infrared fluorescent dye (excitation 788/ emission 813nm) that localises to atherosclerotic plaque, was injected into the system (2 mg/kg) and left to circulate for 90-minutes. The arterial tissue (Figure 1E – posterior tibial [left] and fibular [right]) was then dissected, and fluorescence reflectance imaging performed at 790 nm on the extracted tissue (Figure 1F). This confirmed indocyanine green uptake in areas of calcific atherosclerotic plaque on intravascular ultrasound and optical coherence tomography. Conclusions This is the first demonstration of this novel ex vivo on ECMO “living” limb experimental model of atherosclerosis, which shows promise for future studies in translational interventional imaging and molecular targeting. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Wellcome Trust Clinical Research Fellowship

BACKGROUND:Primary mitral regurgitation (PMR) results in adverse remodeling changes and left ventricular (LV) dysfunction. Assessing LV function has prognostic value in predicting morbidity and mortality. Indications for surgery include parameters such as LV ejection fraction (LVEF) and systolic dimensions. Current guidelines are limited in identifying patients at optimal time for surgery. Impaired postoperative LVEF indicates poor prognostic outcomes and subsequent heart failure. Global longitudinal strain (GLS) via speckle tracking echocardiography (STE) presents as a promising parameter to detect subclinical dysfunction in asymptomatic patients. METHODS:Following PRISMA guidelines, a literature search was conducted with Cochrane Library, PudMed, SCOPUS, and Web of Science. Key MeSH terms included "mitral regurgitation," "mitral valve insufficiency," "global longitudinal strain," "deformation," "LV-GLS," and "GLS." Inclusion criteria included (1) patients with severe PMR, (2) mixed population of symptomatic and asymptomatic patients, (3) standardized methods in assessing LV systolic function using 2D-STE, (4) valve repair or replacement surgery, and (5) patient outcomes measured after surgery. Search returned 234 papers, 12 of which met the inclusion criteria and were subsequently reviewed. RESULTS:Baseline GLS is an independent predictor of postoperative outcomes, ranging from -17.9 to -21.7% GLS. A significant negative correlation was observed between preoperative GLS and postoperative LVEF. Impaired baseline GLS was associated with higher mortality rates. Better long-term survival rates were seen in patients who underwent early surgery. CONCLUSION:GLS shows sensitivity in predicting long-term postoperative outcomes. Further analysis is required to determine preoperative GLS threshold to identify asymptomatic patients at the optimal time for mitral valve surgery.

Central MessageTrends and outcomes of cardiac surgery in the UK show significant reduction in all-cause mortality. This is despite an increase in the risk profile and complexity of procedures.See Article page 259. Trends and outcomes of cardiac surgery in the UK show significant reduction in all-cause mortality. This is despite an increase in the risk profile and complexity of procedures. See Article page 259. In this issue of the Journal, Grant and colleagues1Grant S.W. Kendall S. Goodwin A.T. Cooper G. Trivedi U. Page R. et al.Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016.J Thorac Cardiovasc Surg Open. 2021; 7: 259-269Google Scholar report on the trends and outcomes for cardiac surgery over a 15-year period between 2002 and 2016 in the United Kingdom by using validated data from the UK National Adult Cardiac Surgery Audit database. Congratulations to the authors for performing linear regression analysis on 534,067 procedures to conclude that despite an increase in patient risk profile, there was a consistent reduction of in-hospital mortality from 4.0% to 2.8% in the latter years of the study. Logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) overestimates risk; the authors acknowledge that this improvement in observed to expected outcomes must be interpreted cautiously and that the risk factors required for EuroSCORE II were missing in the earlier original dataset. However, this underlines the limitations in retrospective analysis of a historical dataset, especially when the impact of diabetes, mild-to-moderate renal impairment, and multiple cardiac procedures (>2) were not scored in the older logistic EuroSCORE. In addition, patients are now operated more frequently as inpatients, minimizing the incidence of frequent myocardial infarctions and maintaining preserved left ventricular (LV) function. In the earlier years of the study, the waiting list for cardiac surgical intervention in the United Kingdom could be as long as 12 months. The impact of such delay is immeasurable and unquantifiable say, in terms of, deterioration of LV function; nonetheless, the authors do confirm a reduction in the proportion of patients with moderate or poor LV function over the time period studied. Also, the publication of surgeon-specific mortality data leading to risk aversion is difficult to appraise, but data needed to refute or substantiate this is nonexistent and its impact cannot be trivialized. So, what has driven this reduction in mortality rate, especially as the patient cohort has significantly more comorbidities? The drivers of this trend will inevitably be multifactorial. Improved preoperative and frailty assessment, multi disciplinary teams, operative techniques, postoperative management, and more availability of mechanical support are all likely to have played a role. Increasing adoption of percutaneous options may also have improved outcomes in conventional cardiac surgery and importantly to the reduction of redo procedures to 1% in the most recent year. Another significant limitation acknowledged is the absence of data on the impact of transcatheter aortic valve implantation on surgical aortic valve replacement. Finally, almost all of the risk scores have been developed largely for the coronary disease population. The authors report a decrease in the number of coronary artery bypass grafting procedures by 33.9% with an increase in the number of patients undergoing any valve surgery and isolated valve surgery by 70.7%, with the number of isolated valve procedures (aortic and mitral) up by 42.5%. This increase yet again highlights the need for a contemporaneous risk scoring system to accurately reflect such trends and outcomes. For example, LV ejection fraction of 55% is regarded as good LV function in the context of mitral regurgitation and is classified in the risk scoring systems as good despite well-established evidence base conflict, and certain procedures such as concomitant TV intervention, ablations, and complex aortic surgery are poorly risk stratified. Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016JTCVS OpenVol. 7PreviewCardiac surgery has evolved significantly since the turn of the century. The objective of this study was to investigate trends in cardiac surgery activity and outcomes in the United Kingdom utilizing a mandatory national cardiac surgical clinical database in the context of a comprehensive public health care system (ie, the UK National Health Service). Full-Text PDF Open Access

OBJECTIVE:Various methods for cardiothoracic, cardiovascular, and cardiac surgical training exist across the globe, with the common goal of producing safe, independent surgeons. A comparative analysis of international training paradigms has not been undertaken, and our goal in doing so was to offer insights into how to best prepare future trainees and ensure the health of our specialty.METHODS:We performed a comparative analysis of available publications offering detailed descriptions of various cardiothoracic, cardiovascular, and cardiac surgical training paradigms. Corresponding authors from previous publications and other international collaborators were also reached directly for further data acquisition.RESULTS:We report various approaches to common challenges surrounding (1) selection of trainees and plans for the future surgical workforce; (2) trainee assessments and certification of competency before independent practice; and (3) challenges related to a changing practice landscape.CONCLUSIONS:Cardiothoracic surgery remains a dynamic and rewarding specialty. Current and future trainees face several challenges that transcend national borders. To foster collaboration and adoption of best practices, we highlight international strengths and weaknesses of various nations in terms of workforce selection, trainee operative experience and assessment, board certification, and preparation for future changes anticipated in cardiothoracic surgery.

A 49-year-old diabetic male was admitted to a hospital in 2018 following a 3-week history of worsening dyspnoea and pedal oedema. Early review and investigations indicated acute heart failure. Transthoracic echocardiogram (TTE) revealed mitral regurgitation (MR), aneurysmal change of the ventricles, a ventricular septal defect (VSD) and systolic dysfunction. Coronary angiogram demonstrated a significant left anterior descending and right coronary artery disease. He was diagnosed with a late presenting myocardial infarction (MI) with secondary mechanical complications. Mechanical complications of MI frequently require surgical intervention. The patient underwent a repair of VSD, mitral valve repair, excision of aneurysmal segment and coronary artery bypass grafting. Post-operative recovery was complicated by a sternal wound infectionmanaged in conjunction with the plastic surgeons. A post-operative TTE showed a repaired ventricular septum and no residual MR. Early recognition and appropriate medical optimisation are required to achieve good patient outcomes.

Background: Cardiopulmonary exercise testing (CPET) is a pre-operative risk stratification tool utilising factors such as the anaerobic threshold (AT). Evidence suggests that patients undergoing major hepatobiliary surgery with an AT < 11 ml/kg/min are at increased risk of post-operative morbidity and mortality. This review aims to compare outcomes in patients with a pre-operative CPET with a AT > 11 ml/kg/min against those < 11 ml/kg/min.