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Hello, everyone. Thanks for joining us this evening. Um We're gonna aim to make a start fairly soon. So it's a pleasure to introduce Miss Georgia Leighton, who's our cardiac registrar that joined us earlier in the week. Um She's gonna be talking us through um an a dissection video of the heart and talking us through some of the important anatomy. Um Just an important thing to note before we start, this obviously contains animal tissue. So if anyone doesn't want to watch this part of the lecture or wants to join back a little bit later, we'll aim to restart the second part of the talk at about half past seven. So please feel free to kind of pop away and have a cup of tea and come back if this, if this part of the lecture isn't quite for you. Um So without further ado I'll, I'll hand over to Georgia. Thanks Kirsty. So I'm just gonna share my window. Are you able to see my slides? No. Oh, yeah. Yeah, we can, yeah, you can see my face. Yeah. Yeah, perfect. And now you can see full slide. Yep. Uh A daily life is a bit of a lag. Ok. Uh, maybe try again. Yeah. Technical difficulties. Any luck. Uh, no. Ok. So I think it's just my laptop lagging and it will pop up in a minute but while we're waiting, so I'm oncotic surgery. So that means that I am a doctor. I've now been a doctor for coming up on, uh, you qualified nearly 9, 10 years. And, um, I'm in sort of the mid part of my training. So I've done all my basic training, tried less of everything and now I have dedicated myself to going through cardiothoracic surgery pathway. Um, there's a couple of different specialties, subspecialties within cardiothoracic as a whole. And I think the program this week is really nicely highlighting all the different aspects of that. So tonight's focusing mostly on cardiac surgery. So surgery of the heart specifically and that tends to be adult surgery and uh child surgery. Let me, uh, I think it's working. Now, can you now see my slides in my face with my pa? Yeah. Yes, I think there's a lag. Oh, gosh, I'm sorry, I don't know why it's, uh, that's ok. We can see, yeah, we can see them kind of in pre present of you. Ok. So then now in full view, so hopefully you can see them coming up. Um, let me know if they switched from present to you in a minute. Ok. Uh, so as I said, I am now mid department training. So we, I'm going to be doing this for a number of years. And this is basically the core part where you're focusing on the strategy that you're interested in and you're really working towards becoming a consultant. So I'm just going to touch briefly on um what kind of a normal day as a registrar look cycle should say a normal week. So um by the time you become a registrar, you have at least a couple of years of basic training, you will have some experience in the area that you are interested in pursuing long term. So you um there are different levels of senior, but you certainly have a degree of seniority, which means that you may start making a lot of decisions. You start taking on extra responsibilities and these kind of responsibilities are going to be looking after broadly speaking, your patients before operations, your patients during their operations and progressively doing more and more of those operations. And then obviously looking after your patients, once they've had surgery both in hospital and then once they've gone home as well, and it's quite a complex um, job that is going to be very depending on where you're working, your level of experience and who you're working with. But ultimately, you are going to be meeting patients in clinic. So they will come to the hospital just for an appointment to see you or your team. You may also see people who've been admitted unexpectedly to hospital, you will ask them a lot of questions about themselves, about their history. You have a look at the tests that they've had. So in cardiac surgery, that's going to be critically, things like coronary angiograms, looking at the blood side of the heart, um an echo which is going to tell you uh primarily about how the valves are working, how the heart is pumping and the muscle function, um and a whole host of other things. And with experience with obviously some education and knowledge of guidelines and recommendations in your specialty, you will be recommending surgery to patients, you will be telling them about alternative options. Um and you will be talking through the risks and benefits of having surgery, of not having surgery and so on. And when it comes to uh looking after patients during their operation, so the kind of complexity of the operation will determine how much you do or don't do. Um at the very beginning, you're going to do a lot of watching. You might not even be scrubbing in for a surgery, then you're going to be scrubbing in and helping your involvement will be increasingly more. And then once you've demonstrated all the essential skills for a specific step of the procedure, um you will progress to then trying to do that procedure initially, maybe any parts of it initially with lots and lots of supervision. And then as you become more experienced, more confident and more skilled the amount of supervision decreases and the amount that you're doing increases until hopefully, just before you come, become a consultant, perhaps for at least six months or a year, you're going to be doing lots of operating, uh pretty much independently, if not completely independently. So you're ready to become a consultant and be uh the most senior member of the team in that specific circumstance. And then of course, getting patients through an operation in many cases, is not the most difficult part, getting them through the recovery after the surgery. So the anesthetic and everything that comes with it is a much more complex um situation when we do heart surgery, particularly if we're using the heart lung machine, we are temporarily stopping the heart, we are temporarily stopping the lungs. Um We are putting patients at risk of major immune um system activation. They get uh obviously high rates of infection, abnormal heart rhythms, trouble with all sorts of all host of organs across the body, brain, kidney, liver and so on. So, um recovery from heart surgery specifically and particularly the bigger operations that we do can be very complex. It can be very challenging for patients. There's obviously a big psychological component that we have to coach patients through as well as all the classical scientific aspects and the true, true medicine that we're doing. So, an average week it's going to just to interrupt, I don't think your slides have moved on. Oh, Ok. Um, sorry, I don't know what, oh, there we go. It's just moved, it's literally just moved to an average week. Ok. An average week. Great. Um, so an average week is going to look really different depending where you work, what point of your career you're in, who you're working with. But broadly speaking, as a surgical registrar, cardio facet registrar, your average week on a clinical job will hopefully include a good amount of operating and a good amount could be a full day to a couple of days. Hopefully three even four days, those are going to be long days. Often, you will be in the from 7730 in the morning. You may not be going home to a similar time if not later in the evening, but it's not every day. So there is some balance you're going to have clinics and that's when we're seeing, meeting those people with a visiting hospital before and after an operation. Um So that tends to be uh you know, much calmer setting, uh slightly more relaxed than necessarily an operating day. You're going to be doing a ward round and that's seeing all your patients that are in the hospital at any given time. The number again is going to be hugely variable, but that is often seeing everyone at least once in the morning for your postoperative patients. You may see them 2nd, 3rd, 4th time throughout the day and anyone sick, you can be seeing them regularly. So that's kind of an ongoing proactive process. And as part of that is going to be asking for tests and checking the results and asking for blood tests and, and kind of monitoring progress until your patient is discharged. Um You are going to be doing a lot of admin, unfortunately, particularly in the NHS side of things, we don't necessarily have great administrative support overall um compared to places like the US. So you're going to be writing a lot of your, your own notes, you're going to be chasing at clinic, letter chasing at reports and things like that. And that can take up to maybe the equivalent of a whole day in a, in a working week, there will be often lots of meetings MDT S where we get together with specialists from different um environments that will be colleagues from intensive care, anesthetics, cardiology, especially perhaps other branches of cardiac surgery like congenital cardiac surgery, who are um also cardiac surgeons, but they are more specialized in terms of dealing with people who've been born with um abnormal anatomy or defects rather than people that have acquired things, which is the majority of the adult cardiac surgery workload. And that tends to be to help with decision making, making sure that decisions are robust and are coming from multiple expert opinions rather than just one person's subjective opinion at a specific time. And of course, a big part of our role is also learning and being prepared. So you don't turn up to do an operating list and not know what procedure is being done, how to do that procedure. In the, in the most basic concept of that, you know, potential critical things that can go wrong during the procedure when you really need to concentrate more than others. And um you know, the the kind of expected flow of the day and all these things. So there is also a lot of self directed motivation and work that goes into being prepared rather than just turning it for work and, and winging it on the day. And, uh, you know, it's hard work, definitely, it's long hours and there are definitely easier jobs that you can do. There are definitely jobs that afford you more time to have, you know, work life balance. But that's not to say that there isn't any work life balance in our specialty. There absolutely is. Um, you might just have to be able more flexible. So for myself, I know I never ever plan anything on an operating day. If I'm operating, I anticipate that I could be in the hospital the entire night because, uh, the biggest thing that you have to understand before committing to a career such as cardiac surgery or surgery or pretty much anything in medicine is if you are asking patients to trust you to let them to cut them open, to temporarily stop the heart to give them these major life changing operations. They have to believe that you are going to, um, you know, be responsible for them and getting them through that. And part of that is going to be looking after them after the operation no matter what time it is, no matter how long the procedure goes on for. Um, and you learn quite early on if you even try and book something after an operating list, the chances are, that's the one day something will go wrong. You have to stay there all day and miss your plans. But having said that on clinic days, on admin days, you know, much, much more time to yourself to organize your life to do things in the evening. So, um it's definitely not true to say that you have to give your entire life and every single aspect of it to this specialty, there's some give and take. Um you have to be proactive, you have to be motivated not only to get into the post, but also to progress to actually get to the end and be a good surgeon and not just get through for the sake of, of jumping through the hoops that are set for you every year. Um But ultimately, these are incredibly unique and incredibly privileged experiences that we get to have every day by offering patients a surgery. So, um I would say there's very little like it in alternative industries and um you know, every single day, I see something that positively surprises me or I find incredibly interesting and motivates me to keep going. Um You know, you guys are all here, you're already interested, which is amazing and it certainly is an accessible specialty for anybody who is motivated that everyone has their own challenges or difficulties. But um I definitely highly recommend it as long as you're in it for the right reasons as and as long as you're willing to accept the bad with the good. So obviously we spoke about operating. I'm gonna go through an an ask me video now that Kirstie can provided for me. I think it came from, was it the University of Manchester Kirsty? Uh It was one of the scrub nurses in the B ri in Bristol, Bristol. That's it. Yeah. So it can be made this really excellent video. I'm just gonna talk through it as we go. So let me play the video and mute it and I hope can you see the video playing? Um No, it don't, it doesn't, it hasn't changed from the slides. Uh OK, let's give it a minute. It as a backup just in case, but it's obviously just as the video rather than do you want to click it again and see. Yeah, it's playing here. You can't see it. No, no. Do you want to pop it up on yours? Yeah, let me see if I can. Um I'll still be able to see it, um, oh, wait, it just, it just, it's kind of teasing us. Um, how's that? There we go. That's come up. Now, I wonder if you just play, whether it will, is it playing? No. Can you go on to s it's on, can you go into like a show? The slide show? I have. Unfortunately. So, and you can't share another screen. Is there a different, uh, how's this, is that a now and present of you? No, let me um honestly, the technical just before, didn't it? Yeah. Mhm How about if I play any concern that this video is? Oh, there we go. It's ok. So sorry, I know it's a suboptimal window, but I think this would be a good alternative. You can see that. Yeah. Yeah. So this is obviously a heart. This is probably a pig's heart and what they're demonstrating here are the great vessels. So the, the blue one on this model and the one she just pointed to, that's the aorta. So the, the aorta is the major blood vessel coming out the top of the heart and that's going to supply blood to everything important. So it goes to your arms, your head down to your gut, it supplies you um your kidneys, absolutely everything down to your legs. So it's probably the most critical organ in your entire body. And this blue on here. Can you see my cursor at all? Yeah, we can. Yes, great. This is the SVC, the super vena cava. So this is one of the major, the two major veins that drain back into the heart from the body. So this is going to come down from the head and the neck and your arm and then the IVC, which is under her fingers here, which looks very similar, that's going to bring all the blood back from the rest of the lower body. So from your liver, your legs, your gut and so on. So blood is coming from your body down into here and up into here and it's gonna drain into uh a cavity called the right atrium. So this, she's pointing at now, uh this is a small chamber at the top of the heart, there's four chambers in the heart, which was shown nicely later on in the video. Um It is thin walled, it's nice and soft, so it expands nicely when blood returns into it and it's gonna filter blood down into the right ventricle, which is this chamber here. Um And then from this side, this is what we refer to as the right side of the heart. If you're thinking of the heart as um a big cavity with split down the middle with two rooms on one side or two cavities on one side and two cavities on the other. And so there's two on the right, two on the left. So this is the top on the right, this is the bottom on the right and all the job of this side of the heart is just to collect the blood coming back from the body and send it over to the lungs. So all the blood from entering here now is going to have used up all its oxygen. It's going to be carrying waste products and um have low, low levels of oxygen um because it's been doing good stuff around the body and now it's coming back to go back to the lungs to get rid of the waste products and to receive more oxygen. So what the video is now demonstrating are two major coronary arteries on the surface of the heart. So the coronary arteries are small blood vessels on, on the surface of the heart itself. And their job is to supply the heart muscle with its own blood supply. So the heart is a muscle fundamentally and it needs a blood supply, just like everything else in our body needs a good blood supply. And so, um when the heart is squeezed after it's squeezed and it's relaxing blood is going to be going into these blood vessels and supplying the actual heart muscle with oxygen and nutrients. Um There are two major coronary arteries, one from the right, which is, oh, you can't let me rewind here one from the right, which you, you can't really see them on these models, but that is going to be coming from here and going that way across the heart sorry on the plastic model. And then one on the left, um the one on the left is going to divide into two usually very early. So we actually we refer to three vessels, something called triple vessel disease, which ultimately means all the major coronary arteries of the heart are affected. And I think Mr Ali is going to tell you a little bit more about that later. So we won't go into that in great detail. Um But these are critical to the heart functioning well, if you have problems with them. So primarily narrowings or partial blockages, then you're going to start seeing problems with the heart muscle and how well it's working because if it doesn't have oxygen, it doesn't have nutrients, it's not going to be working well. So now she is obviously making a cut down um between the left and right sides of the heart. So here what is being demonstrated is how the right side of the heart up here, this the right ventricle is um because its primary job is to expand and collect blood, it doesn't need to squeeze very hard. So it doesn't need a big chunky strong muscle. So the wall, if I rewind it a little bit here, nicely demonstrated, there is some good muscle there, but it's relatively thin. And as you'll see in a minute, the left side whose primary job is to squeeze and eject blood out of the heart and supply, the whole body is needs to be a lot stronger. So the muscle I just ran that here is a lot thicker and that's what, what she's trying to show you here. So the left side is very chunky er, compared to the right, excuse me. And so um now something similar is gonna be demonstrated in the cross section of the model. So I think this is a really nice view. So this is the right atrium that top chamber on the right, that's gonna receive blood coming back from the head and neck. And from down here again, not very clearly demonstrated from the inferior vena cava from the liver, the rest of the body. Um This here is one of the um first valves or the first valve you come across when blood is entering the heart, called the tricuspid valve. That's gonna control blood going from here down to the right ventricle and then um here or sorry up here, you're going to have the valve called the pulmonary valve. That's going to be controlling blood going from the right ventricle back into the pulmonary artery, which is going to take blood to the lungs to receive oxygen. So it's just demonstrating in the wall thickness of the ventricles II meant to say at the beginning as well. Um by all means, put some questions in the chart as we go, we can answer them at the end if we're not, if we're not covering it as we go along. So now she's just demonstrating kind of what I was explaining, which is about the pump function of the heart. So when the heart squeezes it squeezes from what we call the apex, the pointy bit, which is the bit that's going to sit at the front left of your chest. Um As you were to look at it, it's going to squeeze from the bottom up, it's going to force blood from the bottom up either to the lungs or out of the aorta into the rest of the body. So now they're gonna give us a much better view of some of our valves. And what they're gonna demonstrate here is the mitral valve. So here we've got tricuspid valve, mitral valve on the left. And both of these are the atrioventricular valve. So they control blood from the top chambers called the atria into the bottom chambers called the ventricles. Um The mitral valve is an incredibly important valve because it's controlling blood. Once it's come back from the lungs, it's gonna enter the heart onto the left side. So, into the pumping side, um through the mitral valve, and then as the heart squeezes, you're going to get obviously very high pressures because that's how your BP is generated in this chamber because blood is going to be dry and you can't really get to get view of it here, but leave out of the aorta. So, um it has a very special structure where it has these very strong muscles called papillary muscles on the inside. And they're connected to the valve. If I go back a little bit through these fibrous tendinous cords called the Ch of Tendinae. And their job is that when the heart squeezes and the pressure is generated and the blood leaves out of the aorta, it stops the blood going back the wrong way into the lungs. And a common problem that patients will come and see us for. And we consider surgery for is a problem with this valve. Um Obviously, it, it has a very different structure when it's a 3d and not slice through. Um but uh you can, they can become too baggy. You can get rupture of these uh tendinous cords, here can get problems with the muscles after heart attacks. Um And the consequences of the valve is not functioning. So it commonly, if the problem is something that's repairable, then it can be repaired rather than removed and replaced. Or alternatively, we can remove it completely and replace it with a prosthetic valve. So a valve that is just made out of plastic and animal tissue or kind of carbon fiber and metallic um materials. So I think what they're going to give us now is a better view of the aorta. Yes. So again, this is the aorta, this is the superior vena cava. And this is a nice demonstration of the fundamental differences between arteries and veins. So veins, by definition being blood vessels going back to the heart arteries, by definition, being blood vessels that are going away from the heart, they're leaving the heart and the arteries because they have to send blood a long way out of around the body are muscular. Um an elastic to, to compensate for the high blood pressures that are going to be generated by your heart and the veins are much lower pressure and all they have to do is basically siphon the blood back and collect it. So they're much more thin walled, less muscular, significantly less elastin. So what she's going to do now, I think if I remember correctly is slice open the heart completely and give us a really nice view of all four chambers, four major chambers of the heart. So, um certainly we do surgery on hearts, but we definitely don't do it like this. So there's definitely not any kind of technical procedure. This is just for dissection purposes can speed this up a little because we get a really nice view. Here we go. So let me go back here. So what we're demonstrating is the four chambers which she's pointed out now. So the right atrium, the left atrium, the right ventricle, the left ventricle. So the 444 chambers of the heart that control everything and the blood supply throughout the whole body. It's a tricuspid valve. So again, that's one of the valves controlling the blood coming back, going into the right ventricle that's then gonna go up to the lung. So this is what it looks like in the plastic model. Um These, you know, pigs hearts and things are very, very good at demonstrating the anatomy and the concepts. Um You just have to use a little bit of imagination in terms of the colors and how things would look in reality. So she's pointing out how the mi evolve, this is the wall of the left ventricle. So again, highlighting the muscle thickness and these are the under here of the fibrous cords. I was referring to in these specifically other papillary muscles that are gonna help the mitral valve maintain its function. And then finally, this is the aortic valve. So this is the valve that's going to sit right at the top of the heart. It sits at the bottom of the aorta that big blood vessel coming out of the top. Again, this is um a tricuspid valve. So we call them cusps rather than leaflets because they're associated with um very special anatomy that helps supply the heart with its own blood supply. So you can see uh left main coronary artery here, as I said, there was one on the left, one on the right, the right would normally be at the front, but it's because it's opened up, it's over this side. Um And the I missed actually what she went. Oh, yeah. So this is just showing. So when blood is coming back from the heart and it comes through the mitral valve, as discussed, it's going to come back through something called the pulmonary vein. So typically, there are 42 on the right two on the left, one from the top of the lung, one from the bottom on each side, and they return blood into the left side of the heart from the lung and that that is going to be full of oxygen, all the waste will have been gone. And that's going to be obviously essential for them, having uh blood supply full of nutrients flowing around your body. So that's kind of a whistle stop tour of the anatomy inside the heart. And broadly speaking, highlights nicely the main areas that we operate often operate on. So common procedures that you were going to see if you spend time in cardiac surgery. If I go back to the uh the uh model of the heart is going to be things like mitral valve surgery, aortic valve surgery, which is, you can't see it, but it's gonna be just under here. Um, less frequently but certainly still done. Commonly is things like tricuspid valve surgery here that's commonly repaired rather than replaced. Um, you may see a lot of aortic surgery and in terms of surgery on the pulmonary arteries. So the big blood vessels going to the lungs more frequently that's done by the congenital surgeons because a lot of the time defects that require surgical repair. I'll go uh using this valve or to this valve or the uh the pulmonary artery are going to be associated with congenital heart defects. So things people are born with. So um getting good exposure to that usually requires a stent in congenital cardiac surgery. Um So I've done a lot of talking, I'm anticipating that maybe there might be some questions. So I'm gonna stop there, open the floor. Very happy to answer questions now or after Mr Ali has um, talk to you to everyone. Thank you. Thanks, doctor. That was great. Um We've got a few questions in the chat. I'm just gonna try and pop back through them cos I've been spamming people with questions as well, quizzing them on their cardiac knowledge. Um So one of the questions earlier on was kind of how do you feel that your work life balance has changed throughout your career? Uh It's, it's really, really variable. Um So definitely you probably in terms of hours work, I don't want to speak out of term in terms of hours worked. My subjective opinion is you do your longest hours when you are a registrar. Um, you certainly do long hours at all times and you know, when you get emergencies, it's not common, but you may end up doing, you know, a 24 hour shift or even longer because if a patient needs emergency surgery, it goes on for an unspecified amount of time. So you definitely, I my understanding, I'm not a consultant, so I can't say is probably you have a bit more control of your work life balance once you become a consultant, um you know, depending on your department and where you work, I think work life balance is what you make of it. It means different things to different people. So some people probably look at my schedule in my life and think that it's terrible and it wouldn't be for them. I personally, very happy, still have a good quality of life outside of work, still maintain some hobbies and things. So it's not easy. Um And there are definitely things that you can do that have more predictable hours, shorter hours. Um But equally, there are not many jobs where you get the same kind of experiences and exposures that we do. So it's definitely a trade off. There's no shame in thinking that those long hours are not for you and vice versa. There's no shame in thinking that actually you're very happy to commit your life to becoming an expert in a very specialist field. II don't think that's controversial at all. I think um, everyone has echoed the same things that you said this week, a couple of the consultants that we had spoken earlier in the week had said the same things and about work life balance is what you make of it. So, um the next question was, what was the deciding factor in you choosing cardiothoracic surgery? A whole, a whole host of things? Really? Um, I think I could have been very happy in many different specialties. I initially set out in general surgery because that's really what I had the easiest access to. Um, I was a general surgery trainee when I did my first job in thoracic surgery, realized that I absolutely loved it, you know, was encouraged, was told that I probably had the ability to do it if I wanted to. Um, and then went from there and I haven't really had a single regret at any point because it really is amazing, the kind of things that we can do. The amaze, you know, when patients have really severe heart failure, really severe heart related symptoms, they are completely debilitated and when you can offer somebody, you know, obviously it carries risk. But when you can offer somebody, you know, resolution of their symptoms, you can give them their quality of life back in the same way that when someone's debilitated by hip pain, you give them a hip replacement. They are so grateful and it has, it changes the trajectory of their life in many ways and it's the same kind of thing and it's just really, really satisfying. So, um, yy, there was no one specific thing or one specific point that made me change my mind. There was a lot of deliberation but, um, it's definitely no regrets at any point again. That is something that's been echoed this week of if you had your time again, would you do it again? And it's always been? Yes. So that's always a reassuring thing to hear from everyone at different stages of, of their training. Um, there was another question. So how much is the heart sliced open during surgery? And if you're performing surgery on the heart, how is blood pumped around the body? Which I mean, I suppose we could go into a whole talk about that, but I guess briefly talking about the principles of bypass and that kind of thing. Yeah, I, what I don't want to do is tell you something that Mr Ali might be covering in his talk. Is that right, Mr Ali? Yeah. So I'm gonna leave that to him and I'm sure he'll cover that in great detail and probably a lot more um efficiently and clearer than I will. Great. Thank you. Um There's a couple of other questions just about the structure of the heart valves and then what are the most common surgeries that are, are done on a weekly basis? But I think if Mr Ali is gonna cover some of the topics about the commenting for you as well, um, then if we don't answer your questions by the end of the talk this evening, please feel free to pop them back in the chat, but we might leave them for the end of the end of the evening, if that's ok, sounds sensible. So I think, I think that's the majority of the questions that we've answered now. Thank you so much for the talk for this evening, Georgia that was really helpful. Um And hopefully the people that missed the session on, on Monday night also got a bit of an insight as to, to what it is like to be a, a registrar and that kind of thing at different stages of your training. Yeah. No, thanks for having me. And if anybody has any questions, you know, contact Ky, she can forward them to us. Very happy to answer them advice and all that. Ok. That's great. Thanks Georgia. Take care. Perfect. Thank you so much Georgia. Um That was absolutely fantastic. And these guys have been asking such great questions. So please continue to do that. I'm gonna hand over to Mister Lie now who is a consultant cardiac surgeon. Um So Georgia was our registrar. So that that's what she's working towards at the moment um is to eventually one day become a consultant. Um So now I'm just gonna pass over to Mr Ellie who is going to give a talk on common cardiac procedures. Um So a little bit, you've kind of learned a little bit about the anatomy. Um So far, so this is kind of how it's applied um in the actual surgical um environment. So again, ask away in the chat and we will either answer or get Mr lie to answer at the end. Are you able to see my slides? We are not yet. I can. Oh, sorry. Yes, we can. Now, let's come now. Ok. Wonderful. If there's any, if you see that they're lagging because it seemed like that was the case for the Children. Just let me know and I will um try to sort it out. So I'm a consultant cardiac surgeon at P Hospital in Cambridge. And I have been asked to give a brief overview of the, the, the common cardiac surgical procedures that formed and give a little bit of an insight into the work of a cardiac surgeon. And Georgina very nicely described earlier on her experience as a registrant. Towards the end, I will give you a little bit of an overview of how, why we is as well because I think that's can be quite useful for you to have an idea of what the er consultant is like a different. And I think one of the questions that was asked us now about how was the sort of work life balance change time? I think that when you first graduate from men in the sort of early years, I think that you kind of reasonably, but you're still sort of learning the ropes a little bit. And I think as a registrar, I think that was the time that I had. And actually now that as a consultant I've been because for two years almost and I think that the life balance is, is much better now. And I think that the main difference really is that you have much more control over your time as a registrar or as a junior doctor in general, you're it a little bit in control of your own time to some extent. But as a consultant, you certainly have that much more autonomy, much more control over over your schedule. But I'll share a little bit more about that at the end, in terms of what I was hoping to cover, I was go as, as we sort of just briefly alluded to one of the differences with cardiac surgery to other operations is that in order to stop the heart, we need to be able to contain Contin, to continue circulation to the rest of the body briefly introduce cardio bypass, which is the means by which we're able to achieve that an answer to any other questions regarding the operations. I think the, the the operation that the heart surgery, Coron bypass grafting and I was gonna talk a little bit about that and probably the second commonest is a valve replacement and now it is out. So first cardiopulmonary bypass when you, this is a uh hopefully this video is showing and this is a video of a human heart during an operation. As you can imagine trying to do surgery on a heart that's beating is challenging And whilst you can do co coronary artery bypass grafting with the heart beating, doing things like valve surgery is is impossible with the heart beating like this. And so, in order to manage that situation, we have available coronary bypass and the, the, the, the design and innovation of card coronary bypass led to cardiac surgery being born as a special because this technology was developed and allowed to stop the heart, open the opportunity to, to, to be able to do surgery on the heart. I'm, I'm sorry to interrupt. Um, your internet signal is a little bit jittery. I didn't know whether there was somewhere with a slightly better signal. It's just meaning that your slides are constantly loading and it's a little bit of a lag on, on some of the videos and things. So there is only one video. So hopefully that is it, that video is gone now. So hopefully it will be better from now. Ok. Yeah, we can give it a go. I'm sorry, I'll try to move as well in case that's an opportunity. But you can see at the moment. Can you? Yeah, we can see the screen. Um, it's just, your voice is a little bit crackly, but I think we can, we can probably bear with it and hope that it, it's ok if it seems to be a major issue, let me know and I'll see if I can change something else. So cardiopulmonary bypass in the simplest form, essentially is a pump that oxygen. So in order to be able to, to do this, called cannulas or pis into certain blood vessels of the heart, in order to, to the blood that comes to the, from the rest back to the heart arrives into the inferior superior vena cave into the right atrium. We take blood fro that's returning to the heart, that's deoxygenated blood, that blood drains into the cardiopulmonary bypass machine is TED and is returned back to the daughter. Essentially, the cardiopulmonary bypass circuit takes over the function and the lungs. And this allows us then to start safely. This is a very simplified figure. This is a, this is a cardiopulmonary circuit during an operation. And what you can see is obviously that it's much more complicated than what I've shown you. But the details of this you don't really need to worry about, but in essence, the blood returned, the pump is oxygenated and is pumped back into the aorta. In, in order to do, I suggest we need to stop the heart and to stop the heart. We do that essentially with a with potassium. So by what we do essentially is to put a clamp across the aorta. And that means that no blood is down the coronary arteries. So we then use different tube to d high potassium solution into the coronary arteries. And by giving that high potassium solution, the heart will stop and it will remain stopped for about to 30 minutes every 20 to 30 minutes. We'll need to give more of that solution. Make sure that the heart muscle doesn't die. That period that we have the heart is stopped as to do the surgery in a safe way. So that is cardiopulmonary bypass. Uh The design of cardiopulmonary bypass, essentially, as I said, led to the birth of cardiac surgery as a specialty because it allowed for the first time people to operate on the heart because doing it with the heart beating is obviously ques. So just before I want, is the, are you able to hear me more clearly? Now, we can definitely hear you. There's a slight lag on the, the s the slides keep flicking. Um, they stay on the same slide but they go on and off. Er, so I wonder if there was somewhere with a slightly better signal that would be slightly better, but I think we can probably bear, bear with it if not. Ok, I'm not sure I'll, what I'll do. Just bear with me a second. Ok. Ok. Ok. Sorry about that. I hope that this might be a little bit better. Let's give it a go. Thank you. So, carry bypass grafting is the communist operation. That's a cardiac four, essentially a treatment for a disease that's called AROS, which I'm sure that you may have heard about in biology. Atherosclerosis is, is essentially the furring up of arteries and it can happen in arteries all across the body. It happens in the arteries to the brain. It can lead to um the development of stroke. If it happens in the in into the arteries to the legs, it can be the reason why sometimes people need amputations. But for a cardiac surgeon, it is this atherosclerosis happening in the arteries to the heart, the coronary arteries which you saw in the administration just now. And what this picture on the left hand side of the slide shows is that this is a sort of gradual process that develop the things that predispose to people. Developing AOS includes smoking, diabetes, high BP, cholesterol amongst other things. But they're the four most common risk factors. And as the artery gets narrowed and more and more narrowed, it's the amount of blood being delivered to the heart muscle reduces. And so sometimes when people decide and they have the increased need for oxygenated blood to be delivered to the heart muscle, that there is a mismatch between the supply of the blood and oxygen and the demand. And that's when you get symptoms. And the symptom that it causes here is, is chest heaviness, chest tightness, which is called angina. And here is just a sort of under the microscope of, of a coronary artery. And the picture, the, the sort of slide on the left shows a very healthy artery, the the sort of dark pink is represents sort of the, the sort of muscle of the, of the, of the artery. And what you're seeing here on the finger on the right is that you similar outline of muscle. But you can see that the there is, there is, there is a, there is a thickening of the wall and that this sort of space which is, is significantly narrowed. And you can imagine that the amount of blood that can pass through those vessels significantly reduced, that leads to the problem of uh that eventually, if it gets blocked, that's what a heart attack is. And whilst it is very narrowed, ca causing this mismatch in supply and demand is when you get an, one of the things that was one is a Corio gram, potentially a picture of the coronary arteries that we can achieve by placing AAA tube into the coronary artery in the aorta injecting a dye that you can see on X ray. The figure on the left, this is the left coronary artery and what you've highlighted with a red circle, same space, same position as it were on in two different people. The on the left has a normal coronary artery. You can see there's a sort of the width of it remains constant, constant along the length. But this image on the right, you can see there's there's a significant narrowing and that is a sort of athero atherosclerotic plaque or leading to a significant constriction of the blood that is flowing beyond it. How can we do to treat that? There are obvious to treat any illness. There are three options, you can treat it medically with tablets. There are options for treating it using interventional techniques. For example, this could the dentin but when the pattern of disease is such that it's very is more severe then becomes the best treatment option. And that is the operation we most commonly perform. And this is a sort of a nice cartoon actually showing you the same thing as as per last angiogram. And you can mention that when that you can see here that within the wall of the artery, there is this plaque that significantly the blood flow causing turbulence, but also significantly affecting flow of blood. And you, you can see that these develop in the on the surface of the heart. And you can, the way that we treat that is essentially by bypassing it, literally bypassing it. So on this figure, this blue um line is sort of to give you an impression of a bypass graft. The bubble here shows you where that is and we sew a a blood vessel beyond to the narrowing and then onto the aorta and therefore blood come out of the aorta and it will pass through this blue tube down into the rest of the coronary artery, bypassing this area of narrowing. And to do that, we essentially need to sew a blood vessel onto the coronary artery the most common blood vessel that we use is the Safaa, which is the vein that you find within your leg. So at the same time as I will be operating on the heart, there will also be a, so there will be someone in pa was a nurse practitioner who will be harvesting some vein from the patient's leg. We can also use arteries. So we would, we would typically use an artery that runs behind the breastbone, which is called the internal mammary artery. And you can also use the ra radial artery, which is an artery in your arm. And we to do these, this surgery is very fine. And so in order to do this operation, surgeons will use magnifying glasses like you saw in the picture that Georgina, we look through these special magnifying glasses which which magnifies so that we can see in much more detail what we're doing. And essentially, we use very fine suture that's probably as thin as your hair to, to essentially sew a this vein or artery onto the coronary artery of the aorta. And this is a photo which shows you exactly what I'm just deri what in real life, what you see on that cartoon? So this is this sort of purplish tube here in a piece of vein that you can't see with the other end of it where it's joined onto the heart, but this is where it's joined onto the aorta. And so eventually blood is bypassing the blockage in your main artery, passing the vein and then passing to the rest onto the, narrowing onto the rest of the um, into the heart muscle. So that's coronary artery grafting. And it's probably the operation that we do most frequently. And it has a significant impact on people's lives as to do all of the operations, we perform. The second type type of operation to touch upon which is really the second commonest operation that we perform is surgery on the tic valve. So the aortic, so this is a sort of a thing showing the heart, the left atrium which delivers blood into the left ventricle. The left ventricle has a very thick muscular wall that needs to pump to the rest of the body. It pumps it out of the heart through this. What's the aortic valve into the aorta to the rest of the body? This aortic valve lies between, it has to sustain a large amount of pressure difference and it has to and essentially is there to stop blood falling backwards into the heart. The heart relaxes make sure that blood in one direction. And that's the purpose of all of the valves of the heart to make sure that blood flows in one direction. Normally, the aortic valve leaflets are paper thin even slightly see through because they're so thin. But what can happen is there, there's sort of two disease processes that can occur with the aortic valve. One of them is called aortic stenosis. And that is essentially where the aortic valve leaflet become very thick and very stiff. So essentially, in order for the heart to pump blood out, there's a, there is a mechanical obstruction, there's a resistance. So the heart has to pump much harder. I think I've got a photo here. So like I said, the aortic valve in a healthy person is paper thin and sort of translucent. You can see here is that these leaflets, the three leaflet, the aortic valve are very thick. You can see this sort of light and that disrupts the flood through the heart because the heart muscle has to pump much harder to be able to get blood out. And ordinarily the the heart valve will open completely allowing very, allowing the blood to flow very freely through the. But the these thickened and stiff fat only are they harder to actually open. They also don't open normally. So we can do about that. We we can replace the heart valve. So we would put the patient on the heart lung bypass machine to stop the heart and essentially cut out this all with scissors. And so a new van and there are two types of heart valve that we can use to replace the the the native valve. One type is called a tissue and the tissue valve originates from animal material. This is the valve that I use and it is a valve that this this yellow mati, the actual valve leaflets are made out of um cow pericardium. Pericardium is the sac. That's the heart. So the that that sort of sac is, is coming from, from cow and his hand sewn into these valve leaflets. The tissue valve is used for older patients because they don't last forever. These valves will last probably 15 to 20 years at most. On the other side, you can see this very shiny looking valve, which is made out of something that's called pyro. It's essentially a carbon based um they're called mechanical valves. These valves will last forever and this type of valve because it's made of this carbon material click. So you have these valves and you listen carefully, you can hear their heart rate by a sort of ticking sounds if there's a inside them. The disadvantage of this type of valve though is that blood clots can form on it because unlike this biological tissue, this foreign material, the blood wants to clot on it. And if blood clots on this valve, the blood clots will fly off around the body and cause terrible problems like strokes. So to avoid that patients who have these mechanical valves will need to have anticoagulation. So that is one that essentially prevent the blood from clotting. And the book is used is called Warfarin, which is actually a sort of uh uh also as rat poison. This drug thins the blood so that it doesn't clot very easily and that allows you to, to develop blood clots on these mechanical heart. The problem is is that thinning, the blood also has risks and can lead to people developing, being very prone to bleeding, having any or or having a range of other problems with bleeding such as uh bleeds on the brain, for example. So of these are the perfect solution. The tissue valve won't last forever. The mechanical health needs anticoagulation, which can be dangerous. A related aortic valve surgery is a, the other element to aortic surgery is actually replacement of the aorta itself. An an aneurysm is essentially where the an artery dilates and becomes much larger than it's been. And this sort of cartoon on the left hand side shows that this first part of the aorta is much wider than the rest of the aorta. And that's essentially what an aneurysm is. The risk of it is that it can birth. And if you have an aneurysm in the, which of course is a, is a very large blood vessel. If that bursts, it's very likely that a patient will die. So if we find that patients do have aneurysms, we can do an operation to essentially r that part of the aorta. We cut out the, the Eurys aorta and sew in a graft a, a tube. This is synthetic material which you can see here someone is sewing into the, the heart and into the aorta to replace the a, the aneurysmal part of the aorta. And this is another type of operation that a heart surgeon will do more frequently than the bypass surgery and the valve replacement surgery. But nevertheless, another type of surgery that we do. The other thing to say of course is that we also can operate on the other heart, but I haven't been into too much detail about that because I don't, I don't want to sort of overwhelm with information. But the probably the next valve operation that is performed is the mitral valve. And that's the valve that lies between the left atrium and the left ventricle. And that valve replaced in a similar way to the aortic valve using either a tissue or mechanical valve. The mitral valve can also be repaired sometimes and there are a lot of different techniques that allow you to be able to repair mitral valve. The other thing I wanted to briefly touch on related to the approach to how do we do these operations? I think it's fair to say that far, the most common approach to which heart surgery is performed is through what's called a steno. And that is essentially an incision of the breast bone. And you can see the, the sort of photo on right hand side which is of a patient who's had a steno. You can see the scar right down the middle of the chest. We use a retractor and a photo on the left shows you the excellent view that we get out of the heart. And what you can see here is the the just to, to, to orientate you. This here is the aorta. So you can see how big it really is. This purplish structure here is the right atrium. The majority of what you can see here is the ventricle. So for example, if the body gets stabbed in the chest, the most common heart be injured is the right is the one that's mostly at the front. So the sty is the trial and tested approach to cardiac surgery and it is by far the most common used worldwide. But how is the case? And as you heard yesterday from the thoracic team, there is a there is a move to more minimal access surgery. It is also possible to do operation the cardiac surgical operations through a more minimal access approach. And this is particularly suited to the mitral valve position of the mitral valve very nicely to accessing it through the side of the chest or not, that tiny scar that you can see on the right hand side, a patient had a mitral surgery done through that scar. You can see here that there is a sort of device that sort of helps to open out. And so you can see the hole is there and similar to how the keyhole surgery that you saw and heard about yesterday from the Thoracic surgical team. We can do the cardiac surgery using instruments that reach in and a and a video to allow us to see that what we're doing on the screen to be able to perform minimal access surgery. And for mitral valve surgery, it is becoming increasingly a popular technique. And med centers use that approach for some of their cardiac surgery. And again, similarly to thoracic surgery, there is also increasing number of people, although it still remains for cardiac surgery to be performed using a robot and robotic. In particular mitral valve surgery. Again, I think it's the mitral valve position lends itself very nicely to be able to be accessed through the um through the right chest allows itself lends itself very well because you can get an excellent through both minimal access and robotics. We don't do robotic surgery at work. And there's probably only two centers in that you do robotic cardiac surgery, which is different to face surgery where it's sort of becoming the norm with most thoracic yes, centers having access to a perhaps this is the future of it's difficult to tell. But at the moment, there are many operations that can be done through these more minimal access routes. And cardiac surgery is, is is joining the sort of uh bandwagon as it were and certainly there are people doing cardiac surgery. So in some to some extent was a sort of brief overview I wanted to give you of surgical because obviously there's a lot of detail. I don't want to overwhelm you with information, but co coronary artery bypass grafting and an introduction to valve surgery is what I was hoping to convey through those pictures and slides. And I hope that that has been AAA useful uh introduction and, and in a moment, I'll be very happy to answer any questions that have arisen. I can't see the chat at the moment. So I'm not sure what questions are, are coming through, but I'll be very some in a moment similar to the thoracic surgeon you spoke yesterday. I thought it might be nice for you to as well have a sort of an oversight of, of my, of, of my journey and I've sort of have kind of done a timeline. I also listened at Cambridge University but I stayed for the entire duration of my course. So in 2002, it embarked upon medicine. And I think what, what this probably show you is that studying medicine is only the start of, of a, of a quite a long training period. So six years at Cambridge, are you enter the workforce? As what? And that is a two year rotation where you rotate around different jobs in different hospitals. After that, I entered what's called core surgical training, which is um sort of surgical training where you rotate again around different surgical specialties. At that time, I was, I then took time out from surgical training to undertake phd. So I did a uh a phd which is a prolonged research project. And I did that in the field of transplant immunology, whereby I was studying how the immune response um recognizes and rejects um trans organs. After that, I embarked on my surgical training as and that's period there in cardiovas surgical training is when IW is when you become a registrar. And during that period is when I was at the stage that Georgina is at the moment and we um rotate through and spend time in cardiac surgical training, getting exposed to the breadth of the specialty and learn, learning the job essentially. And finally, in 2022 is when I became a consultant. And as you can see from starting medical school to become a consultant for a year period, of course, after you finish mental, you start working, start getting paid and that so although you, it is a still a prolonged period of training, it is a sort of very enjoyable path. And I think the what medicine offers you is a true breath. There are so many different things that you can do after you've finished medical school within medicine. Be that surgery, radiology, medicine become a GPA forensic. Um One of my colleagues from medical school is a, is a team doctor or a championship football team. There are so many different directions you can take with a medical degree. But that's my my long journey from starting out medical school at 18 and becoming a consultant 20 years later. So from the questions I've seen in a couple of days, people are saying, why do you, why have you done what you want? What, what you are doing? So why did I want to do cardiac surgery? And I think what I think, what, what, what I can see is that cardiac surgery is specialty. It is hard work. The surgery is technically challenging as I was trying to convey coronary artery bypass graft surgery. It's very delicate. You use very fine sutures, you need magnifying glasses to be able to see what you're doing. On the other hand, you have big surgery where you're facing part of the aorta. As you saw in that, uh in the last photo I showed the patients we operate on are very sick, you don't just do the operation, but we have very, I is the intensive care unit, managing the physiology, helping the working together with the intensive care doctors to manage the patients that we are on. And the other element to this though is that however challenging, however tough it is we have a subtle effect on patients lives. What I didn't really describe. So for example, the patient with sis and the patient with severe angina, these patients have such a poor quality of life. They are unable to uh in the most severe situations, they're unable to even leave their house because they get so short of breath every time they walk, they get such chest tightness and it is so gratifying to see a patient who comes into the clinic being brought in a wheelchair because they, they just associate walk, you do the operation. And then six weeks later when they come back to scenic, they are so happy. They are the, the, the the difference that you see in the patients is so substantial that it, it's such a gratifying part of the work. And that is uh that helps to balance the, the, the, the challenge and the toughness, the work, the patients coming back to you who are just so grateful for what you've been for them. But as I sort of alluded, it can be a tough specialty. It's hard work, it's probably harder work than some of the other specialties. Sometimes you just the thoracic surgeon yesterday was talking about his sort of operations, taking 123 hours. I would say the majority of cardiac surgery operations probably take more like 345 hours and sometimes emergency operations may take eight, 9, 10. So these operations can be very long. And so it can be physically challenging. And the other important thing of course is that although you do such a significant impact on patients lives, not everyone that you alive. And so there is an element, there is an aspect to the work where some of your patients unfortunately will after you have done surgery on them, not making it through the postoperative period. And that can be quite challenging, but I have to balance it against the fact that the patient want the operation because they have such a poor quality of life and the you have overall fire with those uh much more infrequent situations. So just to give an example of my typical week at the moment, my operating days are Monday and Friday. So on Monday and Friday, I'll spend most of my day in the theater on my clinic day. So this morning, I had my clinic, I see patients who are, who have been referred, who may need operations. And I also see some of the patients who I operated on a few months ago who come back just to check that they were on Tuesday. I'm involved with Tavi, which is a sort of minimal access patient of the aortic valve, which I haven't really gone into, but is a sort of minimal access procedure to replace the aortic valve. And there are a lot of meetings and multidisciplinary team meetings. And I'm also in, in leading the medical student program at Papworth. And so I have a lot of commitments relating to that on Wednesday. So that's my and on call, I'm on call one every six days. And when you're on call, if there are emergency patients who come to the hospital who need um emergency surgery, then I'm on call to do that and one of the more common operations to deal with in that situation is to, to help people who have what's called an a dissection, which is a, a tear in the aorta, which is obviously a very serious problem because a tear in the aorta can lead to very can can in 50% of cases will lead to someone dying immediately. Those patients who survive the the tear are in a precarious situation and the only treatment for them is to have surgery. So in summary, in two lines, really cardiac surgery, I hope I can have, have been straight to you is really a very rewarding specialty that you have. You are managing patients, procedures can be challenging. But the results are truly gratifying a as was sort of asked earlier, I would, if I could go back and start medical school again, I would definitely follow the same path again. Thank you for listening and I can answer any questions. Brilliant. Thank you so much, Mr Ellie. That was fantastic. Um We do have a few questions and we've been trying to kind of wade through them and answer a few in chat. Um But I've kind of waded through what I think we haven't answered. And from the start, uh one of the first questions was, what is your opinion of off bypass grafting? Hm. That's very, was my opinion. I think that. So I would say so that is a very, that is a sort of very controversial question, to be honest because some, there are some surgeons who are very strong proponents of off pump carriage, coronary artery bypass grafting. And I think that so we at Papworth, we pretty much do most of our surgeries using cardiopulmonary bypass. So all of our operations are done on bypass the with the heart beating. It's a it is, it can be a little bit more difficult. And some of the coronary arteries are really at the back of the heart and to be and to stop the heart allows you to really get good access to. And unless you are a true expert at off pump, that's bypass surgery with you with the heart beating. Some people, the sort of that some people argue that the um that, that the quality of the, the operation is less good using off pump. But to be honest, I think experts at off pump surgery will be able to do as good a job as someone who's using on pump. But I would say probably around, it's only probably around 20% of cabbage operations in, in the UK at least are done off pump. So it is a, it is by far more common to, to use heart, the the heart lung bypass machine. Perfect. Thank you so much, Mister. Uh one of our next questions was then um what solution was put um into the heart muscles every 30 minutes so that they don't die I assume they're talking about during the procedures. So it is so the so the this different hospitals use slightly different combinations of, of things. But essentially the the the overall name of it is called cardioplegia, which which is sort of literally translates to stop heart. And it is essentially the what we use in Papworth is a mixture of blood and a solution that contains a high concentration of potassium. We use blood so that we can deliver some oxygen. And the po high concentration of potassium is what leads to the heart stopping. And so we need to d so to when you deliver that solution, after a few seconds of it, of it being infused through the coronary arteries, the heart will just will stop and become very relaxed. The reason that you need to keep giving it is because the the other thing to say is that it's, we usually use it cold. So not only does it stop the heart, it also cools the heart down. Both of those things lead to a substantial reduction in the oxygen demand of the heart muscle because of course, if we don't give any oxygen to the heart muscle, the heart muscle will die. So that's the reason why we need to, to, to give that solution. But in order to help preserve the heart muscle, we cool it down because that reduces the oxygen um demand. So Papworth is a combination of blood cold, a cold blood potassium, there are also additives like a bit of glucose and other substances that help uh with metabolism. But the the key ingredients are, the key ingredient is high concentration of potassium. Perfect. Thank you. Um Our next questions kind of focus a bit on bypass. So we've had a question kind of about how um kind of bypass works and you know, where is it connected to and then kind of leading on from that. Um I suppose how does the heart stay alive if you're not pumping blood through it um during the procedure? Yeah. So it, so in essence, we the blood returns to the heart um through the inferior and superior vena cava to the right atrium. So we put a pipe into the right atrium that essentially takes, that sucks all of that blood out of the heart, so that blood drains into the bypass machine. So therefore, there is no, if you imagine what's happening, there is no blood any longer passing through the right atrium into the right ventricle and to the lungs and coming back from the lungs to the left side of the heart. So by drawing out of the blood from the right atrium, you essentially have no blood flowing through the lungs and then back into the heart, we return the blood from the heart lung bypass machine into the aorta. So we then put a, so there's a pipe in the right atrium and a pipe in the aorta, the blood is returned to the aorta. So at that moment, blood that is flowing into the aorta will perfuse the coronary arteries. So what we do then is to clamp the aorta and you're right that then the heart is not receiving any blood and the heart muscle will die except for the fact that we used the cardioplegia that I was just describing. So we give cold blood with high concentration of potassium and that stops the heart and cools it down and reduces its oxygen demand. And by in the same way that you can transport a heart for transplantation by putting it in an ice bucket essentially and transport it for an hour or two, the heart can stay alive when it's cooled down like that for a bit of, for a bit of time with no blood. So that is how so in a similar way by cooling it giving the potassium, you'll find that that, that the heart muscle is preserved for those periods of time. Perfect. Thank you again. Um So kind of Nick's question focuses a bit more on aneurysms. So if one were to potentially burst during surgery, um kind of how would you deal with that? And um is there ever an instance where the patient might not be able to be saved at that point? So if it is a sort of planned aneurysm surgery, I think it would be very unlucky if that happened, but it would be a very dramatic event. But for the people who have the aortic dissection, which is a tear in the aorta that, that is something that does happen. Unfortunately, so sometimes when you're opening the chest and you relieve the pressure, that tear, which is, it can be a bit fragile, can burst. I got there. I would say that it is, that is a very kind of bad situation of, obviously, it's something that uh you haven't got much time before the patient will die. It is possible to essentially you need to put the patient onto the heart lung bypass machine as quickly as possible to regain, regain control of the circulation. So most often you should be able to salvage the situation by going urgently onto cardiopulmonary bypass by very rapidly putting these pipes in as we were discussing previously. However, there are occasions when that happens and unfortunately, the patient can't be saved and and doesn't make it through the operation. So that is that does happen. Brilliant. Um So I suppose just a few questions then about um cardiac surgery as a specialty. So would you say that this is um especially in where you have more flexibility or would there be other specialties that would give you um kind of more flexible work schedule? I didn't hear the first part of the question you said, but does it have, does it give you, what kind of is, does cardiac surgery give you a flexible work-life balance. Um or how would you compare this? I mean, I think that cardiac surgery is a busy, is a busy specialty. I think it's fair to say that it is one of those sort of busier specialties. If you want a very sort of more chilled out life, there are many better options for you. However, when you reach, when you reach consultants level, you do have a lot more control over your time. And the other thing to say, of course is that different hospitals across the country are, are, are work in different ways. And some there are some hospitals that are much more busy than others. And so I think that there is a, there is a there you you can certainly develop flexibility in your work schedule. And I think you, you also have the opportunity when you're a consultant to pursue interests because there are a lot of different opportunities. So for example, um there are opportunities to pursue sort of management roles within the hospital, opportunities to get involved with medical schools and teaching and um opportunities get involved in some legal work, medical legal work. So I think that when you, when you do become a consultant, you do have much more control over your time. And you can, I mean there are consultant cardiac surgeons who are part time, for example. So there are so there, there is, I think there is flexibility to a degree. But I think there will be other specialties that are much more flexible than cardiac surgery. The, the problem with cardiac surgery is that patients are sick and sometimes patients have problems. And if you operate on the patients, I operate on, if there's any problem happens to those patients, I'm the first person they're gonna call. So I'm sort of always on call for my patients most of the time you don't get called because the patients generally have made good progress. But there are occasions when patients don't do so well and you may then need to come in at the weekend or whatever, to try to sort of do other procedures or do to, to kind of see these patients. So I think that becoming a cardiac surgeon, there is a commitment to that, but it is uh very, very rewarding as I've alluded to. Um But I think other specialties will offer more flexibility to be OK, perfect. Um And so kind of two of our questions kind of merge into one. How would as a student, how would you recommend um them to stand out if they wanted to pursue a career in cardiothoracic? So I think that um there as a medical student, there are plenty of opportunities to, to, to, to um get exposure to the specialties and get come. I mean, if I think essentially in order to apply for most jobs within medicine, there are certain things that you need to demonstrate that you have achieved, for example, teaching, getting involved in research projects, giving presentations at conferences amongst other things. And these are exactly the things that you can try to get involved in as a medical student. And the the there are the most medical schools will have plenty of opportunities for you to get involved in these type of things. On a national level. The the the the committee members that you're seeing in front of you are medical students who are part of the Instinct Committee, which is essentially a national committee that is essentially designed to try to encourage people into cardiothoracic surgery. And medical students can get involved as, as Alana and most that you can see in front of you are at the moment, medical students who are holding these national leadership positions, which will obviously help them to stand out when it comes to um medical school, er to, to, to, to apply for cardiac surgery in the future. But this the Instinct Committee also run many events, medical student engagement events. There's soon to be a sort of mentorship program and a range of other things to try to encourage and help to facilitate medical students getting exposed to and getting involved in cardiothoracic surgery to help achieve the type of things that you need to in order to be successful in applications later on. So I think that there are many opportunities on a national level and also on a local level to to gaining experience and the opportunities to stand out, applying later on. Yeah, absolutely. Um And so kind of coming to the end of our questions. Um What is there a most memorable moment that you've had um since starting medical school in 2002 or potentially a memorable period in your life? I think, to be honest, the, the the most memorable thing I think I did as a medical student was deliver a baby, which was quite a remarkable thing. To be quite honest with you. I think that's uh it's such a kind of amazing thing. And to, to have, I remember we had to sort of, so we had to get, we had to like see a certain number of deliveries. And anyway, this, I kind of saw a bunch of them and I was in Kings Lynn at the time actually. And they, they allowed sort of, I was able to deliver a baby and I remember they, it was just such an amazing thing to be honest that that was to be honest, that was probably a couple of things that at medical school along the way. I think there's so many different things that uh has happened along the way that uh it is difficult to pick one specific thing other than that, I suppose, something that was a bit sort of uh a memorable at Papworth Hospital has a brand new hospital uh that opened a few years ago and the queen came to visit to open the hospital and I managed to take a selfie with the queen, which ended up in most of the newspapers, which was quite, quite funny. That was relatively memorable. But, uh, I think that, um, I think you, you see so many things and you can, you can sort of amazed and by the sort of things that you see throughout your time in medicine, you can kind of see some crazy things. I sort of, we had a patient once who, who come, who, who I think, I don't know what happened. But the, but basically the wife of this person basically got a sort of like sledgehammer and like, no, it was, it was a machete. They got a machete and stabbed the guy in the chest and the, the paramedic who turned there, there was, there was some sort of ambulance crew that turned up to, to this person's house and actually sort of cut open the chest of the patient in their living room and sewed and used some kind of suture to sew up the whole in the heart and basically saved this guy's life. And it was just quite a, like a what a phenomenal story like this guy had been. And then the, the funniest thing of all was that, that week, there were two other men that got admitted to Papworth who had been stabbed by their partners. So it was a sort of like an epidemic that happened on that week. But that one was sort of so dramatic that this person had, had their chest opened in their living room and they sort of, I think they had just been very lucky to have a doctor who was on the ambulance at the time, who had just cut open this guy's chest in his living room and used whatever sewing material they had to sew up the hole in the heart temporarily and then brought him to Papworth, which is quite a phenomenal uh case. I'm absolutely flabbergasted by that story. I don't know about anyone else. I can't never mind three, speechless. But yeah, that was really, really cool. I just wish it was me who had been the one to do it because that was a story. I'm just telling you about a story. But if it was me, I went to this guy's living room, cut open his chest and got some wall out of his granny's packet and used a knitting needle for as well. So, I mean, that's what a story to tell your kids. Someone said it sounds like Grey's anatomy. I agree with that. It does, but it was, it was true. That's madness. Um Guys, I'm not seeing any more questions. Potentially, I've missed a couple on my way down. Um Can you spot anything else? Um There's a question here. I can see about infective endocarditis. So infective endocarditis, if it affects the aortic valve, then you would replace the aortic valve in the same way. Um You also mentioned aortic regurgitation. So, aortic. So what I talked about with the aortic valve is when it becomes very stiff and doesn't open properly. The opposite problem is aortic regurgitation, which is when the leaflets don't close properly and blood just leaks back into the heart. And similarly, the treatment for that is mo more or less is aortic valve replacement. So, valve replacement or valve repair will be the treatments for these type of procedures for these conditions. There's a new question that just came in. What is it like? What was it like leading up getting into, into Cambridge? Well, I think that um there people seem to be a bit obsessed by getting into Cambridge and things because I saw that on the questions yesterday. I think that so I came from a state school. I had a, I went to a college that had never sent anyone to Oxford or Cambridge. So I think it was a sort of a bit of a daunting, it was, it was very daunting process to be honest. And um I remember having to go coming to Cambridge for my interviews and I had like three interviews and I was very stressed. I sort of had a meeting with the sort of careers person of the college I was at, who gave me a sort of practice interview and it was all sort of it at that time, the web, the internet was not, was much less sort of developed than it is now. And I think the fact is that now there's so much information available to you and, and I actually interviewed for Cambridge for, for my college. And, um, I think that there is so much more information available out there now, I think that there was opportunities to, there were a lot of events that run throughout Cambridge to sort of give people the opportunity to come and visit the colleges and all the rest of it. And there's um the interviews that we've done in the last few years have all been online, which is rather than uh coming to um having to traipse all the way to Cambridge. I remember it was very sort of very nervous on the train going to Cambridge for my interviews and the interviews. People you hear rumors about crazy interviewers that sort of have a newspaper and set fire to them and ask you like, what should I do and like that sort of sort of mythical stuff, you know, I think it is um the interviews are not so bad. So don't worry about all of that. I think preparing for applying to Cambridge, it should be the same as preparing to apply for any medical school. Really. I think the interview style may be a bit different. But um in essence preparing to apply for medical school, you just need to think about things like getting good work experience, make sure that medicines right for you. Hopefully, this week has given you the opportunity to get a bit of an, uh, an exposure into what it's like to be a doctor. And that sort of, obviously we're, we're very much focused on cardiothoracic surgery, but some of the experiences will be very similar, whatever specialty you're doing. And I think, I hope what you can see is it's not, it's, it's hard work and it is, it requires a long commitment. And so I think you just need to make sure that medicine is for you. And that's why it's important to get some work experience is to, to just get an exposure to what it is to be a doctor. And hopefully we're giving you a bit of an insight um through this series of lectures that um I think just work hard, be prepared for the practice your interview, practice your interview with uh people at your college and things and uh I'm sure that you'll do fine. Yeah, if I may, I'll just add that. Um CM so Cambridge Widening Access Medics Society uh runs um practice interviews in the autumn each year as well. So, um you can find them on a, on Instagram and um they run practice interviews where Cambridge Medics will volunteer to be um interviewers and then uh you can practice your, your interviews and get a sense of the type of interview that Cambridge does. Um they do every year in the autumn. I think it's around October, November time or maybe a bit earlier than that. But keep an eye, you can check them out on Instagram. They do quite good. Uh They have quite good resources on their Instagram as well on the types of questions that you may encounter and, and like tips for preparing and all universities will have something similar. So don't if you're not planning to apply for Cambridge, that's ok. There are all other universities will have similar sort of uh um similar sort of er programs. And I II was conscious when I saw that, that consultant thoracic surgeon yesterday also started from Cambridge. It can get the I and most as well from Cambridge. And you think, oh, you have to go to Cambridge if you want to be a cardiac surgeon. This is, that is not the case at all of all, the surgeons at Papworth of which there's sort of 18, I think there's only two who uh originate from Cambridge. So it is not a, it, although it may seem like it through the, the people participating in. This is not the case at all. I wonder if, I mean, there's a few more questions in the chat, but I wonder if we, we kind of wrap up there for the evening. Thank you so much for your time this evening. Mr Ali, it's been really helpful and hopefully the students have a bit more of an understanding of some of the procedures that you're performing. We've slightly saved it for later in the week. Um But uh we also had a talk on Tuesday night about transplant surgery and covered some of the background then. So I think hopefully we've built on the knowledge throughout the week and that's been really helpful. Um So just a few kind of admin notes before we wrap up. Um So tomorrow evening, we'll be doing a kind of case based discussion style lecture. So it'll be a bit of a quiz where you can ask a fake patient some questions and try and get to the bottom of the diagnosis and then myself and a couple of the other members of the committee. Um We will be doing a talk on our advice for applying into medical school, some of our top Ts for, for, for getting through. And then also I can give my perspective as a, as a junior doctor who's recently qualified about 18 months ago. So hope so that will be helpful and we can continue to answer some of your questions tomorrow night. Um Med for those of you that haven't joined earlier in the week. Med will automatically send you a feedback form at the end of this session. If you can please take a couple of minutes to fill that out, that would be really helpful. Um A lot of the sessions this year are different to the ones from last year based on the feedback we got. So I promise we are reading it and we're trying to act on it and make this scheme as helpful as possible. Um In return for filling out that feedback, you will automatically get a certificate of participation, someone had asked what they can use those certificates for which is a very relevant question. Um So when you're at medical school, quite often, you're very used to collecting certificates to put in a portfolio. But I think certainly for, for those of you that are considering applying to medical school, keep them in a file somewhere on your laptop and keep them on the back burner because, you know, they always will come in handy. But certainly this is definitely something that you can talk about on your personal statement. Um in the absence of being able to get work experience directly, then this kind of scheme is something that you can definitely talk about our interview and also think about some of the learning points that you've learned this week. Um and also reflecting on them and how that might make me might make you act differently if you do become a doctor and all of those things. So, um hopefully that this week has been helpful from that point of view as well because we know how difficult it is to get face to face work experience. Um I think that's it from me. I can't remember if II was kind of rambling now. I don't know if I've forgotten anything Alana or Mustine. Um No, I think feedback links uh will be provided automatically check your junk mail. I think you've said that already. Um And yeah, look forward to tomorrow's session. Um and we'll be doing a brief recap of what happened on Monday. Apologies that we had some tech issues with sending the link out on Monday. So if you miss a session on Monday, no worries, um come to the session tomorrow and we'll have a brief recap of the uh journeys and day in the lives of a um medical student up to a working doctor. Um And yeah, if you have any other questions, get in touch with us, but thank you so much for coming along today. I will put our email address in the chart. If anyone has any issues with accessing the feedback or getting their certificates, please just drop us an email and I'll try and get back to you as soon as I can. The only other thing was. Um So unfortunately, we aren't able to share last night's lecture just because there was some sensitive content in there and photographs of, of patients that um ideally we aren't sharing online. So I'm sorry for those of you that um missed last night's lecture. There are actually recordings from last year's lecture series on Medal. Um So for those of you that are wanting to watch some more, um some more content and we have five lectures available from last year that you could watch back. Um And some of the other sessions have been recorded this week and will be available at the end of the week. So keep an eye out for those and more ap apologies again about last night. All right. Thanks very much, everyone.