A European training system in cardiothoracic surgery: is it time?

OBJECTIVE: Training in cardiothoracic surgery across Europe remains diverse and variable despite the ever closer integration of European countries at all levels and in all areas of life. Coupled with the increasing ease of movement across Europe, the need for uniform training programmes has arisen to allow for equivalent accreditation and certification. METHODS: We review the current training paradigms within the specialty across the world and in Europe and also explore the concept of competence. RESULTS: There are diverse training systems across the world and in Europe in particular. Competence-based training is the new model of training; however, competence remains difficult to define and measure. We propose a European Training Programme in Cardiothoracic Surgery that aims to standardize training across the European countries. CONCLUSIONS: The difficulties in unifying training across Europe are numerous, but it is time to implement a European Training System in Cardiothoracic Surgery that will deliver a competence-based curriculum.

Off-pump coronary artery bypass grafting: Anno 2011.

Since 1998, a large body of literature regarding off-pump coronary bypass surgery has been published, although varying techniques and outcomes likely have led to its inconsistent application. One approach has been developed and standardized at the University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium. This approach is straightforward and can be replicated without need for conversion toward cardiopulmonary bypass. The patient is 'conditioned' before and during the procedure. Both mammary arteries are harvested through a standard median sternotomy. The anterior surface of the heart is exposed with a horizontal line of left-sided pericardial stitches, just above the level of the heart. The anterior coronary vessels are anastomosed after routine shunting. The lateral and inferior aspects of the heart are exposed without deforming the atrio-ventricular axis. This is performed in a stepwise manner. The first step is anchoring a sling into the posterior pericardium under the roof of the left atrium. Second, this sling is gradually pulled upwards, supporting the heart as a cradle. Once the heart is exposed towards the zenith, an apical suction device stabilizes, reformats and exposes the ventricle. The lateral and inferior walls are then revascularized. As a strict no-touch aorta technique is used, free grafts are anastomosed to in-situ arterial grafts.

EACTS/ESCVS best practice guidelines for reporting treatment results in the thoracic aorta.

Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR: It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the reports.

Revascularization for unprotected left main stem coronary artery stenosis stenting or surgery.

For coronary artery disease with unprotected left main stem (LMS) stenosis, coronary artery bypass grafting (CABG) is traditionally regarded as the "standard of care" because of its well-documented and durable survival advantage. There is now an increasing trend to use drug-eluting stents for LMS stenosis rather than CABG despite very little high-quality data to inform clinical practice. We herein: 1) evaluate the current evidence in support of the use of percutaneous revascularization for unprotected LMS; 2) assess the underlying justification for randomized controlled trials of stenting versus surgery for unprotected LMS; and 3) examine the optimum approach to informed consent. We conclude that CABG should indeed remain the preferred revascularization treatment in good surgical candidates with unprotected LMS stenosis.

Primary bacterial pericarditis.

Purulent pericarditis is rarely the primary site of bacterial infection. It is usually a complication of an infection originating elsewhere in the body, arising by contiguous spread or haematogenous dissemination.This paper, however, describes a previously healthy young man, who developed a purulent streptococcal pericarditis with no localizable primary focus. Although many possibilities were investigated, the entry site of the pericarditis remains unknown. The incidence of purulent pericarditis has decreased considerably since the antibiotic era. It is typically an acute and potentially lethal disease, necessitating rapid diagnosis and adequate therapy to improve prognosis. Standard treatment combines appropriate antibiotic therapy with surgical drainage. However, the exact timing and type of surgery is still under discussion. Our patient was treated with antibiotics, subxiphoidal tube drainage of the pericardial fluid and intrapericardial thrombolysis. After three weeks, he developed tamponade, requiring partial pericardiectomy. He recovered completely and resumed his normal activities after a two-month hospitalisation.