Cardiac Output

Dr Mike Charlesworth
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Cardiac Output is a podcast on cardiothoracic anaesthesia and intensive care medicine. Dr Mike Charlesworth and Dr Calum Downes bring you tacit knowledge from a national transplant and ECMO centre — the reasoning that never makes it into the textbook.

  1. 13h ago

    Minimally Invasive Cardiac Surgery, Part 2: The Mini Mitral and the Robot

    The patient's draped, the neck cannula is in and the TOE is done. Then the surgeon puts the knife down, turns round and says: "Timeout. Tell me what I'm fixing." They already know it's severe mitral regurgitation. What they want is everything that will change what they do over the next three hours. In part two of our series on minimally invasive cardiac surgery, we cover the mini mitral: why it's done this way, the levels of invasiveness, and who's suitable. Then a cautionary case about selection. Then the repair itself: Carpentier's principles, resection versus artificial chords, and using P1 as the reference for chord length. Then the TOE timeout: the Carpentier class, the segments involved, mitral annular disjunction, the risk of systolic anterior motion and how the surgeon changes the repair to avoid it, sizing, a quick systematic leaflet exam, and what to check after the repair, including the aortic valve and the circumflex territory. Then the robot: the set-up, the fluorescent endo-aortic balloon, how the balloon is inflated and what the TOE shows, cost, the learning curve and why base camp is the mini mitral, and three rules for a robotic programme. Finally, the anaesthetist's own job: placing, checking and removing the SVC cannula in the neck. We finish by giving the surgeon a proper timeout. Chapters (00:00) Cold open: the surgeon's timeout (00:45) What this episode covers (01:10) Why do the mitral minimally invasively? (01:45) Levels of invasiveness (02:15) The ideal patient (02:45) Poor candidates (03:20) A cautionary case (04:25) Carpentier's principles (04:50) Resection or artificial chords (05:15) Using P1 to set chord length (05:50) The TOE timeout: what to report (06:15) Mitral annular disjunction (06:40) Predicting SAM (07:05) Changing the repair to avoid SAM (07:30) Sizing and the rest of the heart (08:10) Checks before using a balloon (08:30) A quick systematic leaflet exam (09:05) After the repair: the aortic valve and the circumflex (09:40) The robot (10:10) Clamping with a fluorescent balloon (11:00) How the balloon is inflated (12:00) When the left atrium is open (12:45) Cost and value (13:20) The learning curve (13:50) Three rules (14:20) Placing the neck cannula (15:00) Insertion and tip position (15:55) Taking it out (16:25) The timeout, properly Key takeaways Selection is everything: degenerative mitral regurgitation, ideally a flail P2, with a repair rate over 90% Poor candidates include moderate aortic regurgitation, severe annular calcification, poor femoral access and a failing right ventricle likely to need tricuspid surgery Very long bypass times in difficult patients are costly; a new regional wall motion abnormality after a mitral repair always needs explaining Aim for a coaptation length of 5–10 mm and roughly a 2:1 ratio of anterior to posterior leaflet height P1 is almost always normal, so its height on TOE is a useful reference for artificial chord length Before the first cut, report the Carpentier class, the segments and width involved, the redundant tissue, disjunction, SAM risk, sizing, and the rest of the heart SAM risk is a combination: a short coaptation-to-septum distance, a narrow aortomitral angle, a tall posterior leaflet, a small hyperdynamic ventricle and a septal bulge; the fix is usually changing the repair, not abandoning it After the repair, check the aortic valve and look for wall motion abnormalities in the circumflex territory With an endo-aortic balloon, check the sinotubular junction and coronary anatomy first, watch the ME aortic valve long-axis view during inflation, and rely on the radial traces once the left atrium is open Robotic programmes should build on a large mini mitral experience, because the bailout is to undock and carry on as a mini mitral Place the SVC cannula in the right internal jugular with two wire checks, agree the tip position with the surgeon, and flush it straight away References / further reading Akowuah EF, Maier RH, Hancock HC, et al. Minithoracotomy vs conventional sternotomy for mitral valve repair: a randomized clinical trial. JAMA 2023; 329: 1957–66 Carpentier A. Cardiac valve surgery — the "French correction". J Thorac Cardiovasc Surg 1983; 86: 323–37 Maslow AD, Regan MM, Haering JM, Johnson RG, Levine RA. Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease. J Am Coll Cardiol 1999; 34: 2096–104 Parnell A, Prince M. Anaesthesia for minimally invasive cardiac surgery. BJA Educ 2018; 18: 323–30 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    Minimally Invasive Cardiac Surgery, Part 2: The Mini Mitral and the Robot

  2. 2d ago

    Minimally Invasive Cardiac Surgery, Part 1: Setting Up the Case

    The patient's on femoral bypass for a mini mitral. You've stopped ventilating so the surgeon can get the right lung down. The pump flow looks fine, but the right-sided cerebral oximetry is drifting down, and there's still a little pulse on the arterial line. The heart is still ejecting blood that has just been through lungs nobody is ventilating. This is the first of four episodes on minimally invasive cardiac surgery. We start with what counts as minimally invasive, why patients want it, and what worries surgeons. Then the evidence from two UK randomised trials: mini-sternotomy versus full sternotomy for aortic valve replacement, and the UK Mini Mitral trial. Then patient selection: the CT from the neck to the groin, absolute and relative contraindications, and whether the patient's lungs and right ventricle will cope with one-lung ventilation. Then the set-up. External defibrillator pads and why the empty right lung matters when you shock. Cerebral oximetry, temperature, and four transducers for an endo-aortic balloon, or a transthoracic clamp instead. Double-lumen tube or bronchial blocker, positioning and nerve protection. Then TOE-guided femoral cannulation: following the wires, small femoral arteries, checking for dissection, and draining the head with a superior vena cava cannula or a neck sheath. Finally, carbon dioxide in the field, what else the TOE does, pacing wires, and the anaesthetic itself. We finish with a pre-flight checklist. Chapters (00:00) Cold open: falling right-sided cerebral oximetry on femoral bypass (00:35) Harlequin syndrome and the fix (01:00) What this series covers (01:35) What counts as minimally invasive (02:05) Why patients want it (02:40) The surgeons' concerns (03:00) The mini-sternotomy aortic valve trial (04:10) The UK Mini Mitral trial (05:10) Patient selection and the CT (05:40) Absolute and relative contraindications (07:10) The lungs and one-lung ventilation (07:40) Pulmonary hypertension and the right ventricle (08:05) Defibrillator pads and the empty right lung (08:35) Monitoring, cerebral oximetry and temperature (09:45) Endo-aortic balloon or transthoracic clamp (10:50) Double-lumen tube or blocker (12:00) Positioning (12:35) TOE-guided femoral cannulation (13:25) Small femoral arteries and dissection (13:55) The venous cannula (14:30) Draining the head: SVC cannula or neck sheath (15:55) Carbon dioxide in the field (16:15) What else the TOE does (16:55) Pacing wires (17:35) The anaesthetic (17:55) The pre-flight checklist Key takeaways On femoral bypass, keep ventilating until the heart stops ejecting; otherwise deoxygenated blood from the left ventricle can reach the right side of the brain (Harlequin syndrome) The benefit of minimally invasive surgery is mainly faster early recovery; in the UK aortic valve trial, bypass and clamp times were longer and lung function at six weeks was worse Everyone planned for peripheral bypass needs a CT from the neck to the groin Absolute contraindications include an ascending aorta over about 40 mm, no clear sinotubular junction, more than moderate aortic regurgitation, mobile atheroma, and being unable to pass a TOE probe Put external defibrillator pads on first; if a shock fails with the right lung down, re-inflate the lung and shock again With an endo-aortic balloon, use bilateral radial lines; a falling right radial pressure suggests the balloon has migrated and is blocking the innominate artery A double-lumen tube gives quick, reliable lung isolation; a blocker avoids a tube exchange at the end and helps when the TOE probe won't pass Use TOE to follow every femoral wire, in biplane, before the cannula goes in With narrow femoral arteries and a high arterial line pressure, put the balloon in the other groin, and check the descending aorta for dissection once on bypass An SVC cannula is essential if the right heart is opened, to avoid an air lock in the circuit Flood the field with carbon dioxide, and use TOE to guide de-airing, because no one can lift the heart References / further reading Parnell A, Prince M. Anaesthesia for minimally invasive cardiac surgery. BJA Educ 2018; 18: 323–30 Akowuah EF, Maier RH, Hancock HC, et al. Minithoracotomy vs conventional sternotomy for mitral valve repair: a randomized clinical trial. JAMA 2023; 329: 1957–66 Hancock HC, Maier RH, Kasim AS, et al. Mini-sternotomy versus conventional sternotomy for aortic valve replacement. J Am Coll Cardiol 2019; 73: 2491–2 Rosengart TK, Feldman T, Borger MA, et al. Percutaneous and minimally invasive valve procedures: a scientific statement from the American Heart Association. Circulation 2008; 117: 1750–67 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    Minimally Invasive Cardiac Surgery, Part 1: Setting Up the Case

  3. 3d ago

    Thoracic Regional Anaesthesia: Getting the Paravertebral Right

    Ask anyone in an exam what shape the paravertebral space is and they'll say a wedge. Look at a CT scan, or a cadaver with dye in it, and it's something else: a continuous channel beside the vertebral bodies, with pouches sticking out between the ribs. Put your local anaesthetic in the channel and it spreads over several levels. Put it in a pouch and you've done an intercostal block. In this episode we cover regional anaesthesia for thoracic surgery. Why it matters more now: lung cancer screening, rising resection rates, and the chronic pain that persists after keyhole surgery as often as after open, most often at the port and drain sites. Then the menu: serratus anterior, erector spinae plane and paravertebral blocks — how each one works, what it covers, and why only the paravertebral reliably reaches the sympathetic chain and visceral pain. Plus paravertebral versus epidural, the European and enhanced recovery guidance, and whether blocks prevent chronic pain. We talk about surgically placed catheters and why many end up too lateral, preventative rather than pre-emptive analgesia, local anaesthetic systemic toxicity in thin patients with a low albumin, and then a practical walk-through of an ultrasound-guided paravertebral block: planning around the ports and drain, two-level injections, getting through the superior costotransverse ligament, and checking the spread. Finally, catheters, adjuncts, cryoanalgesia, and keeping the list moving. We finish by planning three thoracic lists. Chapters (00:00) Cold open — what shape is the paravertebral space? (01:00) Why thoracic regional matters now (01:35) Keyhole surgery and chronic pain (02:40) How often do patients get a block? (03:20) Getting started: the anatomy (03:50) Serratus anterior plane block (04:45) Erector spinae plane block (05:40) The paravertebral block (06:25) Paravertebral versus epidural (06:55) What the guidelines say (07:20) Preventing chronic pain (08:05) Surgically placed catheters (09:05) Blocking before and after surgery (09:35) Safety and local anaesthetic toxicity (10:25) The paravertebral anatomy, properly (11:30) Doing an ultrasound paravertebral block (12:35) Catheters, adjuncts and cryoanalgesia (13:30) Making time for the block (14:00) Planning three lists Key takeaways Around a third of patients have chronic pain after thoracic surgery, including after keyhole surgery; severe acute pain is the strongest predictor, and port and drain sites are the commonest sites The paravertebral space is a continuous longitudinal channel with lateral pouches between the ribs — inject medially, under the transverse process, for spread over several levels Serratus anterior: less hypotension, useful for rib fractures and drains, but spread is variable and analgesia tends to fade after about 72 hours Erector spinae: reliably covers the back but is less reliable for the front of the chest, where most incisions and drains are Only the paravertebral block reliably reaches the sympathetic chain, and so visceral and pleural pain Paravertebral and epidural give similar acute analgesia, but the paravertebral causes less hypotension, nausea, itch and urinary retention European procedure-specific guidance recommends a paravertebral block for thoracotomy and thoracoscopic surgery, and advises against an epidural for thoracoscopic surgery Think preventative analgesia: cover every painful phase rather than timing one block before incision Surgically placed catheters are often too lateral — audit whether both the wound and the drain site are numb Plan around the ports and drain; two-level injections (around T3–4 and T7–8) help make sure the drain site is covered Dose local anaesthetic by weight, think about the albumin in thin and frail patients, and know where the lipid is References / further reading Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2022; 77: 311–25 Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019; 55: 91–115 Yeung JHY, Gates S, Naidu BV, Wilson MJA, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; 2: CD009121 Weinstein EJ, Levene JL, Cohen MS, et al. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 6: CD007105 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    Thoracic Regional Anaesthesia: Getting the Paravertebral Right

  4. Nov 6

    The Aortic Valve, Part 2: Stenosis, Regurgitation and LVOT

    "Severe aortic stenosis means a mean gradient over forty." Yet in one study of patients with true severe stenosis examined on TOE after induction, 54 per cent had a mean gradient under forty. General anaesthesia lowers the flow, and the gradient falls with it. This is part two of two on the aortic valve on transoesophageal echo, following the aortic valve chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. For aortic stenosis: calcific versus rheumatic valves, 2D versus 3D planimetry, colour as a screen, continuous-wave Doppler and its pitfalls (including mistaking a mitral jet), the severity grades, the continuity equation, the double envelope and the dimensionless index, and low-flow, low-gradient stenosis — true versus pseudo-severe, dobutamine, and the paradoxical form — plus the indications for surgery. For aortic regurgitation: causes in the leaflets and in the root, describing where a jet starts and where it goes, jet width, vena contracta and 3D vena contracta area, PISA and its limits, holodiastolic flow reversal in the descending aorta, pressure half-time, the severe thresholds, and the indications for surgery. Then endocarditis — vegetations, perforation, abscess and fistula — and obstruction below the valve: dynamic outflow obstruction and how to treat it, versus a fixed subaortic membrane or ridge. We finish with a round of grading, starting with an anaesthetised valve whose numbers say moderate. Chapters (00:00) Cold open — the gradient under forty (00:45) Causes of aortic stenosis (01:10) Calcific versus rheumatic valves (01:45) Planimetry in 2D and 3D (02:15) Associated findings (02:45) Colour Doppler (03:10) Peak velocity and mean gradient (04:15) Grading aortic stenosis (04:40) The continuity equation and the double envelope (06:05) The dimensionless index (06:30) Low-flow, low-gradient stenosis (07:20) True or pseudo-severe? (08:00) Paradoxical low-flow stenosis (08:40) Indications for surgery in AS (09:20) Causes of aortic regurgitation (10:10) Describing the jet (10:40) Jet width and vena contracta (11:50) PISA for the aortic valve (12:35) Flow reversal and pressure half-time (13:40) Indications for surgery in AR (14:15) Endocarditis (15:00) Outflow tract obstruction (16:15) Grading round Key takeaways General anaesthesia lowers flow and gradients: over half of true severe AS can have a mean gradient under 40 mmHg under GA — rely on the pre-op echo and flow-independent measures Calcific AS: heavy, asymmetric calcification and a star-shaped orifice; rheumatic: more commissural fusion and less calcium; no calcification makes significant AS very unlikely 3D planimetry at the leaflet tips correlates well with the continuity equation; 2D planimetry does not Use the highest of several CW velocities; beware an MR jet (usually >5 m/s, holosystolic, rounded) and use the long Bernoulli equation if LVOT velocity >1.5 m/s AS grades: mild 2.0–2.9 m/s, mean 4, AVA stays ≤1) from pseudo-severe (AVA rises >1) Paradoxical low-flow AS: normal EF, small thick LV, SVI 6 mm, EROA ≥0.30 cm², regurgitant volume ≥60 mL, regurgitant fraction ≥50% Holodiastolic flow reversal in the descending aorta with an end-diastolic velocity >20 cm/s is a sensitive sign of severe AR; PHT 200 ms suggests severe Endocarditis: vegetations on the ventricular side, perforation, abscess and fistula — check all the other valves Dynamic LVOT obstruction is late-peaking: fill, slow the heart, add a vasoconstrictor and stop inotropes; fixed subaortic stenosis peaks early with normally opening leaflets References / further reading The aortic valve and left ventricular outflow tract (Chapter 10). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686 Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021; 143: e72–e227 Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the EACVI and the ASE. J Am Soc Echocardiogr 2017; 30: 372–92 Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr 2017; 30: 303–71 Machida T, Izumo M, Suzuki K, et al. Value of anatomical aortic valve area using real-time three-dimensional transoesophageal echocardiography in patients with aortic stenosis. Eur Heart J Cardiovasc Imaging 2015; 16: 1120–8 Whitener G, McKenzie J, Akushevich I, et al. Discordance in grading methods of aortic stenosis by pre-cardiopulmonary bypass transesophageal echocardiography. Anesth Analg 2016; 122: 953–8 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    The Aortic Valve, Part 2: Stenosis, Regurgitation and LVOT

  5. Nov 6

    The Aortic Valve, Part 1: Anatomy, Measurement and Bicuspid

    Two numbers for the same aortic annulus: 23 mm on the 2D long-axis view, 27 mm on the 3D reconstruction — and the surgeon is sizing a valve. Neither number is wrong. This is part one of two on the aortic valve and left ventricular outflow tract on transoesophageal echo, built around the aortic valve chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. We start with the anatomy of the aortic root: the crown-shaped leaflet attachments, the sinuses of Valsalva and coronary origins, and the difference between the basal ring, the ventriculo-aortic junction and the functional aortic annulus — then the walls of the outflow tract and why the root's neighbours matter. Then the four standard views, how an off-axis short axis can fake a perforation, and where to find the coronary origins. The core of the episode is measuring the root properly: how to tell your long-axis view is truly centred, where to put the biplane cursor, which measurements are mid-systolic inner-edge and which are end-diastolic leading-edge, and why the annulus is an ellipse — with the 3D mean-diameter method for when the number really matters. Finally, the bicuspid aortic valve: prevalence, the Sievers classification, the elliptical orifice and doming, why a calcified bicuspid valve can be impossible to recognise, and why finding one should always make you look up at the aorta — plus unicuspid and quadricuspid valves. We finish with six measurement mistakes for Calum to spot. Part two covers stenosis, regurgitation, endocarditis and outflow tract obstruction. Chapters (00:00) Cold open — 23 or 27? (01:00) Why the aortic valve suits TOE (01:20) The aortic root and its crown (02:40) Where exactly is the annulus? (03:20) The outflow tract and neighbouring structures (04:10) The standard views and the coronaries (05:10) Measuring through the centre of the root (05:30) Checking you're on axis (06:10) Systole or diastole, inner or leading edge (06:35) The elliptical annulus and the mean diameter (07:40) Transgastric views and 3D (08:25) The bicuspid valve and its classification (09:25) Recognising a bicuspid valve — and looking up (10:20) Unicuspid and quadricuspid valves (10:45) Spot the error Key takeaways The aortic root runs from the ventriculo-aortic junction to the sinotubular junction; the leaflets attach in a crown shape, not a ring The basal ring is a virtual plane through the leaflet nadirs; the ventriculo-aortic junction sits slightly above it; the whole crown is the functional aortic annulus The non-coronary sinus lies next to the interatrial septum; the left and non-coronary leaflets are in continuity with the anterior mitral leaflet An off-axis short-axis view can fake a coaptation defect or perforation A centred long-axis view passes between the left and non-coronary cusps: a flat posterior root with no posterior leaflet or sinus; two sinuses and two leaflets mean you're off-axis In 3D biplane, place the short-axis cursor through the left/non-coronary commissure and the centre of the right coronary cusp Measure the LVOT and annulus in mid-systole, inner edge to inner edge; the sinuses, STJ and aorta at end-diastole, leading edge to leading edge The annulus is elliptical — axes can differ by up to 6 mm, and 3D measures larger than 2D; mean diameter = 2 × √(area ÷ π) Transgastric views give the only good Doppler alignment and see past shadowing from calcium or prostheses Bicuspid valves affect 0.5–2% of people (male:female about 3:1); left–right fusion is commonest; Sievers type 1 (one raphe) is over 90% Look for an elliptical systolic orifice and doming — and always measure the root and ascending aorta, and think about coarctation Unicuspid valves present young and go with aortopathy; quadricuspid valves usually leak and go with coronary anomalies References / further reading The aortic valve and left ventricular outflow tract (Chapter 10). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686 Charitos EI, Sievers HH. Anatomy of the aortic root: implications for valve-sparing surgery. Ann Cardiothorac Surg 2013; 2: 53–6 Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults. J Am Soc Echocardiogr 2015; 28: 1–39 Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007; 133: 1226–33 Michelena HI, Della Corte A, Evangelista A, et al. International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy. Eur J Cardiothorac Surg 2021; 60: 448–76 Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol 2010; 55: 2789–800 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    The Aortic Valve, Part 1: Anatomy, Measurement and Bicuspid

  6. Nov 1

    Cheap Knowledge, Scarce Experience: Training Generation Alpha

    If you're listening to this in the car or at the gym, you're part of the argument in this episode. Mike talks through his new editorial in Anaesthesia, "Cheap knowledge, scarce experience: training Generation Alpha" — and Calum points out the irony of discussing it on a podcast, along with the paper's own warning that a poorly produced podcast can be less useful than a dry lecture. We cover how each generation of anaesthetists has handled knowledge, and why generative artificial intelligence changes not just access to knowledge but what written work can prove. Then assessment: why chatbots nearly passing the FRCA doesn't make the exam redundant, why the conditions of an exam matter more than its content, the changes coming to the FRCA from July 2027, and the inversion that the exam residents complain about most is now among the best-defended evidence we hold. Then the workplace — supervised learning events, entrustment, and the tacit, pattern-based skills that make an anaesthetist safe — and why the real crisis is not one of knowledge, but of how we recognise competence and experience. Plus the case for abolishing the written reflective entry, the trouble with generational stereotypes and learning styles, and what departments should do now. We finish by sorting training into cheap and scarce — and making the case for using podcasts for the cheap things, so the scarce things get the time. Chapters (00:00) Cold open — you're part of the argument (01:20) How each generation handled knowledge (02:35) Why Generation Alpha matters (03:30) What was scarce, generation by generation (04:30) What written work can now prove (05:25) Chatbots and the FRCA (06:40) The 2027 exam changes (07:45) The workplace and tacit knowledge (09:15) What needs to change (09:45) Abolish the written reflection (10:10) Generations, learning styles and the paradox (11:40) What should happen now (12:45) Declaring artificial intelligence use (13:10) Cheap or scarce? Key takeaways Generative AI changes not just access to knowledge but what written work can prove — the artefact no longer shows the thinking happened Generation Alpha (born 2010–2024) starts medical school from 2028 and may be the first cohort for whom AI is simply part of the learning environment AI text detectors are unreliable, which weakens the evidence from text-based portfolio entries even for the honest majority A chatbot's exam score says nothing about the inference drawn from a human candidate under closed-book, invigilated, timed conditions Open-book assessment tests a different construct — searching and appraising — not a worse one; the error is changing conditions without deciding what to measure From July 2027, the FRCA primary becomes two 80-question applied knowledge papers and the final written a single 100-question paper, without constructed responses The exam is now among the best-defended evidence of competence; much of the portfolio relies on trust Workplace-based assessment and entrustment by a named consultant can't be generated by AI — but need trained assessors and protected time The crisis is not one of knowledge but of recognising competence, experience and clinical exposure The written reflective entry was always a poor proxy; reflection happens in a person Generational differences confound age, period and cohort effects, and matching teaching to learning styles isn't supported Use efficient formats for information, reserve face-to-face time for scarce things — and don't confuse delivery preference with educational value References / further reading Charlesworth M. Cheap knowledge, scarce experience: training Generation Alpha. Anaesthesia 2026. doi:10.1111/anae.70452 Birkett L, Fowler T, Pullen S. Performance of ChatGPT on a primary FRCA multiple choice question bank. Br J Anaesth 2023; 131: e34–5 Cai SC, Tung AMS, Eslick AT. Performance of ChatGPT on a free-response anaesthesia primary examination. Br J Anaesth 2024; 133: 219–21 McLachlan J. Independent review of the assessment processes of the Royal College of Anaesthetists. 2023 Risko EF, Gilbert SJ. Cognitive offloading. Trends Cogn Sci 2016; 20: 676–88 Newton PM, Najabat-Lattif HF, Santiago G, Salvi A. The learning styles neuromyth is still thriving in medical education. Front Hum Neurosci 2021; 15: 708540 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    Cheap Knowledge, Scarce Experience: Training Generation Alpha

  7. Oct 23

    The Right Ventricle, Part 2: Function and Congestion

    After a straightforward valve operation, TAPSE is twelve millimetres — well under the transthoracic normal. But the fractional area change is 40 per cent, the 3D ejection fraction is 48 per cent, and the lactate is falling. Which number is lying? This is part two of two on the right ventricle on transoesophageal echo, following the right ventricle chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. It's about measurement: which numbers to trust, when, and why bypass changes the way the right ventricle contracts — longitudinal shortening falls and circumferential contraction rises, for up to a year. We go through each systolic measure: TAPSE and the TOE alignment problem (and anatomical M-mode), S-prime and why transthoracic cut-offs don't transfer, fractional area change, 3D ejection fraction, speckle-tracking strain, and the myocardial performance index — with normal values and pitfalls for each. Then diastolic function — E, A, E-prime and deceleration time — and how E over E-prime unmasks pseudonormal filling. Finally, congestion beyond the heart: the A, S, V and D waves of hepatic vein flow and how they change as the right ventricle fails, portal vein pulsatility, intrarenal venous flow and the resistive index, and why IVC collapse doesn't translate to TOE. We finish with Calum sorting every measure into traffic lights: trust it, use with caution, or leave it. Chapters (00:00) Cold open — TAPSE says failing, FAC says fine (01:05) Geometric and non-geometric measures (01:25) TAPSE on TOE (02:40) Tissue Doppler S-prime (03:15) Fractional area change (03:55) 3D ejection fraction (04:50) Strain and speckle tracking (05:45) Myocardial performance index (06:35) What to trust after bypass (06:55) Diastolic function (07:55) Relaxation, pseudonormal and restrictive filling (08:45) Congestion beyond the heart (09:05) Hepatic vein Doppler (10:05) Portal vein pulsatility (10:30) Renal venous flow (10:55) The IVC on TOE (11:10) Traffic lights Key takeaways After bypass, RV longitudinal function falls and circumferential contraction rises for up to a year — interpret TAPSE and S′ with caution and lean on global measures TAPSE (normal >16 mm on TTE) is underestimated in the ME four-chamber view unless anatomical M-mode or the deep transgastric RV inflow view is used S′ (TTE normal ≥9.5 cm/s pulsed-wave, ≥6.0 cm/s colour TDI) has not been validated in TOE views FAC = (RVEDA − RVESA) ÷ RVEDA; below 35% is abnormal; angle-independent, includes trabeculations, inflow portion only 3D RVEF above 45% is normal; needs ≥25 Hz, often multi-beat ECG-gated acquisition; may underestimate volumes RV free wall strain more negative than −20% is normal; speckle tracking needs good images and frame rates above ~40/s MPI = (IVCT + IVRT) ÷ ET; normal 6 with a normal E/A suggests pseudonormalisation Restrictive RV filling: E/A >2.1 with a deceleration time 120 ms Hepatic vein flow as the RV fails: exaggerated A-wave, blunted then reversed S-wave, relatively larger D-wave Portal flow becomes pulsatile with congestion (pulsatility index normally 0.5); intrarenal venous flow becomes pulsatile and the resistive index rises (normal 0.7) IVC size and collapsibility are not validated with TOE or positive-pressure ventilation References / further reading The right ventricle (Chapter 14). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686 Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010; 23: 685–713 Silverton NA, Gebhardt BR, Maslow A. The intraoperative assessment of right ventricular function during cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36: 3904–15 Denault AY, Haddad F, Jacobsohn E, Deschamps A. Perioperative right ventricular dysfunction. Curr Opin Anaesthesiol 2013; 26: 71–81 Rola P, Miralles-Aguiar F, Argaiz E, et al. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. Ultrasound J 2021; 13: 32 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    The Right Ventricle, Part 2: Function and Congestion

  8. Oct 23

    The Right Ventricle, Part 1: Anatomy, Physiology and Views

    In the 1940s, researchers burned away most of the right ventricular free wall in dogs, and the venous pressure barely moved. For decades, the right ventricle was treated as a passive conduit. Nobody who has watched one fail coming off bypass believes that now. This is part one of two on the right ventricle on transoesophageal echo, built around the right ventricle chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. Severe acute right ventricular failure after cardiac surgery is uncommon, but when it's refractory, hospital mortality is between 22 and 90 per cent. We cover the anatomy — three parts, four walls, a 55-degree angle between inflow and outflow, and a peristaltic contraction with three distinct movements — and how much the left ventricle contributes. Then the blood supply wall by wall, and why air in the right coronary is the commonest cause of sudden right ventricular failure as you come off bypass. Then the physiology: why the right ventricle tolerates gradual rises in afterload but not sudden ones, and why more fluid can lower the cardiac output of a failing right ventricle. Then the six TOE views, normal sizes for the inflow, outflow and wall, and the rule that right ventricular enlargement should never go unexplained. Finally, reading the septum — volume overload versus pressure overload, the eccentricity index, and the interatrial septum — before Calum tests himself with six true-or-false statements. Part two covers measuring function and seeing congestion beyond the heart. Chapters (00:00) Cold open — the passive conduit (01:00) Who's at risk (01:20) Anatomy: three parts and four walls (02:05) Recognising the right ventricle (02:30) How it contracts (03:10) Blood supply, wall by wall (03:40) Air in the right coronary (04:10) Other causes after bypass (04:25) Physiology and afterload (05:00) Volume, Frank–Starling and the septum (05:40) The TOE views (07:15) Measuring size (08:05) Wall thickness and unexplained enlargement (08:45) Reading the septum (09:25) The eccentricity index (09:55) The interatrial septum (10:15) True or false Key takeaways Severe acute RV failure after cardiotomy is around 0.1%, but refractory RV failure carries 22–90% hospital mortality Highest risk: pre-existing RV dysfunction, severe pulmonary hypertension, heart or lung transplant, and LVAD implantation The RV has an inlet, an apical trabecular part and an infundibulum; four walls (free/lateral, anterior, inferior, infundibulum); inflow and outflow at about 55° Contraction is peristaltic, from apex to infundibulum, with three movements: free wall inwards, base towards apex, and traction from LV contraction — the LV contributes up to 40% of RV pressure Blood supply: lateral wall from the RCA alone (acute marginals); anterior wall and infundibulum from RCA and LAD; inferior wall and posterior third of the septum from the PDA Air embolism to the RCA or RV grafts is the commonest cause of acute RV dysfunction when weaning from bypass The RV tolerates gradual increases in afterload but decompensates with sudden ones; chronic pressure overload causes hypertrophy and a D-shaped LV in systole Excess volume dilates the RV, shifts the septum left, impairs LV filling and worsens tricuspid regurgitation Abnormal sizes: basal diameter >41 mm, mid >35 mm, proximal RVOT >35 mm, distal RVOT >27 mm, free wall >5 mm RV enlargement should never go unexplained — exclude a shunt or other primary cause before blaming the LV Volume overload: septal flattening in diastole only; pressure overload: in systole and diastole; a systolic eccentricity index >1.08 predicts pulmonary hypertension A leftward shift of the interatrial septum suggests raised right atrial pressure References / further reading The right ventricle (Chapter 14). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686 Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010; 23: 685–713 Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation 2008; 117: 1436–48 Crystal GJ, Pagel PS. Right ventricular perfusion: physiology and clinical implications. Anesthesiology 2018; 128: 202–18 Silverton NA, Gebhardt BR, Maslow A. The intraoperative assessment of right ventricular function during cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36: 3904–15 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.

    The Right Ventricle, Part 1: Anatomy, Physiology and Views
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About

Cardiac Output is a podcast on cardiothoracic anaesthesia and intensive care medicine. Dr Mike Charlesworth and Dr Calum Downes bring you tacit knowledge from a national transplant and ECMO centre — the reasoning that never makes it into the textbook.

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  • Creator
    Dr Mike Charlesworth
  • Years Active
    2026
  • Episodes
    41
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    Clean
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    © Copyright 2024 All rights reserved.
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