Eugen Varlan was advised as a stager reseacher in scientific laboratory of cardiosurgery of Cardiology Institute In 1995 and in few months (November 1995) sucessfully performed extracorporeal circulation in cardiac surgery operations. During 22 years he performed above 3500 extracorporeal circulations in the majority cases of paediatric cardiac surgery (radical correction of Tetralogy Fallot, radical correction of Atrioventricular Canal, mitral and tricuspidal annuloplastic, Glenn and Fontan operations with extracorporeal circulation assistance, switch correction of Transposition of Grand vessels, Mustard operation, Norwood correction) and, of course, assistance at all adult operations and ECMO. By his insistence the method of modified ultrafiltration (see his publications in” Art of Surgery”- journal of Moldavian Surgery Society) was introduced In practice in the Republic of Moldova. He wish to see the “Hospital for Sick Children “ in Great Ormond Street where Martin Elliot introduced this revolutionary method.

Both severities of cardiac surgery and technical features of extracorporeal circulation circuit demands blood transfusion from donors, which involves a number of risks for the patient, especially with low body weight. Priming of the cardiopulmonary bypass circuit with patients\' own blood [retrograde autologous priming (RAP)] is a technique used to limit haemodilution and reduce transfusion requirements. \r\nPurpose: to explore the possibilities of reducing the volume of homologous blood transfusion in pediatric cardiac surgery.\r\nMaterial and methods: the study included 250 children (131 boys, 119 girls)with congenital heart disease, operated on heart under CPB, weighting less than 20kg (20.45 ± 3.15) and 3.4 ± 1.7 years average age, who were divided into experimental (125 children) and control group (125children). In the control group conventional CPB was performed (supplementing the priming with red blood cells), while in study group CPB was started after RAP via aortic cannula with recuperation till 45 % of “priming”. The hematocrit (Hct), lactate (Lac) levels at two perioperative time-points, and intraoperative and postoperative blood usage were recorded. There were no significant differences in CPB time, aortic cross-clamp time between groups. Cell Saver wasn’t used in both groups (is not effective in children cardio surgery).\r\nResults: No hospital lethality occurred in the study and no surgical hemostasis was performed. Blood loss accounted for 6.2 ml/kg /24h. Postoperative transfusion of homologous blood (erythrocyte mass) as needed 73 children, that make up only 29,2% of the whole study group. Amongst children who received transfusion on pump, the number of homologous units of packed red blood cells was less in the RAP group than that in the standard priming group intraoperatively and perioperatively (0.54 ± 0.17 vs. 1.48 ± 0.68 units, P = 0.03; 0.94 ± 0.54 vs. 1.69 ± 0.69 units, P = 0.15). There were no significant differences in CPB time, aortic clamp, and Lac value between the two groups (P>0.05). Clinical outcomes were similar with respect to pulmonary, renal and hepatic function, length of ICU stay and hospital stay.\r\nConclusions: “priming” minimalisation and autologous blood priming, ultrafiltration, could diminish the necessity of perioperative homologous blood transfusion in infant cardiac surgery.\r\n

Dr Neil Bodagh is an academic foundation year 2 doctor currently based at Barts Health NHS Trust. He completed his foundation year 1 training at Barking, Havering and Redbridge NHS Trust which is where this project was undertaken. Dr Fahad Farooqi is a consultant cardiologist based at the Barking Havering and Redbridge NHS Trust.

High quality discharge summaries facilitate safe transfer of care by communicating relevant clinical information to GPs after hospital discharge. This is especially important in complex clinical syndromes such as chronic heart failure where multidisciplinary teams are required to effectively co-ordinate community care and minimise the risk of re-hospitalisation.rnThe quality of heart failure discharge summaries issued by the two District General Hospitals within our Trust was assessed. We tested the effectiveness of a discharge summary checklist intended to improve documentation. All issued discharge summaries following unplanned hospital admissions with a primary diagnosis of heart failure were identified over a 3 month period using Hospital Episodes Statistics data. The content of each discharge summary was objectively assessed using a point based scoring technique. Junior doctors working on a single ward were exposed to a checklist poster providing guidance on composing a quality heart failure discharge summary (n=24). Their performance was compared against doctors working on other wards who were not exposed to the checklist (n=84).rnA total of 164 discharge summaries were assessed. In the ward exposed to the discharge summary checklist poster the mean discharge summary score was 6.1 +/- 0.59. In the wards that weren\'t exposed to the checklist, the mean discharge summary score was significantly poorer 2.7 +/- 0.19 (p<0.001).rnOur study demonstrates that the provision of a checklist was associated with a statistically significant improvement in the quality of heart failure discharge summaries issued by our Trust. This intervention was simple to implement at minimal cost and potentially helps junior doctors communicate more effectively with primary care.rn

Background: Aorta-to-right atrial fistula is an extremely rare late complication of prosthetic aortic valve replacement. Increased survival and improved patient outcomes following complex aortic valve surgeries poses paramount significance to the recognition of this unusual complication. \r\nCase: An 80-year-old female presented with 2 month history of exertional dyspnea and reduced exercise tolerance. She was 10 months post aortic valve replacement with a pericardial aortic bioprosthesis, and a left internal mammary artery graft to left anterior descending artery, on a background of severe aortic stenosis and ischemic heart disease. Clinical examination demonstrated raised jugular venous pressure and a faint systolic murmur. \r\nDecision-making: Transthoracic echocardiogram revealed a dilated right atrium (RA) and right ventricle (RV), severe tricuspid regurgitation (TR), and a D-shaped septum in diastole suggesting raised RV end-diastolic pressure, possibly pulmonary hypertension. These findings were absent prior to cardiac surgery.\r\nCardiac magnetic resonance imaging (CMR) was performed to evaluate the unexplained TR. CMR raised the possibility of an aortic root to RA shunt, but aortic valve artefact limited complete evaluation. The RV to LV stroke volume ratio of 2:1 was more compatible with a shunt rather than isolated TR. \r\nSubsequent transesophageal echocardiogram (TEE) colour Doppler demonstrated a systolic shunt through an echo-free space from the aortic root into the RA, converging with the severe TR jet, with evidence of RA and RV volume overload.\r\nThe patient was referred back to the cardiothoracic surgeon in view of revision surgery. The prosthetic aortic valve was excised with placement of a new aortic bioprosthesis and suturing of the fistula, followed by insertion of a tricuspid annuloplasty band.\r\nThe patient made a good recovery without any complications and reported significant improvement in her symptoms in clinic follow-up at 8 weeks.\r\nConclusion: Denovo cardiac symptoms and evidence of pulmonary hypertension on transthoracic echocardiogram in a patient post aortic valve surgery warrents further investigation with CMR and TEE, considering the possibility of aorta-to-RA fistula.\r\n

Ramesh is a core medical trainee at the cardiology department at Queen Elizabeth Hospital Woolwich. This provides management for a broad range of cardiology diagnoses.

Introduction\r\n\r\nInvasive coronary angiography has risks. We were concerned by evidence at our centre of high numbers of ‘normal’ coronary angiograms.\r\n\r\nAim\r\n\r\n1. Are referrals appropriate?\r\n\r\n2. Can we implement non-invasive pathways in low risk patients?\r\n\r\nMethod\r\n\r\n• Retrospective data collection over 8 months\r\n\r\n• Exclusion criteria: Pressure wire study or showed more than ‘moderate atheroma’.\r\n\r\n• Exclusion criteria for sub-group analysis: preceding functional testing or incontrovertible indications (eg cardiac arrest).\r\n\r\nResults\r\n\r\n37% of coronary angiograms were ‘normal’ (302) (67% outpatients; 33% inpatients).\r\n\r\nOutpatient: Indications included angina (83), atypical chest pain (51) and breathlessness (21). The number of risk factors was evenly spread between 2-5. Only 5 patients with greater then 5 risk factors had ‘normal’ coronary angiograms\r\n\r\nInpatient: Indications included NSTEMI (53) and unstable angina (27). 23 unstable angina patients had a GRACE score below 140 and 12 also had no regional wall motion abnormalities (RWMAs) and normal Left ventricular systolic function on echo.\r\n\r\nDiscussion\r\n\r\nOutpatient: NICE guidelines recommend the use of CT Coronary Angiogram as a first line in the investigation of low-medium patients.\r\n\r\nInpatient: Unstable angina patients with low GRACE score and no RWMAs can be managed with functional testing as per ESC guidelines.\r\n\r\nConclusion\r\n\r\nNew pathways:\r\n\r\n• Outpatient Investigation of Chest Pain:\r\n\r\n1. CTCA\r\n\r\n2. Non-Invasive Functional testing\r\n\r\n3. Coronary Angiogram\r\n\r\n• Inpatient Investigation of Unstable Angina with functional testing if:\r\n\r\n1. Trop negative\r\n\r\n2. GRACE score <140\r\n\r\n3. Normal LV function and no RWMAs\r\n\r\n\r\nFuture studies\r\n\r\n1. Efficacy of functional testing at local centres?\r\n\r\n2. Re-audit after pathway implementation\r\n