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Axillary artery cannulation is an ideal arterial inflow site in cases where the ascending aorta is unsuitable as it is safe, reliable and reduces the risks of atheroembolization and malperfusion. Major complications are rare with this meticulous technique and it is our standard practice in complex cardiac and aortic surgery.

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The tricuspid valve (TV), although occasionally considered "neglected" is the subject of renewed and increasing interest. Factors include an awareness that tricuspid value dysfunction is influential in patient outcomes, an improving understanding of valve anatomy and function and evolving techniques available to address tricuspid regurgitation. Tricuspid regurgitation (TR) can be classified as being due to primary diseases of the valve or functional in nature, with the majority being functional. Whilst it was previously believed that such functional TR, resulting from left sided disease, would resolve after correction of the underlying pathology this is now known not to be true. In fact, annular dilatation, TR and right ventricular dysfunction may all continue to progress after successful surgery on the aortic or mitral valve. Although there are many modalities with which to image the TV, this lecture will focus on echocardiography, primarily transesophageal echocardiography (TEE). In every patient undergoing cardiac surgery with TEE, a thorough and systematic examination of the TV structure and function should be performed, utilizing quantitative and qualitative measures with both 2D and 3D echocardiography. As the appearance of TR can be significantly influenced by hemodynamic factors, it is essential that echocardiography to investigate TR also be performed in the resting conscious state. Ideally, deciding whether the TV warrants operative attention at the time of planned cardiac surgery should be determined preoperatively based on a high quality transthoracic echocardiography (TTE) and relevant patient and surgical factors. This lecture aims to give an overview of the echocardiographic assessment of the TV, parameters available to grade the severity of TR, and how these may be utilized to assist the surgeon considering intervention. Whilst the surgical management at the extremes of TR (mild or severe) is relatively clear, the ideal intervention in intermediate grades, especially during concurrent left sided surgery remains uncertain and is the subject of ongoing research.

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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?’ Altogether more than 118 papers were found using the reported search, of which 4 represented the best evidence to answer the clinical question, which included 2 prospective cohort studies and 2 retrospective observational studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. There is a significant variation within the MIDCAB and TECAB techniques amongst the studies-including the experience of the surgeon, use of cardiopulmonary bypass, patient selection, and target vessel grafting strategies-highlighting the complexity of comparing these two minimally invasive procedures. Operative times were comparable across all studies, with TECAB patients having higher transfusions rates and conversion rates to either a median sternotomy or MIDCAB procedure. Overall safety was comparable between the two cohort groups, with similar length of stay and 30-day mortality. However, the TECAB group were more likely to require re-operation for bleeding and reintervention for early revascularisation with greater total hospital costs than the MIDCAB patients. Based on the available evidence, we conclude that TECAB is associated with a higher rate of transfusions, conversion to median sternotomy or MIDCAB, early graft failure and reintervention compared to the MIDCAB approach. We advise caution in adopting a TECAB approach.