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ObjectiveTo compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care).DesignA single-blind, randomised controlled trial.SettingSingle centre UK National Health Service tertiary hospital.ParticipantsAdult patients undergoing aortic valve replacement (AVR) surgery.InterventionsIntervention was manubrium-limited mini-sternotomy performed using a 5–7 cm midline incision. Usual care was median sternotomy performed using a midline incision from the sternal notch to the xiphisternum.Primary and secondary outcome measuresThe primary outcome was the proportion of patients who received a red cell transfusion postoperatively and within 7 days of index surgery. Secondary outcomes included proportion of patients receiving a non-red cell blood component transfusion and number of units transfused within 7 days and during index hospital stay, quality of life and cost-effectiveness analyses.Results270 patients were randomised, received surgery and contributed to the intention to treat analysis. No difference between mini and conventional sternotomy in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, OR 1.0 (95% CI 0.5 to 2.0) and risk difference 0.0 (95% CI −0.1 to 0.1). Mini-sternotomy reduced chest drain losses (mean 181.6 mL (SD 138.7) vs conventional, mean 306·9 mL (SD 348.6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between mini-sternotomy and conventional groups; 23 mm vs 24 mm and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass (82.7 min (SD 23.5) vs 59.6 min (SD 15.1)) and cross-clamp times (64.1 min (SD 17.1) vs 46·3 min (SD 10.7)). Conventional sternotomy was more cost-effective with only a 5.8% probability of mini-sternotomy being cost-effective at a willingness to pay of £20 000/QALY (Quality Adjusted Life Years).ConclusionsAVR via mini-sternotomy did not reduce red blood cell transfusion within 7 days following surgery when compared with conventional sternotomy.Trial registration numberISRCTN29567910; Results.

BACKGROUND—There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs). OBJECTIVE—To quantify the effect of training on outcome and costs. DESIGN—Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs. SETTING—Regional cardiothoracic surgery unit. MAIN OUTCOME MEASURES—Postoperative mortality; hospital costs. RESULTS—Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three different levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant differences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was £6619, £6572, £6494, and £6404 (NS). CONCLUSIONS—Trainees performed 44.4% of all CABG operations. There was no detrimental effect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes. Keywords: coronary artery bypass surgery; training; costs

A 65-year-old woman presented with acute central chest pain. Her ECG showed inferior ST elevation and she was transferred to our cardiac catheterisation laboratory for primary percutaneous coronary intervention. Coronary angiography showed no obstructive coronary atheroma, though a foreign body appeared to be lodged within the heart (panel A). The following morning her troponin T level was raised at 1.15 ng/ml. A Port-O-Cath had previously been inserted via the right subclavian vein as part of the treatment of breast carcinoma. Thoracic CT demonstrated a fragment of the catheter lying across the fossa ovalis. There was no evidence of pulmonary thromboembolism or recurrence of the breast carcinoma. Transoesophageal echocardiography suggested thrombus was adherent to the fragment within the right atrium. After 1 weeks treatment with heparin, thrombus was still visible. As we considered percutaneous retrieval might cause systemic embolism, the fragment was removed under direct visualisation through a longitudinal right atriotomy while the patient was on cardiopulmonary bypass (panel B). At operation, most of the catheter fragment was seen within the left atrium without any visible thrombus attached; the patent foramen ovale was repaired and the remainder of the Port-O-Cath removed. The patient has remained asymptomatic. Catheter fracture usually results from compression of implanted catheters lying between the first rib and the clavicle. We suspect that the acute presentation was secondary to paradoxical thromboembolism to the coronary circulation. As far as we know, this is the first report of migration of a fractured venous catheter across a patent foramen ovale resulting in acute myocardial infarction. Coronary angiogram: right anterior oblique projection demonstrating the embolised venous catheter fragment within the atria. Hub port and catheter after removal; centimetre scale rule for reference.