Revolutionizing Cardiac Surgery | Dr. Kendra Grubb's Story

🎙️Living Legends and Luminaries in Endovascular Medicine | Episode 3: Dr. Kendra Grubb

In this episode, Drs. Zvonimir Krajcer and Stephanie Coulter sit down with Dr. Kendra Grubb as she shares her inspiring journey from aspiring surgeon to a leader in endovascular therapies. Discover how her unique childhood experiences shaped her career path, her pioneering role as one of the few women in cardiothoracic surgery, and her dedication to advancing transcatheter technologies. 

Notably, Dr. Grubb candidly shares her belief that "...the way that we train surgeons is probably a little dated, and it leaves a lot of room for really being innovative, in the way that we think about what counts as an operation".

Watch the interview on Texas Heart TV: https://tv.texasheart.org/living-legends-and-luminaries/videos/living-legend-dr-kendra-grubb-on-mentorship-tavr-and-the-future-of-cardiac-surgery

Watch this podcast: https://www.youtube.com/playlist?list=PLwtwDoqK7vrhE4Nxs22OPbxhQqgulv0u6

Transcript

00:00:00:00 - 00:00:31:21
Unknown
Doctor Greg, thank you very much, for accepting the invitation to join us, to Texas Hana's to do the podcast on living legends and luminaries and then the vascular medicine. Joining me today is, my associate, doctor Stephanie Colter. Stephanie, welcome to this podcast. If you don't mind to introduce. Thanks for inviting me to participate. And I'm actually so honored to be involved today.

00:00:31:21 - 00:01:00:23
Unknown
And, talking with Doctor Grubb. I'm actually the director of the cardiovascular training program here at Baylor Saint Luke's, Medical Center at Texas Heart Institute. And I founded a women's focus research collaboration, I guess, almost 15 years ago, and run a busy clinical enterprise in that regard. And I'm really interested in, you know, in selecting candidates for our program.

00:01:00:26 - 00:01:23:16
Unknown
You know, I'm interested in what makes people tick. And, and for somebody to do something out of the box, they have to be, you know, unique in some way and, you know, enough initiative to do something different. So I'm wondering, how young were you when you decided to be a physician, and what steps did you take to get this far?

00:01:23:19 - 00:01:47:21
Unknown
Well, thank you. I, I really appreciate the opportunity to speak with you today. I am honored to be part of your program. But to address your question, it's actually kind of a funny story. I'll try to keep it as short as possible. Well, the the desire to be a cardiac surgeon didn't happen till later, but my father tells a story that I started telling people that I was going to be a surgeon when I was about three years old.

00:01:47:23 - 00:02:06:22
Unknown
So imagine now your little three year old with her pigtails running around, telling people they were going to get a surgeon. Needless to say, there was a lot of laughter involved. But, on my my father's veterinary practices in our home and watching him operate on animals as a child, it was pure magic and, inspired me to want to be a surgeon.

00:02:06:25 - 00:02:32:01
Unknown
When I went to the University of Southern California or medical school, I didn't go there to be a doctor. I went there to be a surgeon, and at the time thought was orthopedic surgery. But then through a series of opportunities that were afforded to me, I was able to, be exposed to cardiac surgery very early and my general surgery training in Chicago and really recognized that that is what I wanted to do.

00:02:32:03 - 00:02:58:25
Unknown
And then ended up at the University of Virginia, with some tremendous mentors that then, again, gave me opportunities and then went on to be trained in interventional cardiology at Columbia. So right place, right time was a lot of it. I wish I could say I had this master plan when I, you know, I sat there and I figured out what I was going to do when I grew up, but some of it was just, an opportunity to take advantage of.

00:02:58:27 - 00:03:30:15
Unknown
But the door opened and I walked through it. It sounds like you were really well prepared for a life of choosing an intellectual challenge, and it sounds like the unique childhood you had well prepared you to take chances that other people weren't as eager to take. So what led you really to choose this pathway to do endovascular interventions at this point?

00:03:30:15 - 00:04:00:14
Unknown
And I mean, it was very unusual for a cardiac surgeon to choose that path. You know, you were clearly not worried about more lengthening of your training or, you know, putting off living. So what made you choose that? Yeah, I don't know that. Like there was a big master plan when I started. I had gone to business school before I went to medical school, and so I knew that I needed to find my niche.

00:04:00:17 - 00:04:26:06
Unknown
And, when I went to medical school, was the idea to be an orthopedic surgeon. But I quickly did my research in orthopedics, and they are fantastic technicians. But there's there was something missing about the doctoring in that, and when I was exposed to cardiac surgery, then that was that was the game changer for me. But again, looking for that niche, I thought I was going to be a robotic mitral surgeon.

00:04:26:08 - 00:04:50:06
Unknown
That was the big thing then. And, certainly at the University of Southern California medical school, that was, you know, the hot topic of what was the newest, latest, greatest. But that changed when I started hearing about the transcatheter therapies. And now I'll tell a little short story, but I was interviewing at Emory, actually, on one of the off days because I couldn't make the regular interview day.

00:04:50:06 - 00:05:11:03
Unknown
And, Robert Guyton now was interviewing me, and he gets called to the operating room and he asks, hey, do you want to come to the O.R. with me? Well, of course I'm going to come to the O.R. with Robert Guyton, and I go down and and Doctor Guyton and, you know, trainee, we're doing, partner case. And I saw transcatheter valves for the first time and transcatheter aortic valve replacement.

00:05:11:03 - 00:05:31:26
Unknown
And, of course, it's this huge team in the operating room, but, I immediately saw that this was not going to be technology just for high risk or inoperable patients. This was going to be something eventually for everyone and and for every valve. And that really sparked the desire to be an endovascular surgeon, or a hybrid surgeon even.

00:05:31:28 - 00:06:01:21
Unknown
And the opportunities at the time after training at UVA and we did, transcatheter valves there. So I had some exposure to transcatheter therapies and certainly a lot of exposure to te vars, and endovascular aortic therapies. But the training was enough. But to really lead a heart team, I needed more. And so either go the endovascular route, or the transcatheter route.

00:06:01:24 - 00:06:20:00
Unknown
And I had the opportunity to go to Columbia and train with, Marty Leon and the group there. And Matt Williams had been the first in that group is, you know, at NYU now, the first to be trained in interventional cardiology after CT surgery. And then Isaac George, who was still at Columbia, was the one right before me.

00:06:20:03 - 00:06:47:02
Unknown
So really unique opportunity. And I did enough PCI to be certified and checked off to do PCI. And I took a Stemi call, and did all of those things that a cardiologist would, would normally do to be, certified as a, interventional cardiologist. I just would go back and do, the, cardiology fellowship or fellowship and, and, internal medicine residency to be boarded up.

00:06:47:02 - 00:07:13:08
Unknown
But the thought process, the learning about large for access catheter and what are skills that really propelled my career. And so when I was able to go out on my first job, I wasn't just a member of the heart team. I could lead a heart team. So very interesting, Deborah. But one thing that fascinated me is that you, your original training in the cardiovascular medicine was in cardiothoracic surgery.

00:07:13:10 - 00:07:35:15
Unknown
And number one, there are not too many women that are in this field. But what was also very exciting that you, pursued additional training in, in the fellowship in interventional cardiology. How did this happen? Well, it's an interesting time. You know, I think timing is everything. And, it's all about the door of opportunity opening. And when it does, look through it.

00:07:35:15 - 00:07:54:08
Unknown
So when I, when I went to medical school, I thought I was going to be an orthopedic surgeon. I, really did my research in orthopedics. But as I explored it a little bit more, there was a little bit of the doctor ring missing, and I and I wanted a little bit more, and I didn't know at the time what type of surgeon that that would be.

00:07:54:08 - 00:08:19:16
Unknown
So I went the traditional general surgery pathway, and during the course of my second year was exposed to cardiac surgery and knew pretty much immediately, that's what I've wanted to do, is to kick start the impact that you could have by performing an operation to either fix a valve or bypass. Was never interested in transplant, but, at the time I really thought I was going to be a robotic mitral surgeon.

00:08:19:16 - 00:08:39:13
Unknown
That was going to be my my thing and robotic mitral. So kind of the, especially at the University of Southern California, that was a big deal. And so I set the course, to, to to that be my future to and I was trained in robotics in general surgery during my residency. I then went on to fellowship, as you suggested, at UVA.

00:08:39:16 - 00:09:00:19
Unknown
And about that time, that was about the same time as the the partner studies were really getting going. And you can imagine that I had gone to business school before I went to medical school, and my business brain clicked in and said, do you really want to be a robotic medical surgeon, or do you want to get involved with this new technology of transcatheter therapies?

00:09:00:21 - 00:09:28:13
Unknown
And when you thought about just high risk for a number of patients, you realize the technology was purposely going to be for all patients and eventually for all that. Now, if I had to add a little interesting antidote when I was applying for fellowship in cardiothoracic surgery, I actually went to Emory and, walked in and, Doctor Galen had to run down and do this new procedure.

00:09:28:13 - 00:09:49:20
Unknown
And he said, hey, do you want to come to the operating room with me? And I, of course, jumped at that opportunity. I was interviewing on one of those off meetup days, so we went down to the operating Roman that Doctor Guyton and Doctor thronging were doing a tapper's part of the partner study and just seeing that technology, you know, that that kind of sealed the deal.

00:09:49:23 - 00:10:10:06
Unknown
So I then had to figure out, well, how can I get the skill set in order to be able to do that now? At the time, you could have probably just joined the team and said, you're interested, but I wanted to do more. And getting back to Stephanie, the original question, I really wanted to have this been something that defined my career, not just something that I could do.

00:10:10:06 - 00:10:36:07
Unknown
And so getting those Catherine wires the time, yet two different had the nurse, you could go the endovascular route. So I applied for some of the intravascular fellowships, but that was more vascular surgery based borders. And I had already had a very good experience at UVA with two bars and felt very comfortable with that technology, but like to go out and practice, partner with vascular surgeon said really be able to treat the whole layer that and branches.

00:10:36:09 - 00:10:59:17
Unknown
But transcatheter valves were a little bit different. And you know knowing the mitraclip was coming in on other transcatheter technologies, I wanted to really have a different skill set. And the opportunity to I trained at Columbia, became available and I jumped at that opportunity. This was a little bit different than just the Structural Heart fellowships that we see today.

00:10:59:20 - 00:11:25:25
Unknown
I was an interventional cardiology fellow. I did more PCI that I needed to be certified and could could have gotten out and become an individual cardiologist, although not board eligible. Because I would have had to do an internal medicine and all cardiology. And I wasn't really willing to invest those years. But the skill set and the language and the understanding of what you are capable of doing with catheters and wires was really what I was after.

00:11:25:25 - 00:11:51:28
Unknown
And I ended up with a pretty tremendous education because that that then subsequently propelled my career. When I went out to practice. This is really amazing, you know, truly one of a kind. I'm sure that Doctor Colter agrees with that. And she has another burning question for you. So during the period that you were training, it was kind of not common for women to go down this path.

00:11:51:28 - 00:12:18:11
Unknown
And so could you tell us some of the, you know, conflicts or hazards in the way and why were you able to persevere when it's so difficult? Well, I think it's all again about the door of opportunity. And so even even at UVA, they never treat a woman before. And during the interview, I actually had the audacity to ask Irv Krumm, why have you never trained a woman?

00:12:18:11 - 00:12:47:00
Unknown
And I did this in front of the entire group of applicants and, and volunteered to be the first. So you have to be willing to be the first, and you have to be willing to maybe be the only woman in the room. But I actually never really felt like there were barriers. It was more about how hard I was willing to work and whether or not there would be people who were willing to be mentors, sponsors, allies and give me the opportunities that I needed.

00:12:47:03 - 00:13:15:13
Unknown
And so I think lucky, right place, right time, whatever, whatever it was that put me in those situations, I was given an opportunity and whether that be at UVA to be the first woman to complete their fellowship, or the opportunity at Columbia, I was the fifth surgeon and the group that has trained under that, kind of pathway was Matt Williams being, the first, just now at NYU.

00:13:15:13 - 00:13:44:18
Unknown
And then Isaac George, who still at Columbia was the one ranked the for me. So they had some, experience training surgeons, this interventional cardiologist, and I was just lucky that that they were willing to, include me in that group of people with this really specialized training. Interesting. Since you are trained in many different areas, not just structural heart, but, endovascular interventions in general in Europe.

00:13:44:19 - 00:14:07:05
Unknown
Union. What are the most important contributions in the last several decades in the field of endovascular interventions? Well, I think it's really interesting. I think at them, the technology that immediately comes to mind because of how disruptive it has done is tower, of course, but Taven wouldn't even have the sword up, so it wasn't for endovascular aortic work.

00:14:07:05 - 00:14:41:05
Unknown
And so the cardiac surgeons and lastly, the surgeons who took on large pour access much earlier and adopted endovascular techniques. Those people really laid the foundation for a lot of the work that we were subsequently able to do. I think that when we got into the valve space with endovascular techniques, that became an opportunity to really treat patients who had no options, and expand the patient population that we can serve.

00:14:41:07 - 00:15:15:18
Unknown
The dissemination of that technology. And then the progression to intermediate risk could lower risk and potentially younger patients. What it allows us to do is to better triage your patients, because age is just a number. And sometimes you have patients that are really not very good surgical candidates, and they may or may not, even be offered therapy, but with transcatheter options, you can actually better select patient for the right therapy for them to broaden your portfolio of what's offered for a specific disease process.

00:15:15:18 - 00:15:38:20
Unknown
And so, of course, tether was extremely disruptive. And now you're getting into mitral and tricuspid therapies, being able to treat patients who probably wouldn't have been treated at all, especially that might just space. We know that there's a tremendous amount of patients who are never even sent to a surgeon because they're cardiologists or even, you know, earlier in the process of the patient care pathway.

00:15:38:24 - 00:16:06:23
Unknown
They're just never offered therapy. They're they figure they're too old or too sick, you know, and, and they think that surgery is at high risk. Well, what I would say is, you know, that that we have these therapies. The best part is that we can send these patients to a heart team and let the heart team decide in mitral, okay, that you've got open heart surgery, you've got robotic microsurgery, minimally invasive, you have mitraclip and then soon to be transcatheter mitral replacement therapies.

00:16:06:26 - 00:16:32:02
Unknown
And and so I think it opens the doors for patients to receive appropriate care. And what they've shown also is it's a at least seems to be appropriately selecting those high risk patients for lower risk therapies. So the surgical outcomes have actually gotten better as well. And so I think that there's a whole series of endovascular therapies that have really been game changers.

00:16:32:04 - 00:17:02:19
Unknown
But it all leads back to the vascular surgeons. Pretty at surgeons treating the aortic pathologies was endovascular techniques. Yeah. It's interesting you mentioned something that's really dear to me and that's, large bore access and difficulties that we had to go through when we started to do, diver procedures, as you know, in partner trial or initial trials, the vascular complications were, 16% or even higher.

00:17:02:21 - 00:17:33:18
Unknown
And, it's dramatically lower. It shouldn't be no more than 2%. If so, at the present time, it our institution is probably below 1%. And, a lot of those interventional is had to learn how to manage large bore access which to cardiologists was a totally new experience. And of course, there were cardiothoracic surgeons assisting them. But, again, the devices were not ready necessary for large bore access.

00:17:33:18 - 00:18:00:18
Unknown
And now we have dedicated large bore access, percutaneous, repair devices. So that has, how tremendously no doubt I agree. I mean, I think we were all learning together and we we certainly had to leverage the knowledge of the surgeons and, the surgeons who were involved in T-bar had already had some experience with large bore access, helped with, the adoption of that technology.

00:18:00:20 - 00:18:28:20
Unknown
But the companies that were creating the devices, I think, also have to be credited with really innovating quickly to go from the early Larkspur access. We were talking about something that was quite large to now at 14 French, where 95% of patients are eligible for transdermal transcatheter aortic valve replacement. And I mean, that's pretty remarkable in basically a decade time, a decade of time.

00:18:28:23 - 00:19:05:00
Unknown
So, I think that, you know, we all learned together. I certainly remember the days of everybody getting a cut down or having to do trans apical. That is the alternative access of choice. And, I think that we quickly learned that it needed to be a percutaneous approach and that the cut down also had its own, set of complications and risks and certainly any interest thoracic, whether it be trans, apical or trans aortic surgery, fire risk and with innovation and with the implant was, you know, really pushing for better technology.

00:19:05:00 - 00:19:33:02
Unknown
And then the company's listening and providing what we needed so that we could more safely coupling these procedures and then to optimize them, decrease pacemakers, decrease Parabellum our leak, decreased stroke. Leave it. So I think that we have evolved so much from those large four access states, but, it's a combination of the innovation from the industry partners as well as from the physician saying we need something better.

00:19:33:04 - 00:19:59:27
Unknown
It's interesting that diver is, already a 23 year old procedure, so it's no longer in infancy, and we're still evolving technology. And, there is obviously, more to come and there are still certain unmet needs that you just mentioned there as well. Well, doctor, culture has another very, important question related to women and, the smart trial.

00:20:00:00 - 00:20:24:08
Unknown
Stephanie. Yeah, but I wanted to ask a little bit more about what do you think are some of the virtues that go in to be an inventor and a physician leader today, especially one that can, you know, walk on both sides of the line being in academic medicine and also be in an industry, that that helps us propel our field forward because we're moving forward quickly.

00:20:24:10 - 00:20:51:10
Unknown
Like, I'm listening to you. And I was there as, noninvasive cardiologist, and I was wondering if you were going to mention about trans apical, because we did a lot in the olden days that way. And, how we've moved the field forward and we're moving the devices into ever younger populations, which actually worries me because, well, I'm on the forefront of working on those valves that have failed.

00:20:51:10 - 00:21:20:00
Unknown
So what do you think makes a virtue for an inventor or a leader in the field today? Well, I don't necessarily think of myself as an inventor, but I've had the opportunity to work with some amazing, and amazing, innovative people. And beyond those teams that were able to really push the limits of technology and push out ideas that people did not react well to.

00:21:20:00 - 00:21:48:15
Unknown
It firmwares to me that I claim just most recently from Emory, and that's kind of one of the big hubs of elective surgery. And when you think about putting catheters and wires, the places that we've put them and burning holes and things to make a, you know, a connection between the IVC and the water. So that we can do valves on patients that don't have, a little formal access or splitting leaflets or, you know, the newest ssme.

00:21:48:18 - 00:22:10:10
Unknown
It's been incredible to be part of those teams, although I can't claim that any of those innovations were mine. I think one of the things is pretty consistent is that you have to have a, a spirit of how can we help this patient that's in front of me? They have no options. And we were certainly the best center for an option patients.

00:22:10:13 - 00:22:34:16
Unknown
And with that guys how can I help. Then you can start to think about what what can we do in the box that can that might work. And then we of course had a really interesting, collaboration with the NIH where we could backbench it, interested in the right in, in the person under a joint IRB at a pretty rapid succession.

00:22:34:18 - 00:23:03:02
Unknown
And with that, you had to have the ability to learn from your mistakes. You had to have the ability to not consider failure. As an end point, I think somebody calls it like feeling forward, afraid that before where you have a misstep, but you learn from it because it's not a failure as long as you learn a new could somehow take the process forward.

00:23:03:09 - 00:23:24:12
Unknown
And maybe you didn't help that very first patient. But the concept was good and so that you could help another patient. And so when you think about some of the devices out there, I think about like early feasibility trials or think about the very first fibers, you know, those initial patients had failed, we would not be where we are in this technology.

00:23:24:15 - 00:23:44:03
Unknown
And certainly there were other companies that came along, and especially in the ideal space, there's been lots of valleys that that never made it through the air space. So you have to be willing to innovate. You have to be willing to be critical of your own thinking. You have to take an idea and say, okay, this is a good idea, but we did it.

00:23:44:04 - 00:24:05:07
Unknown
We didn't do it as well as we could have. What can we do better? And and how can we make this work? So constantly asking those questions of yourself and your team. And I think the key point and this gets into your question about leadership and being able to cross from being a physician to being on the other side.

00:24:05:07 - 00:24:32:11
Unknown
And industry now is really listening to the people around you asking the critical questions. You don't always have to have the answer. I don't have to have the answer. But getting the most voices engaged because we surround ourselves every day. It was really, really smart people and asking those difficult questions and collaborating. I would like to ask the person who has not said a word what they think because, I'm a bit of an extrovert, right?

00:24:32:11 - 00:24:51:00
Unknown
So while I'm rapidly trying to think about what I'm going to say next, there's a person in the room was not going to say anything, but they've been listening the whole time. And they often times have the most, pertinent piece of information to add to the discussion. And so I think that that's one of the critical things is that critical listening?

00:24:51:02 - 00:25:20:13
Unknown
Well, Doctor Gro, can you tell us a little bit about, the reason for the Smart trial that was recently published and what were the results? Sure. Well, the Smart trial, I can't claim to be part of the, the leadership that designed the study. That Roxana Maria and Howard Harmon and did THG or the pieces of the of the study and the sponsored by Medtronic.

00:25:20:13 - 00:25:47:29
Unknown
And the question really had to do with patients with small and annual and in particular women. So over 85% of the patients in the study, are female. And they used a cut off of the annual cost of 450mm and millimeter squared. And so, is a smallish though. So if you're talking about the safety and bowel, that's been a problem with the 20 or 23 mostly 20 threes.

00:25:48:01 - 00:26:12:18
Unknown
And if you're talking about the platform then that's going to be a 23, 26, 29 in some cases. And it's just has to do with the sizing matrix. They can even get a 29. And some patients with that same annual criteria. And I wanted to look at, you know, the usual endpoints, death stroke rate, hospitalization, as well as some floating down endpoints.

00:26:12:23 - 00:26:34:24
Unknown
And from the clinical charting points, there was no difference at one year. You know, in terms of mortality, struggle and hospitalization. But the reality is, I would expect there to be at one year. I think that the chemo dynamic impacts, patient practices mismatch. Those don't play out till later. At least known that in the surgical literature.

00:26:34:24 - 00:27:01:23
Unknown
And if you look at the long term, follow ups and meta analysis, it's a problem that happens later. It's certainly something that we like to avoid in surgery and in transcatheter, valve replacement, where the biggest difference was noted is in the hip bone index with much lower gradients, larger airways with the self expanding envelope platform, well, as lower patient prosthesis mismatch.

00:27:01:28 - 00:27:24:10
Unknown
Now, some of the other things that pour out is, you know, traditional I think you we thought that, an any of the core valves had much higher pacemaker rates. Turns out, the rates were not statistically different. We used to say that, you know, the core valve always said, care about our leak. It turned out that the absolute cohort had less significant probably than the CPR cohort.

00:27:24:12 - 00:27:56:16
Unknown
So there's some interesting things in the mix. And, location prosthesis mismatch was the inter annular safety valve. Yeah. Recording in progress. No different. So I think that what it really show was that at one year the heart's on cloud and points. The valves are pretty similar. But there are some signals based on numbers and structural valve deterioration metrics that suggest over time we could expect a difference.

00:27:56:19 - 00:28:16:03
Unknown
When that will happen. Well, we'll have to let it play out. It's a five year trial. Two year data will be presented later this year. I don't expect, you know, there to be tremendous differences, but at two years, it's just not what we've seen in the low risk studies, or in surgical. But over time, I do expect there to be a difference.

00:28:16:06 - 00:28:47:16
Unknown
Wow. Fascinating. I'd like to say I've. I've thought of. I was trying to to be what you were describing, the person sitting and listening. And I'd like to make a new, word for word. What you've done is that you've, pa, you've become part of, a team of disruptors. You're disrupting industry, you're disrupting surgical practice. You're disrupting the financial models that actually go into keeping hospitals viable.

00:28:47:16 - 00:29:20:21
Unknown
And as an industry, you and Doctor Frazier have been really part of this disruptor. And it's changing how we practice, how we think about the future. And I really want to applaud you both, really, for taking that role and being unafraid to say, you know, there might be a better way to do this, and it may disrupt the practice that I'm used to being part of, but we're going to move the ball forward.

00:29:20:23 - 00:29:57:12
Unknown
And I think that's very valuable. And it's good for industry because industry leaders that take chances and disrupt can actually, you know, win. And of course science comes into this as well. And so being a careful scientist and looking at the data, you know, prospectively like you're doing, it's it's going to change how we evaluate and treat, you know, women and men in the next, you know, 20 years especially as, you know, these techniques have moved more and more into the community.

00:29:57:15 - 00:30:21:23
Unknown
People are putting valves in younger and younger patients and, doctor creation. I sometimes catch the opposite end of a good thing on that. Being in a large medical center, but looking forward to the future of endovascular interventions, how do you think it will affect current surgical, techniques and how we train the surgeons for tomorrow?

00:30:21:23 - 00:30:49:24
Unknown
Because I'm I'm kind of worried about that. Well, I think that it's a it's a challenging question because I think that the way that we train surgeons is probably a little dated, and it leaves a lot of room for really being innovative in the way that we think about, what counts as an operation. So, you know, if a person stands on the other side of the table and assists, they're going to count that as a surgery.

00:30:49:24 - 00:31:15:25
Unknown
Well, I would say that using a simulator like pilots do and flying the plane and counting that as hours using some type of cardiothoracic surgery simulation should count as those hours. If the simulation was high fidelity. So we have to think a little bit more creatively about how we train our fellows and the quality of the experience that we're providing.

00:31:15:27 - 00:31:40:07
Unknown
I also think that, you know, all of the surgeons should be exposed to endovascular therapies TAVR, Tava, the mitral therapies, tricuspid therapies, and then some of them will select to use that as their basis of their career, like I did. And some of them will go on and be vascular. Excuse me. A transplant surgeons or VAD surgeons, but I would suspect that over time the VAD is going to get smaller.

00:31:40:07 - 00:31:59:19
Unknown
And you can also put that in on a stick. And so then, you know, you're going to need those large for access and endovascular skills that we talked about earlier. So I think the paradigm of how we train physicians and surgeons in particular cardiac surgeons, has to change. It has to evolve with the technology that's available to us.

00:31:59:21 - 00:32:30:27
Unknown
Because you're right, if we just continue to rely on the way that we've trained the, residents and fellows are not going to be adequately trained to face the challenges of the surgeries that are going to be coming their way, particularly when you're talking about this new subspecialty, which is removal of transcatheter valves. I have often said that if you don't know how to put the valves in, then you're going to struggle to figure out how to put the valves out or take the valves out.

00:32:30:29 - 00:33:02:05
Unknown
The you know, the obvious example is something with a nitinol frame, right? If you had to compress it into a tube to put it into the heart, you compress it into a tube, it comes out of the heart much better. So whether that's a failed self expanding transcatheter aortic valve or any of the micro technologies, this is going to be a whole new animal that, we're going to have to train people to be able to do, and let and having them be part of a heart team so they understand the technology will help them.

00:33:02:05 - 00:33:24:18
Unknown
Then when the valves fail, be able to operate on those patients. Now concurrently, we're going to have to be looking at other ways to help patients. And I think that really understanding patients anatomy so that we choose the right procedure for the right patient upfront, and make sure that we're putting the right valve in that we think is going to last the longest.

00:33:24:18 - 00:33:56:06
Unknown
And we're talking about lifetime management, really planning for, you know, if we can for like, for example, for aortic stenosis, one's anatomy in their lifetime, where in that timeframe does that go? So we as, surgeons need to do a little bit better job of training and really thinking through not just the operation today, but, you know, in the whole scheme of things, maybe Tavenner first is right, or maybe we need to start thinking about mechanical valves more.

00:33:56:09 - 00:34:19:14
Unknown
Certainly when I trained, I didn't think I'd put in a considerable number of mechanical valves. By the time I, I, was a few years into practice, I realized there's a large patient population that's best served with a valve that's going to last the longest. And now recently at the STS, that just reaffirmed, there was a presentation there that reaffirmed what we've been saying, that for young patients, that's just the right therapy.

00:34:19:16 - 00:34:51:21
Unknown
So surgeons need to keep their seat at the table. They need to keep their skills. And we need to train surgeons in more innovative ways than we have in the past. Well, there I have one more question for you. It might be very difficult to answer. I don't know if you have a crystal ball or if I'm try to give you a crystal ball, but let's see, what do you think will happen 5 or 10 years from now as far as, for ten years, aortic mitral tricuspid valve repair.

00:34:51:23 - 00:35:21:15
Unknown
What did you see? This, happening? What what kind of things can we expect to, to come in the future? Yeah. Well, I forgot to ask for my crystal ball during the onboarding process, but, next time, next time I have an annual review, I'm going to ask for that crystal ball. No, I think that you're going to see progression of the, the therapies that are endovascular, especially with our aging patient population.

00:35:21:18 - 00:35:40:04
Unknown
You know, when, when I would sit in, our valve clinic and we would do this as a heart team. So to, two physicians, a interventional cardiologist and cardiac surgeon paired together, seeing the patient at the same time, these patients are not coming to the clinic saying, I want surgery. They're coming to the clinic saying, I want mitraclip.

00:35:40:04 - 00:36:15:04
Unknown
I want to go over. And, as the data accumulates on the safety and efficacy of the various transcatheter devices, then there's going to be even more justification for, using those therapies as first line therapies in a broader range of patients. So I certainly suspect that, you know, that we'll have a device for aortic concurrence. I certainly suspect that, asymptomatic and then moderate aortic stenosis will gain approval, broadening the range of patients that are treated with these therapies.

00:36:15:07 - 00:36:39:09
Unknown
On the mitral side, I do expect that you will see transcatheter mitral replacement devices, available for those patients who are not surgical candidates. And then we'll be looking at, you know, are there groups of patients that are better served with replacement versus mTOR? Tricuspid, I think is a tremendous opportunity just because the bar is set so low.

00:36:39:11 - 00:37:22:01
Unknown
We as surgeons have never really tackled that patient population. And often when we did, it was at end stage, which is oftentimes too late. So I think you're going to see a tremendous number of options available for these patients. I hope that the mitral toolbox expands and then there's a tremendous opportunity and, heart failure patients. So interventional heart failure devices, whether it's shunts or ventricular pads or other therapies to treat, treat heart failure patients because these patients are miserable, and many of them the they either are non-compliant with their medical therapy or you know, they're they don't tolerate it.

00:37:22:01 - 00:37:52:02
Unknown
So although we know guideline directed medical therapy works, the number of patients who are actually on the recommended five drug regimen is small. And so there's tremendous opportunity to treat patients who are now suffering from, congestive heart failure, either from valvular heart disease or other reasons. So this whole, arena of transcatheter therapies, I just think, will continue to grow the stories beyond need for surgeons, cardiac surgery is not going away.

00:37:52:02 - 00:38:16:14
Unknown
I still think it's a very, very interesting field with, a lot of history. And we we certainly need to continue to, recommend heart teams for these difficult therapies. And for teams to take care of these difficult patients. Because we've pretty much demonstrated that having that collaboration has provided excellent outcomes. But that would be my crystal ball prediction.

00:38:16:14 - 00:38:41:18
Unknown
So, it's a little bit of a hodgepodge of everything. But in short, I don't see that, there is an end in sight for the opportunities to treat patients with transcatheter therapies. Well, there. But let's hope that this enthusiasm that you have will rub off to the, the executives said, Medtronic and that we'll see all those technologies available in, let's say, 4 or 5 years from now.

00:38:41:21 - 00:39:06:09
Unknown
Yeah. Okay. So let's certainly hope so. Thanks for joining us. And hope we can, have another podcast with you. There are so many exciting and burning issues related to a structural heart disease that we didn't have a chance to discuss, but we hope that we'll be able to do it in the very near future. Thank you once again for the opportunity to, have this, podcast recorded with you.

00:39:06:11 - 00:39:14:20
Unknown
Oh, thank you for this opportunity that welcome the opportunity to come back and chat for. Thank you.