The TSF/FFF International Traveling Fellowship: A Life-Altering Experience

Dr. David Zapata pictured at left with Drs. Marcio Rufino Barbosa Jr. (center) & Scott C. DeRoo (right).

Background

It was in November of 2022 when I was notified that I was the recipient of the 2023 TSF/FFF International Traveling Fellowship. I remember how excited I was. What I also remember is telling Brad Taylor, chief of cardiac surgery at the University of Maryland, that I received the award; his reaction was one of pure joy and elation. He was ecstatic. His reaction actually was quite surprising to me, and I wondered if I was missing something because of it. Perhaps I did not understand the importance of the award. Perhaps I did not recognize how influential the experience would be on my career moving forward. After having been through the experience of a three-month international venture, it turns out that every bit of my misinterpretation was true. This fellowship opened my eyes to different hospital systems, strategies, techniques, operations, and cultures, while allowing me the distinct pleasure of meeting an entire international community of surgeons along the way.

The experience was truly life-altering, and I will be forever grateful to those who made this opportunity possible.

Selecting a Mentor

For my fellowship, I decided to spend my time in the great city of Brussels, Belgium, at their University Hospital, Cliniques Universitaires Saint-Luc. I chose to be in Brussels to work with both Laurent de Kerchove, the chief of cardiac surgery at Saint-Luc, and his immediate predecessor, Gebrine El Khoury, who is known worldwide as one of the masters of cardiac surgery. I chose this location with the intention of learning their management of mitral annular calcification (MAC), in order to further advance my mitral practice, and to learn their techniques in aortic valve repair. I can say with confidence that I learned these skills along with much more.

From day one, it was clear that I made the right decision.

I was immediately greeted with kindness and warmth by all of the surgeons and operating room (OR) staff. I also discovered that two other surgeons had the same idea (and timing) to spend time in Brussels: Marcio Barbosa of the Universidade Federal do Espirito Santo in Vitoria, Brazil, via the TSF/FFF International Traveling Fellowship in partnership with LACES, and Scott DeRoo of the University of Washington in Seattle, Washington, USA, via the TSF Nicholas Kouchoukos Award (photographed above). We quickly became friends and spent a great deal of time learning various surgical techniques and exploring the city together.

My first impression was one of awe; I was pleasantly surprised at how welcomed I was, and how down-to-earth and level-headed the surgeons were, all while performing the highest quality of surgery. And as I spent more time there, I realized just how great the quality truly was.

In the Operating Room

These surgeons are some of the best native-tissue-preservation surgeons that I have ever seen. The surgeons at the institution had mastered the Carpentier techniques of mitral valve repair. They also extrapolated these techniques into their own El Khoury classification for aortic valve repair, and applied these techniques to David and Ross procedures along with isolated aortic valve repair. Furthermore, the thought process was not that ‘one surgeon does mitral surgery while another surgeon does aortic surgery’. Rather, it was a combined practice with the focus being tissue preservation. As an example, the first two cases I witnessed Laurent de Kerchove perform were a robotic mitral repair followed by a Ross procedure. On the same day. This thought process is very foreign in the United States, and is one that I believe we can learn from and that I plan to apply to my practice going forward.

The entire experience felt as though I was a student in a course focused on mastering cardiac surgery

In the three-month timeframe, I learned advanced techniques in durable mitral valve repair, management of MAC, and repair of infected and rheumatic mitral valves, all of which will greatly benefit my open and robotic mitral valve practice. Furthermore, I learned the finances and advanced application of aortic valve repair, and their specific methods for the David and Ross procedures. At first, my role was primarily as an observer, which gave me the opportunity to witness their technique and take notes on the differences between their strategies and my own. Of note, the camera system at their institution was outstanding and allowed for an observer to very clearly see the details of the operation. In the second half of my three-month fellowship, I served primarily as a first assistant, and had the opportunity to practice and implement some of the techniques that I learned. The diversity within the opportunity made the experience very wholesome and allowed me to truly grasp the knowledge that I sought.

As an aside, I did feel proud to be able to share tips and tricks in my robotic cardiac surgery experience with them, which I felt made the entire experience more collaborative and collegial.

A Varied Experience

Being overseas, I was also able to participate in a number of events that allowed for collaboration with other surgeons across Europe. I was an attendee at the EACTS Annual Meeting in Vienna, Austria, and was able to witness a variety of international techniques and practices from across the world. During the meeting, I took the opportunity to meet Antonios Pitsis, a minimally invasive surgeon in Thessaloniki, Greece, who I later ended up visiting and operating with for three days. Antonios Pitsis and his team have a wonderful setup and practice, and I would encourage anyone with the opportunity and interest in minimally invasive surgery to spend a few days with him.

I also traveled to Aalst, Belgium to meet Frank Van Praet, who was a mentor for my chief. He was willing to host me for the day and introduce me to his operative team while demonstrating his mitral valve repair techniques. Also in Belgium, I attended a course hosted by EACTS on Aortic Valve Repair and the Ross operation at my home institution. Finally, I spent a few days visiting Barcelona, Spain, to attend a Medtronic MICS course hosted by the Hospital Clinic de Barcelona at the Universitat de Barcelona. Here I met minimally-invasive surgeons from all over Europe, and had the chance to learn new techniques and ask questions about strategy, setup, application, and other facets of minimally-invasive surgery.

The Impact

Having the opportunity to interact with this many surgeons from different backgrounds and cultures was eye-opening and humbling.

Everyone is trying to achieve the same goals all across the world, and yet the intercontinental collaboration is far from adequate. I learned so much from a short period of time with these surgeons, and I believe that, as a specialty, we could do much more to encourage intercontinental collaboration in the future.

Apart from surgery, one of the most fascinating things I experienced is how different each hospital system seems to run. For example, I experienced absolutely wonderful and healthy cafeteria food, OR staff nap-time during lunch break, a regular OR start time of 10 am, and a strong emphasis on finishing work at a reasonable hour during my time visiting various hospitals. All of these observations were of things that were unusual to me.

As I considered these observations as a whole, I concluded that each of these experiences channeled into a central goal of a better work-life balance.

The concept of protecting work-life balance despite the unwavering demands of cardiac surgery seemed to be engrained in the culture of every hospital I visited. Based on what I observed, I would envision that this cultural shift preserves team morale and prevents physician burnout, issues that are becoming more common in the United States today. There have been multiple instances of great surgeons at national meetings discussing that, in their efforts to achieve greatness within cardiac surgery, their family had to be put to the side. This notion is usually presented with a sense of regret. Perhaps, these observations suggest that there is a better way to balance our lives, as cardiac surgeons, outside of cardiac surgery, and that a balancing of priorities may be of benefit to our society as a whole. Overall, I would say that experiencing a variety of cultures and hospital systems has been very formative and instructive to my entire life.

The Takeaway

This experience was truly life-altering for me. From experiencing different cultures and societies, to working in different healthcare systems, and to learning a variety of techniques and surgeries from surgeons across Europe, I would say that this fellowship provided an opportunity that was more fruitful than I ever could have hoped for. I have already changed multiple tenants of my practice and anticipate that I will continue to assimilate what I have learned abroad with what I already knew.

I would encourage every future cardiothoracic surgeon to strongly consider gaining international experience, and I would encourage every leader in cardiothoracic surgery to consider ways to encourage international collaboration.

I truly believe that our entire society would be greatly benefited by these efforts. Thank you to the administration and surgeons involved with the Thoracic Surgery Foundation for selecting me for this wonderful and transformative opportunity.

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David Zapata
Assistant Professor of Surgery
Division of Cardiac Surgery
University of Maryland School of Medicine