2024 Sarns Terumo Perfusion Award Fellowship

Introduction

As a healthcare professional, I am proud to serve society as an active member of the cardiovascular surgery and extracorporeal circulation technology team at one of the leading cardiac surgery and perfusion training centers in my region; Rajaie Cardiovascular, Medical and Research Institute, Tehran, Iran.

I am passionate about engaging in high quality medical services by continuously studying and connecting with professionals in my field worldwide. Providing excellent medical care and setting high standards in my work brings me fulfillment and productivity. My philosophy in life and work is to maintain a positive attitude, strive for state-of-the-art knowledge, and implement my achievements in medical practice.

Patient safety has always been my top priority, and I consistently seek to learn practical skills that benefit patients. I am immensely grateful for the opportunity provided to me through the Sarns Terumo Perfusion Fellowship Award 2024 at Mayo Clinic. In our dynamic world, where change is constant, new procedures are introduced daily, and standards are continuously improving, so this fellowship has allowed me to adopt the most recent advancements in my field.

Background and Impact

I would like to express my deepest gratitude to my supervisors, Dr. Arman Arghami and Dr. Joseph A. Dearani, President of the Thoracic Surgery Foundation (TSF), for their unwavering dedication and support in making this fellowship opportunity possible. Their commitment to training healthcare professionals from developing countries like me is invaluable. As a researcher, perfusionist, and mentor for perfusion master's degree students at Rajaie Cardiovascular, Medical and Research Institute, I recognize the importance of staying updated with the latest advancements in our field. Our institution performs approximately 5,000 pediatric and adult cardiac and 50 cardiac transplant surgeries annually, with a team of 32 perfusionists.

We train about seven perfusion students each year, and the scientific experience gained from this fellowship will significantly enhance the knowledge of both my colleagues and students. This fellowship not only equips me with the skills and knowledge necessary to improve patient care but also empowers me to contribute to the ongoing development of cardiac surgery and perfusion practices in my country. I am committed to share what I have learned with my peers, ensuring that we can provide the highest standard of care to our patients and continue to serve humanity effectively.

Educational Experience During Observership

This unique opportunity at Mayo Clinic in Rochester, made possible through the Sarns Terumo Perfusion Fellowship Award 2024, has allowed me to learn high standards in:

1. Pediatric, adult, and adult congenital redo surgeries CPB management

During my fellowship, I had the privilege of observing various advanced procedures and techniques, including:

• The latest standards and approaches in patient management, especially in complex surgeries and redo aortic arch surgeries.
• Updates about deep hypothermic partial circulatory arrest and EEG monitoring during cooling and CPB.
• Antegrade and retrograde cerebral perfusion methods.

Additionally, I observed and learned about:

• Auto-transfusion approaches, including the use of cell saver technology to minimize allogeneic blood transfusions.
• Perfusionist interactions, teamworking skills to cooperate with surgery and anesthesia team and communication strategies, including the implementation of Retrograde Autologous Priming (RAP) to minimize hemodilution during CPB for improving oxygen delivery to tissues and prevention of sudden decline in hemoglobin levels.
• Techniques for miniaturizing the CPB system .

New approaches and CPB conduction for pediatric and redo congenital patients under the supervision of Dr. Joseph A. Dearani and pediatric surgeons at Mayo Clinic.

‍2. Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

In addition, I had the opportunity to participate as part of the perfusion team in Hyperthermic Intraperitoneal Chemotherapy (HIPEC) procedures. In this role, we functioned without boundaries, focusing solely on CPB system management during these complex cases. Our responsibilities included:

• Ensuring optimal chemotherapy solution flow to the site while managing the unique challenges presented by the HIPEC procedure.
• Collaborating closely with the surgical and oncology teams to monitor and adjust perfusion parameters in real-time, ensuring effective drug delivery and patient and team safety.
• Adopting well communication skills to make good collaboration between the surgical, anesthesiologists, oncologist, and perfusionists to ensure optimal patient outcomes.

3. Ventricular Assist Devices (VADs)

• I also gained insights into the Perfusionist role in Ventricular Assist Devices (VADs) procedures.

4. Extracorporeal Membrane Oxygenation (ECMO)

I also gained valuable experience with Extracorporeal Membrane Oxygenation (ECMO), a critical life-support technology used for patients with severe respiratory or cardiac or cardio-respiratory failure. The roles of perfusionists and ECMO specialists are vital in the management of ECMO therapy. There was a difference in ECMO procedures in comparison to our institution. In our institution, all ECMO procedures are done just by a perfusionist, not with ECMO specialists and our students are taught ECMO during their perfusion course in master’s degree.

5. Cardiopulmonary bypass (CPB) considerations for robotic surgeries

Cardiopulmonary bypass (CPB) considerations for robotic surgeries under the supervision of Dr. Arman Arghami and the Mayo perfusion team. This included:

• The use of the Intraclude device for aortic occlusion and its pressure management.
• Implementation of Vacuum-Assisted Venous Drainage (VAVD) techniques.
• Specialized cannulation strategies for robotic approaches.
• Optimizing perfusion parameters to accommodate the unique positioning and access requirements of robotic cardiac surgeries.
• Monitoring and adjusting CPB flow rates and pressures to ensure adequate end-organ perfusion during robotic procedures.
• Strategies for myocardial protection tailored to the robotic surgical approach.
• Using miniaturize CPB system for making enough room for robot equipment.

These observations provided invaluable insights into the adaptation of CPB techniques for minimally invasive robotic cardiac surgeries, emphasizing the importance of close collaboration between the surgical team, anesthesiologists, and perfusionists to ensure optimal patient outcomes.

6. Animal lab perfusion-related procedures

I had an opportunity to observe ECMO implantation and management in the animal lab under supervision of Mr. James Neal, MS, CCP. This experience allowed me to see firsthand technical aspects of ECMO setup, including cannulation techniques and circuit management, as well as the physiological responses to ECMO support in a controlled environment. It enabled me to take into practice my experience in experimental research in the future.

7. Overview of the TransMedics Organ Care System

I also gained the opportunity to learn about the TransMedics Organ Care System (OCS), which represents a significant advancement in organ preservation and providing more chance to transplantation. This innovative system allows for the ex-vivo perfusion of donor organs, providing several key benefits

• Organ Preservation: The OCS maintains organs in a near-physiological state during transport, significantly extending the preservation time compared to traditional cold storage methods. This is crucial for improving the viability of organs for transplantation.
• Increase the Access to Organs: By allowing for better preservation of organs, the OCS enhances access to viable organs for transplantation in the future. This system can facilitate the transportation of organs over longer distances, potentially increasing the donor pool and improving transplant outcomes.
• Real-Time Monitoring: The OCS continuously monitors the condition of the organ, including parameters such as temperature, pressure, and perfusion flow rates. This real-time data allows for better assessment of organ function and suitability for transplantation.
• Clinical Impact: The use of the OCS has been associated with improved graft function and reduced rates of primary non-function in transplanted organs. It decreases the ischemia time for organs that should be transferred to far remote areas. So, it can be result in lowering the post heart transplant complications such RV failure and other ischemic complications.

8. Educational perfusion sessions, conducted by Mayo Clinic School of Health Sciences Perfusion Program Director, Clint Colby, MS, CCP

• CPB management in pregnancy
• Deep hypothermic circulatory arrest

Experiencing the latest standards, approaches, and procedures in patient management within a cardiovascular perfusion setting at one of the world's leading centers has been a transformative event in my life. This educational fellowship award has provided me with invaluable insights and observational experience that will significantly impact my future practice and research.

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Acknowledgements

I extend my deepest and sincerest gratitude to my supervisors from Mayo Clinic and TSF members:

• Dr. Arman Arghami, a professional cardiac surgeon specializing in robotic surgeries
• Mr. Timothy A. Dickinson, Cardiovascular Perfusion Director
• Dr. Joseph A. Dearani, President of the Thoracic Surgery Foundation (TSF)
  • Dr. Dearani's efforts to support me as a healthcare professionals from a developing country after nominees selection in September of 2023, demonstrates a commitment to expanding access to quality surgical care and education globally. This shows TSF's goal of serving humanity through improved surgical practices and outcomes.

Their patience and cooperation since my TSF application in 2023 until the completion of my educational perfusion fellowship at Mayo, have been invaluable. Furthermore, the support and dedications of Mayo Clinic perfusion department members during my educational observership were incredible. They created a comfortable and friendly environment conducive to learning.

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