HCA Travel Fellowship Report

Mentors: UK

Mr. Prakash P. Punjabi and Mr. Jon R. Anderson

Mentors: Belgium:
Supernumerary Post

Prof Gebrine El Khoury

Learning agreement: ISCP

Prof El Khoury / P Punjabi / J Anderson

Fellowship Details:

This international fellowship was in conjunction with Prof El Khoury and Mr. Punjabi. I developed a sub specialty interest in the surgical treatment of valvular heart disease during my last two years of Cardiothoracic Surgical training. I gained further experience on an international observership at the world renowned St Luc Hospital in Brussels chaired by Professor El-Khoury. My primary focus was to learn advanced techniques in aortic and mitral valve repairs and to encompass these techniques in a minimally invasive manner. A secondary objective was to observe in major aortic surgery including Ross procedure, free-style aortic valve replacement, aortic root remodeling surgery, aortic valve preserving surgery and aortic arch surgery. Techniques for off pump CABG using sequential and Y grafts, and other techniques for minimally invasive surgery were also studied during the fellowship.

Importance of my proposal for the advancement of clinical practice in the UK

Valvular heart disease is in the ascendency in the UK with the dramatic rise in the elderly population. Valve replacements offer most patients a good solution and ones deemed unfit for cardiac surgery are now referred for TAVI (trans aortic valve implantation) either via a percutaneous or trans apical approach. Valvular repair is the gold standard intervention but currently very few aortic and only fifty one percent of mitral valves are repaired nationally. (2009 UK Adult Cardiac Surgical Database Report). This data demonstrate a large variation in the use of reparative mitral valve surgery; varying from 20% to 90% among different hospitals. Outcomes are worse in patients whom underwent valve replacement compated to repair, including a higher risk of operative mortality and stroke, in all subgroups examined. The additional benefits of valve repair over replacement include the avoidance of long-term anticoagulation and its associated financial impact, morbidity and mortality and patient related benefits.

I intend to establish the practice in the UK to later be in a position to train others in the UK. My plan is to collaborate with Prof El-Khoury and organise UK seminars/surgical workshops to broaden knowledge and improve clinical practice. The insight into the practice and management of a European health institution has allowed me to address our own strengths and weaknesses in the NHS; this has lead me to implementing ideas, which may facilitate our own practice in the UK.

My reason for choosing the particular institution(s)

The Cardiothoracic and Vascular department at Saint Luc Hospital, Brussels is an internationally renowned institution, in which eighteen hundred cardiac surgical cases are performed annually. St Luc has an excellent reputation for training senior cardiac surgeons from across Europe and the rest of the world. I was made very welcome by Professor El-Khoury and his team to all areas and a concentrated secondment with daily access to the operating theatre for valvular operations allowed me to gain the required knowledge and skills, making an international fellowship in advanced cardiac surgery skills at St Luc ideal. This was supplemented with MDT discussions and daily one to one teaching sessions regarding all aspects of surgery including access to Professor’s collection of surgical movies. Prof El-Khoury is renowned for educating his fellows to perform procedures accustomed to their experience. During the last decade, his department has gained international notoriety for its annual valve surgery symposium and it has an excellent academic department. Prof El-Khoury at St Luc has standardized aortic valve repairs and devised the classification of aortic valve disease based on the original Prof Carpentier functional classification of mitral valve disease. Prof. El-Khoury long-term outcomes studies of aortic and mitral valve repairs have been published to international acclaim. Prof El-Khoury has kindly presented his valvular series at our London Core review course on an annual basis thus broadening knowledge of his techniques and outcomes.

How has my proposal advanced my current skills

Cardiac surgery is at cross roads with the increasing domination of cardiologists with percutaneous interventions, I believe subspecialisation in cardiac surgery is a prerequisite. Valvular heart repair offers an innovative option and an attractive choice for patients especially when performed in a minimally invasive manner.

Whilst I continue to consolidate my experience as new consultant in the UK, the international fellowship at an advanced centre (St Luc Hospital) under Professor El-Khoury was a progressive step towards my future sub specialization of valvular repairs. This fellowship allowed me to develop as a clinician and surgeon. The volumes of surgery performed at St Luc enhanced my understanding of aortic and mitral pathology. This daily exposure to valvular surgery facilitated my opportunity to learn new surgical skills including the art of aortic and mitral valve repairs and to encompass these techniques in a minimally invasive manner including robotic mitral valve repair. During my time there, the robotic mitral valve repair programme was one of the leading centres in Europe in terms of volume of procedures.

The entire experience of academia and clinical surgery of St Luc has broadened my knowledge and technical skills. The technical skills taught at St Luc are not easily accessible anywhere else in the world and thus taking me to a higher level of understanding and surgery.

An opportunity to observe the full spectrum of minimally invasive surgery at a world leading centre has equiped me with the understanding and skills for my own practice in the UK. I believe this would be a superb educational experience for a dedicated senior trainee.

How I expect to use the new techniques I learnt and how I expect to spread knowledge of them

The new techniques will enable me to identify suitable patients in our program and then using a mentoring process (Prof El-Khoury) to perform the new techniques in the UK in collaboration with my UK mentors. Once confident, I will train my juniors and then establish a UK fellowship for senior trainees. I would establish a robust database and audit our results. Once the techniques are established and our results are satisfactory, I would then deliver lectures on the techniques and results in a regional format increasing to national basis with time. A MDT would be fundamental to decision making and spreading knowledge to the local referring cardiologists. The publishing of results would be attractive in recruiting patients nationally to our service.

I would use the new techniques in all types of valvular repair (aortic, mitral & tricuspid) and subsequently arrange seminars and wet labs to disseminate this knowledge. I currently organize with a colleague a 4-day cardiothoracic meeting (The London Core Review) at the Royal College of Surgeons on an annual basis; this meeting will provide a platform to disseminate the knowledge gained from St Luc. In conjunction with the transfer of theoretical knowledge base, we will provide surgical mentorship of practical skills in a wet lab environment at the Royal College of Surgeons. The London Core Review course and similar seminars would allow us to disseminate the educational content and the surgical skills acquired. The London Core Review is comprehensive review of Cardiothoracic used for the exit exam in Cardiothoracic; it is a subsidiary of The Core Review USA. I attended the Core review in Salt Lake City USA in 2009 and found the course to be fantastic. I organized with a colleague in the UK for the course to be run in the UK for cardiothoracic trainees. The UK course is a not for profit organization that provides comprehensive lecture series with an international faculty and it has been a resounding success story. My intention would be develop a similar model course with my experiences in Belgium but focusing on the practical skills in cardiac surgery using wet labs and recorded/live surgery to enhance surgical skills of the UK cardiothoracic fraternity.
At present I am concentrating on establishing my cardiac practice and hope to embark on the above in the near future with the support of my colleague’s at St. George’s.

Patient benefit

Patients will benefit from a new choice that is not easily accessible in the UK. Native heart valve repair is beneficial as the patient retains his own native valve and avoids long-term anticoagulation with its associated morbidity/mortality. (Warfarin 2-4% per year). Better Left Ventricular remodeling occurs with repair and the mortality rate of 50% at 10 years for valve replacements (AVR mechanical 90% survival at 5 years and 80% for biological AVR) continues to show that replacement has high morbidity and mortality in the long term.

Patient benefit will also arise in different models; the quality of life of the patient improves vastly with valvular repair and the avoidance of anticoagulation, improving the patient’s productivity, decreasing economic burden (anticoagulation clinics) and improving recovery times. My individual knowledge and skill set will be enhanced thus optimizing treatment of my future patients; subsequently passing these new skills to colleagues whom I collaborate with in my department and region. Using the London Core Review course, we would plan to educate the national cardiothoracic audience on the best treatment for vavular lesion amenable to repair. We hope to achieve this for the UK cardiothoracic patient population from this experience in Belgium.

Patients will derive additional benefits as I will see the management of a healthcare system that is flourishing in Belgium with an international referral basis and how we could achieve a similar model in the UK.