『Cardiac Output』のカバーアート

Cardiac Output

Cardiac Output

著者： Dr Mike Charlesworth
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概要

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.

Copyright 2024 All rights reserved.
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  • Cheap Knowledge, Scarce Experience: Training Generation Alpha

    Cheap Knowledge, Scarce Experience: Training Generation Alpha
    2026/11/01
    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 happenedGeneration Alpha (born 2010–2024) starts medical school from 2028 and may be the first cohort for whom AI is simply part of the learning environmentAI text detectors are unreliable, which weakens the evidence from text-based portfolio entries even for the honest majorityA chatbot's exam score says nothing about the inference drawn from a human candidate under closed-book, invigilated, timed conditionsOpen-book assessment tests a different construct — searching and appraising — not a worse one; the error is changing conditions without deciding what to measureFrom July 2027, the FRCA primary becomes two 80-question applied knowledge papers and the final written a single 100-question paper, without constructed responsesThe exam is now among the best-defended evidence of competence; much of the portfolio relies on trustWorkplace-based assessment and entrustment by a named consultant can't be generated by AI — but need trained assessors and protected timeThe crisis is not one of knowledge but of recognising competence, experience and clinical exposureThe written reflective entry was always a poor proxy; reflection happens in a personGenerational differences confound age, period and cohort effects, and matching teaching to learning styles isn't supportedUse 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.70452Birkett L, Fowler T, Pullen S. Performance of ChatGPT on a primary FRCA multiple choice question bank. Br J Anaesth 2023; 131: e34–5Cai SC, Tung AMS, Eslick AT. Performance of ChatGPT on a free-response anaesthesia primary examination. Br J Anaesth 2024; 133: 219–21McLachlan J. Independent review of the assessment processes of the Royal College of Anaesthetists. 2023Risko EF, Gilbert SJ. Cognitive offloading. Trends Cogn Sci 2016; 20: 676–88Newton 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.
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    14 分
  • The Right Ventricle, Part 2: Function and Congestion

    The Right Ventricle, Part 2: Function and Congestion
    2026/10/23
    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 measuresTAPSE (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 usedS′ (TTE normal ≥9.5 cm/s pulsed-wave, ≥6.0 cm/s colour TDI) has not been validated in TOE viewsFAC = (RVEDA − RVESA) ÷ RVEDA; below 35% is abnormal; angle-independent, includes trabeculations, inflow portion only3D RVEF above 45% is normal; needs ≥25 Hz, often multi-beat ECG-gated acquisition; may underestimate volumesRV free wall strain more negative than −20% is normal; speckle tracking needs good images and frame rates above ~40/sMPI = (IVCT + IVRT) ÷ ET; normal <0.43 (PW) or <0.54 (TDI); unreliable with arrhythmia or high RAPDiastology: E/A 0.8–2.1, E′ 0.08–0.20 m/s, E/E′ 2–6, deceleration time 120–200 ms; E/E′ >6 with a normal E/A suggests pseudonormalisationRestrictive RV filling: E/A >2.1 with a deceleration time <120 msHepatic vein flow as the RV fails: exaggerated A-wave, blunted then reversed S-wave, relatively larger D-wavePortal 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 9780198873686Rudski 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: 685–713Silverton NA, Gebhardt BR, Maslow A. The intraoperative assessment of right ventricular function during cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36: 3904–15Denault AY, Haddad F, Jacobsohn E, Deschamps A. Perioperative right ventricular dysfunction. Curr Opin Anaesthesiol 2013; 26: 71–81Rola 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.
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    14 分
  • The Right Ventricle, Part 1: Anatomy, Physiology and Views

    The Right Ventricle, Part 1: Anatomy, Physiology and Views
    2026/10/23
    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 mortalityHighest risk: pre-existing RV dysfunction, severe pulmonary hypertension, heart or lung transplant, and LVAD implantationThe 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 pressureBlood 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 PDAAir embolism to the RCA or RV grafts is the commonest cause of acute RV dysfunction when weaning from bypassThe RV tolerates gradual increases in afterload but decompensates with sudden ones; chronic pressure overload causes hypertrophy and a D-shaped LV in systoleExcess volume dilates the RV, shifts the septum left, impairs LV filling and worsens tricuspid regurgitationAbnormal sizes: basal diameter >41 mm, mid >35 mm, proximal RVOT >35 mm, distal RVOT >27 mm, free wall >5 mmRV enlargement should never go unexplained — exclude a shunt or other primary cause before blaming the LVVolume overload: septal flattening in diastole only; pressure overload: in systole and diastole; a systolic eccentricity index >1.08 predicts pulmonary hypertensionA 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 9780198873686Rudski 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: 685–713Haddad 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: 1436–48Crystal GJ, Pagel PS. Right ventricular perfusion: physiology and clinical implications. Anesthesiology 2018; 128: 202–18Silverton 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...
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    12 分
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