Introduction Coronavirus disease 2019 ( COVID ‐19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 ( SARS ‐CoV‐2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. Recommendations We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. Changes in management as a result of this statement This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID ‐19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. Endorsed by Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group.

General anaesthesia with intubation and single lung ventilation has always been considered essential for thoracic surgery. Over the last decade there has been a huge evolution in thoracic surgery with the development of multiport and uniportal minimally invasive techniques. The development of a non-intubated technique during which thoracic surgery is performed on patients who are spontaneously ventilating awake, under minimal sedation with the aid of local or regional anaesthesia or under general anaesthesia with a supraglottic airway device is winning acceptance as a valid alternative technique. The concept is to allow the creation of a spontaneous pneumothorax as the surgeon enters the chest. This can provide excellent lung isolation without the need for positive pressure ventilation on the dependant lung.Awake and minimal sedation techniques, which avoid the need for general anaesthesia, maintain a more physiological cardiopulmonary and neurological status and avoid postoperative nausea and vomiting.However, general anaesthesia with a supraglottic airway device is the technique that provides a more stable airway and facilitates oxygenation in cases where an unexpected conversion to open thoracotomy in needed.For non-intubated thoracic surgery a regional analgesic technique is essential; nonetheless a 'multimodal' approach to analgesia is recommended. Non-intubated anaesthetic techniques for thoracic surgery are innovative and exciting and drive to reduce the invasiveness of the procedures. We recommend that centres starting out with non-intubated techniques begin by performing minor video-assisted thoracic surgery (VATS) procedures in selected low risk patients. Early elective conversion should be employed in any unexpected surgical difficulty or cardiopulmonary problem during the learning curve to reduce the risk of emergency conversion and complications. Further research is needed to establish which patients benefit more from the technique and what is the real impact on perioperative mortality and morbidity.

SummaryReported data suggest that 99% of transfemoral, transcatheter aortic valve implantations in the UK are performed under general anaesthesia. This before-and-after study is the first UK comparison of conscious sedation vs. general anaesthesia for this procedure. Patients who underwent general anaesthesia received tracheal intubation, positive pressure ventilation, radial arterial and central venous access and urinary catheterisation. Anaesthesia was maintained with propofol or sevoflurane. Patients who received conscious sedation had a fascia iliaca and ilioinguinal nerve block and low-dose remifentanil infusion, without invasive monitoring or urinary catheterisation. Recruitment took place between August 2012 and July 2015, with a 6-month crossover period between November 2013 and June 2014. A total of 88 patients were analysed, evenly divided between the two groups. Patients receiving conscious sedation had a shorter anaesthetic time (mean (SD) 121 (28) min vs. 145 (41) min; p < 0.001) and recovery room time (110 (50) min vs. 155 (48) min; p = 0.001), lower requirement for inotropes (4.6% vs 81.8%; OR (95% CI) 0.1 (0.002-0.050); p < 0.001) and a lower incidence of malignant dysrhythmia (0% vs 11.4%; p = 0.020). Conscious sedation appears a feasible alternative to general anaesthesia for this procedure and is associated with a reduced requirement for inotropic support and improved efficiency.

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