Cardiovascular Surgery

INTERVIEW #6 Conducted by 2000-01 Division Coordinator, Gilbert Tang (U. of Toronto) William G. Williams, Division Head, Cardiovascular Surgery, Hospital for Sick Children; Professor, Department of Surgery, University of Toronto

Biography: Dr. Williams attended University of Western Ontario as an undergraduate, then attended medical school at University of Western Ontario. His residency and cardiovascular surgery fellowship was completed at St. Michael's Hospital, Hospital for Sick Children, Toronto Western Hospital. Additional training was acquired in England and Toronto.

Do you have any particular interests in cardiovascular surgery? Congenital adult and pediatric heart disease What attracted you to cardiovascular surgery? In 1963 as a PGY3, felt intrigued by the specialty What level of training does it take to become a pediatric cardiac surgeon? 2 years of fellowship Throughout your career and training, what has been the hardest thing to deal with? Long hours and demanding workload, 8-10 years of training If you could pick the 3 most important characteristics of a cardiovascular surgeon, what would they be? Committed Intelligent Technically proficient Cardiovascular surgeons are busy people. How do you balance between your work and family life? I have a good wife. What is the average income of a cardiovascular surgeon? 60% of adult cardiac surgeon's income Do you have any suggestions or advice for medical students considering a career in cardiovascular surgery? Get exposure early; if interested in peds CV surgery, there are few job prospects available, and only in academic centers. What would you say are the three most common types of operations performed by cardiovascular surgeons today? There are 136 different peds CV operations used in different permutations & combinations. Most common are: ASD VSD PDA Tetralogy de Fallot & Transposition of Great Arteries (TGA) What would you say is the most challenging problem seen by cardiovascular surgeons today? Management of newborns with congenital heart disease What do you see as the 3 most important advances in cardiovascular surgery over the past 20 years? understanding of newborn CV physiology & pathology arterial switch operation - capability of complex peds CV operations What do you see as the 3 most important advances in cardiovascular surgery over the next 20 years? fetal heart surgery gene therapy xenotransplantation

INTERVIEW #7 Conducted by 2001-02 Division Coordinator, Erik Glassman (Boston U.) Dr. Pedro J. del Nido is an Associate Professor of Surgery at Harvard Medical School and an attending Cardiothoracic Surgeon at Boston Children's Hospital.

Biography: As an undergraduate, Dr. del Nido attended the University of Wisconsin where he majored in biochemistry. Dr. del Nido stayed at the University of Wisconsin for Medical School, then came to Boston for a general surgery residency at Boston University. Upon completion of residency, Dr. del Nido then went to the University of Toronto for a cardiothoracic surgery fellowship. He also completed a pediatric cardiac surgery fellowship at The Hospital for Sick Children in Toronto. Dr. del Nido has a particular interest in surgery for congenital heart defects.

Does the institution you are at now or the institution you did your fellowship at split Cardiac and Thoracic Surgery into two separate departments? Yes - both What attracted you to cardiothoracic surgery? I enjoyed studying the cardiac physiology and anatomy required to understand heart defects. I also enjoyed the ability to directly address these defects which is provided by the surgery. Throughout your training, what has been the hardest thing to deal with? Very little has been hard. The hours are long and the field is changing rapidly requiring constant updating but since I enjoy it, I don't consider it a hardship. How would you classify the competitiveness of obtaining one of the cardiothoracic surgery fellowship spots? At this time it is moderately competitive. There are fewer spots but I also think that there are fewer candidates. Do you have any suggestions or advice for premedical or medical students considering a career in cardiothoracic surgery? My advice is generic, get direct hands-on experience with what its like to be in a cardiac surgical service. If you find it intriguing and you find yourself spending a large amount of time thinking about the clinical problems and wanting to be more involved, then pursue it. Although there are shorter careers, remember that once your training is done, you will spend the rest of your life practicing that specialty. If you are not excited or stimulated by it, then it will be a painful and tedious career. Do you have any particular memories from your fellowship that you would like to share? My fellowship went like a blur. Although CT residency was 2 years and Ped. CT 1 year, there was so much going on and I learned so many new and interesting things that it's hard to pick any one event. It is perhaps that excitement about the field I chose and the ability to be involved in it on a daily basis that I remember the most. What would you say is the most common medical condition seen by cardiothoracic surgeons today? Adult CT surgeons - coronary artery disease. For me - transposition of the great arteries, tetralogy of Fallot, atrial and ventricular septal defects. In Ped. CT surgery there are over 120 different congenital heart defects that we see on a regular basis. What would you say is the most challenging problem seen by cardiothoracic surgeons today? The challenge is the same as it was 15 or 20 years ago, How do we make the surgical procedures safer and less invasive. We need to understand the pathophysiology of the defects we treat better so that we can develop better treatments. In 15 years, where do you see the subspecialty of cardiothoracic surgery? We are on the threshold of a new era of minimally invasive surgery, robotic assisted surgery and non-invasive ways of imaging to guide our surgical procedures such as real-time MRI. In pediatric cardiac surgery we frequently need to replace structures in the heart that never formed or are malformed. It is likely that tissue engineering of new arteries, valves, conduction tissue, from the patients own cells will be a reality and we will no longer have to re-operate on children simply because they have outgrown or rejected the implants we have inserted. What do you see as the three most important advances in cardiothoracic surgery over the past 25 years? Safer cardiopulmonary bypass techniques improved methods of protecting the heart during cardiac surgery improved prosthetic materials and tissue grafts for repairs What do you see as the three most important advances in cardiothoracic surgery over the next 25 years? surgery without the need for cardiopulmonary bypass improved instrumentation and techniques for minimally invasive surgery In pediatric surgery, improved 3-D and real-time imaging of intra cardiac anatomy and physiology to guide surgical procedures Throughout your career as a cardiothoracic surgeon, is there a particular case that stands out in your mind? The first time I operated as the responsible surgeon - and aortic valve replacement. Do you have a case report you can share with me that you feel would be of particular educational value to the other students? This is hard since the cases involve so much technical detail. However, a case I like to remember is an infant with a particularly unusual form of transposition of the great arteries where the conventional procedures (wisdom) dictated an approach that I had good evidence would not work out well long term. After much review of the literature, case reports, pathology specimens, and discussions with colleagues, we opted for a new technique that combined procedures for related defects but had not been done before. The procedure went well and I learned an enormous amount from that case. I have performed it again on several occasions and in some cases the outcome has not been as good. I continue to revise minor aspects of the operation based on the follow-up results on the children that have undergone this procedure. In essence, much of what pediatric cardiac surgery is about is exemplified by this case.

INTERVIEW #8 Conducted by 2001-02 Division Coordinator, Erik Glassman (Boston U.) Dr. Thomas J. Kirby is a Professor of Surgery at Case Western Reserve University and an attending Cardiothoracic Surgeon at University Hospitals of Cleveland.

Biography: As an undergraduate, Dr. Kirby attended the University of Western Ontario where he majored in Biology/Zoology. He then stayed at the University of Western Ontario for Medical School. Dr. Kirby completed his general surgery residency along with his cardiothoracic surgery fellowship at the University of Toronto. In addition, Dr. Kirby also completed two years of research. Dr. Kirby's particular interests in cardiothoracic surgery are lung cancer, lung transplantation, and molecular biology of lung cancer.

What attracted you to cardiothoracic surgery? Challenge, gratification, remuneration, research potential Throughout your training, what has been the hardest thing to deal with? Hours, strain on personal relationships How would you classify the competitiveness of obtaining one of the cardiothoracic surgery fellowship spots? strong Do you have any suggestions or advice for premedical or medical students considering a career in cardiothoracic surgery? Take lots of electives and see if this is really what you want to do. $$$’s will not compensate for an unwise career choice. Watch your staffman/woman; their life is a direct reflection of what you will deal with and be like. Do you have any particular memories from your fellowship that you would like to share? Camaraderie, learning, mentors What would you say is the most common medical condition seen by cardiothoracic surgeons today? Coronary artery disease What would you say is the most challenging problem seen by cardiothoracic surgeons today? Continued smoking, declining reimbursement, increased bureaucracy and meddling by insurance companies and government In 15 years, where do you see the subspecialty of cardiothoracic surgery? Eventually molecular genetics will provide a medical solution to most of the problems that cardiothoracic surgeons are asked to deal with. I think that this will definitely happen in the next 50 years, but probably will not have that much effect over the next 15 years. What do you see as the three most important advances in cardiothoracic surgery over the past 25 years? intensive care anesthesia technology, sutures What do you see as the three most important advances in cardiothoracic surgery over the next 25 years? molecular genetics abolition of smoking Throughout your career as a cardiothoracic surgeon, is there a particular case that stands out in your mind? A young patient with a traumatic aneurysm of the aorta who died on the table at least three times, was successfully resuscitated and is alive today. Do you have a case report you can share with me that you feel would be of particular educational value to the other students? Not really Do you have any suggestions for specific areas for me to focus on as I develop material for the other students? I think you should focus on the humantiarian aspects of medicine, that it is a calling and that the happiest physicians I know are those that have always been devoted to their patients. They end up doing the best of all. Future MDs are challenged by the distorted view of life portrayed by Hollywood, TV and magazines. That is not where the heart of the matter is.

INTERVIEW #9 Conducted by 2001-02 Division Coordinator, Erik Glassman (Boston U.) William A. Baumgartner is the Cardiac Surgeon-in-Charge at the Johns Hopkins Hospital and Vincent L. Gott Professor of Surgery.

Biography: As an undergraduate, Dr. Baumgartner attended Xavier University, majoring in Natural Sciences. He continued on the University of Kentucky for Medical School. After Medical School, he moved Stanford University for both a surgical residency and cardiothoracic surgery fellowship. Dr. Baumgartner has special interests in both adult valvular surgery and cardiac transplantation.

What attracted you to Cardiothoracic surgery? The nature of the specialty and Dr. Norman Shumway, Department Chairman at Stanford Throughout your training, what has been the hardest thing to deal with? Prioritizing time within the specialty itself and home life How would you classify the competitiveness of obtaining one of the cardiothoracic surgery fellowship spots? Presently there are fewer United States residency applicants for the number of positions available. This is significantly different from my experience during the application process several years ago Do you have any suggestions or advice for premedical or medical students considering a career in cardiothoracic surgery? Cardiothoracic surgery continues to be an exciting specialty. The prospect of doing several procedures through the use of robotics as well as the application of gene and stem cell therapy will provide significant areas of research. Do you have any particular memories from your fellowship that you would like to share? Although my fellowship was difficult from a time perspective, it was a fun and exciting time of my life. I would certainly repeat it in an instant. What would you say is the most common medical condition seen by cardiothoracic surgeons today? Cardiothoracic surgeons deal primarily with coronary artery disease and valvular heart disease. What would you say is the most challenging problem seen by cardiothoracic surgeons today? I think the biggest challenge today is taking care of the elderly patient. We are seeing an increasing number of elderly patients referred for cardiothoracic surgery. These patients have more co-morbidities than younger patients. In 15 years, where do you see the subspecialty of cardiothoracic surgery? The specialty of cardiothoracic surgery will be engaged in true minimally invasive surgery through the use of robotics. In addition the use of the gene and stem cell therapy will facilitate the treatment of patients with congestive heart failure. Permanent left ventricular assist devices will also be used to take care of this increasing population with congestive heart failure. What do you see as the three most important advances in cardiothoracic surgery? Development of heart-lung machines Advancements made in the treatment of patients with congenital heart disease Advances in treatment of aortic disease Throughout your career as a cardiothoracic surgeon, is there a particular case that stands out in your mind? A young woman we did a heart transplant on approximately 16 years ago. During her first postoperative year, she spent over 6 months in the hospital with recurrent episodes of rejection. She was able to overcome this and has not had a single episode of rejection since that time. she has been able to raise her entire family of 3 children and is presently in excellent health. this woman's care involved interaction of multiple physicians, nurses, and other care givers during that first year. It also points out the tremendous gratification when I see this woman periodically or see her children. Dr. Baumgartner closes by mentioning that: "I think you should focus on all of the good qualities associated with being a physician and or/cardiothoracic surgeon. It is one of the most gratifying professions. One of the hardest parts of our specific profession is dealing with a patient's death or complication, as these can occur suddenly. There is also much excitement in the area of research involved in our field as I have mentioned above. Over the next 10 to 20 years, there will be developments that will significantly increase survival in patients with cardiovascular disease. There remains dissatisfaction among healthcare professionals due to a variety of external forces being exerted today. Patience and perseverance with these external forces along with proper education will lead to amore moderate approach to reimbursement and healthcare regulations.

INTERVIEW #10 Conducted by 2001-02 Division Coordinator, Erik Glassman (Boston U.) Gus J. Vlahakes is an attending pediatric cardiothoracic surgeon at Mass General Hospital and Associate Professor of Surgery at Harvard University.
Biography: Dr. Vlahakes initially attended MIT where he received his undergraduate degree in electrical engineering and a master's degree in biochemistry. He then went to Harvard University for Medical School. After Medical School, he then did both his surgical residency and cardiothoracic surgery fellowship at Mass General. In addition to the adult fellowship, he also did a pediatric cardiothoracic fellowship at Boston Children's. Dr. Vlahakes has additional training in physiology from the UCSF Cardiovascular Research Institute. Dr. Vlahakes has special interests in congenital disease, valve reconstruction, and electrophysiology.
What attracted you to cardiothoracic surgery? Exciting field. The opportunity to make a difference quickly. Throughout your training, what has been the hardest thing to deal with? Time, or lack thereof How would you classify the competitiveness of obtaining of the cardiothoracic surgery fellowship spots? Today - low Do you have any suggestions or advice for premedical students considering a career in cardiothoracic surgery? Include something in your training to differentiate you from the others Do you have any particular memories from your fellowship that you would like to share? Camaraderie among residents. Enormous clinical experience. What would you say is the most common medical condition seen by cardiothoracic surgeons today? Coronary artery disease In 15 years, where do you see the subspecialty of cardiothoracic surgery? Declining in need due to conquest of coronary artery disease What do you see as the three most important advances in cardiothoracic surgery over the past 25 years? New prosthetic valves myocardial protection refinement of coronary artery surgery What do you see as the three most important advances in cardiothoracic surgery over the next 25 years? xenotransplantation Tissue engineering Development of the ideal replacement valve