STS News, Summer 2022 — Four open heart surgeries and a kidney transplant represent stark milestones for STS member Marcus Balters, MD, whose career as a surgeon has been interspersed with stints as a patient, brushes with mortality, new perspectives on teaching, and solidified faith.
Dr. Balters directs the general surgery residency program and serves as vice chair of surgical education at Creighton University in Omaha, Nebraska. His experiences as a young patient—he underwent a coarctation repair at age 6 and a repeat repair at age 16—made a career in cardiothoracic surgery a natural choice.
“My mother would probably tell you I was talking about being a cardiac surgeon from a very young age, probably 7 or 8,” he said. “I remember thinking my pediatric cardiologist was very cool, and even when I moved on to an adult cardiology group, I was imagining him as my surgeon. I have a memory of him standing over me in scrubs as I was going to sleep.”
Dr. Balters studied medicine at the University of Nebraska Medical Center. In 1999, while a fourth-year resident, he experienced a descending aortic graft rupture.
“This rupture presented as an aortobronchial fistula, and it was very emergent,” he recalls. “I started that morning with massive hemoptysis; I was exsanguinating.”
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During his final year of residency, Dr. Balters underwent emergency repair for an aortic rupture.
Dr. Balters credits the world-renowned Lars Svensson, MD, PhD, now at the Cleveland Clinic in Ohio, for saving his life at the Lahey Clinic that day—the first of two such occasions, he’d later discover. Notably, that operation also revealed an ascending aortic aneurysm that warranted a close watch.
“I made it back to residency in about 8 weeks after a very near miss with death,” Dr. Balters said.
He went on to a cardiothoracic surgery fellowship at the State University of New York in Syracuse (SUNY-Syracuse), and from there to a private practice group back in his home state of Nebraska. The group joined Omaha’s Creighton University in late 2005.
A few months later, his aneurysm had grown to the point of needing repair.
“I called Dr. Svensson, and he graciously and adeptly saved my life again in April 2006 at the Cleveland Clinic,” recalled Dr. Balters. “By the grace of God, once again I made it back to work in 8 weeks, and I resumed a very busy clinical practice.”
Being very busy, he now reflects, kept him on a sort of “autopilot,” turning his focus to work, which served as a distraction from what he now recognizes as a form of post-traumatic stress.
“During residency, colleagues would at times take me aside and ask, ‘Are you sure you want to go into this? This is what your life is going to be like.’ And looking back, I realize that I probably spent 10 or 15 years after that third operation wondering, ‘Am I going to die today?’ Every time I would cough, every time I would have a pain, it would remind me of those dramatic events,” he said.
Throughout those years, however, Dr. Balters had a support system that presented him with avenues he’d never considered and with the revelation that it’s okay to lean on colleagues and loved ones, to accept the grace of a higher power, and to employ a little creative assistance.
Another opportunity to broaden Dr. Balters’s viewpoint occurred in early 2006, when he approached the department head to inform him of his plans to undergo the aneurysm repair. “When I had to have that fourth surgery, I went to my chairman and broke down in tears,” he recalled. “He assured me that no matter what happened, even if I could never operate again, there would be a place for me.”
The chair, R. Armour Forse, MD, PhD, suggested that Dr. Balters consider a teaching position, and that recommendation altered the course of Dr. Balters’s professional life.
Meanwhile, Dr. Balters’s wife, Sarah Beth—whom he has known since they were 14 and with whom he celebrated 25 years of marriage this year—was a steady source of spiritual support. “She is the person that lifts me,” he said.
Dr. Balters cherishes the family he's built with his wife, Sarah Beth.
Early in his fellowship, Dr. Balters recalls, he was watching a surgeon deftly perform a procedure, and while observing he had a moment of anxiety about the tremor in his own hands.
“I was thinking to myself, ‘I’m not sure I’m going to be able to do this.’ And right at that moment, without any prompting, my attending said to me, ‘You know, Marcus, I’m resting my hand on the sternum while I do this.’”
Dr. Balters had been so focused on the narrow view through the magnification lenses that he’d never appreciated that his attending surgeon was using a technique to alleviate his own tremor.
Dr. Balters began honing his clinical practice from a mixed bag of cardiac, thoracic, and vascular operations to focus mostly on lung surgery and hemodialysis access at Creighton University Medical Center, now part of CommonSpirit Health, and the Veterans Affairs Nebraska-Western Iowa Health Care System.
The dean of the School of Medicine at Creighton University, Robert W. “Bo” Dunlay, MD, recommended that Dr. Balters turn his talents toward teaching both medical students and general surgery residents.
In the intervening years, Dr. Balters’s kidneys began to fail.
Ultimately diagnosed with idiopathic glomerular nephropathy, he “continued to work the surgeon’s life, though I had stopped doing cardiac surgery back in 2006 when I had the arch repair.” Eventually he required a transplant, and in 2010 he received a kidney from his brother.
“Again, back to work in 8 weeks, though I had multiple issues come up in the next 18 months related to the transplant,” he said. “I have stayed with Creighton—and they have stayed with me—since 2005.”
Dr. Balters has become a source of inspiration for his students and residents.
“I tell them—the students, at least—that I don’t care what kind of doctor they decide to be. There’s of course some satisfaction in ‘converting’ residents to cardiothoracic surgery, but my ultimate goal is to help them be the best doctors they can and save lives. I can only touch so many people in my lifetime as a surgeon, but if I teach people what I think is important, my effects can ripple out to lots of people across years and locations.”
He notes that the students seem to appreciate that he thinks out loud in the operating room. Dr. Balters says that while it’s easy to become silently focused on the task at hand, especially during difficult procedures, he tries to offer insights into his thought processes and decisions by talking them out among the team as he operates.
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Medical students training with Dr. Balters have named him "Most Inspirational Educator."
In 2018, the fourth-year medical student class named him “Most Inspirational Educator” in their yearbook, and this year he achieved the rank of full professor.
And how do his patients benefit from his experiences on—and over—the operating table?
“Once we’ve gotten through the plans for the proposed operation, I’ll say something like, ‘Well, I’ve never had lung cancer, but I’ve had four open heart surgeries and a kidney transplant. And I’m not telling you this because this conversation is about me, but because I want you to know that I’ve sat in those chairs before, and I’ve asked the questions: Why is this happening to me? Who is this person in front of me, and do they know what they’re doing?’”
Dr. Balters answers that he’s just a former kid from Nebraska, but that he’s spent years preparing to be a proficient surgeon, he’s performed hundreds of operations like these, he’s certified by the American Board of Surgery and the American Board of Thoracic Surgery, and he’ll “do everything in my powers to try and make this as uneventful of a valley as possible in what is hopefully an otherwise long and prosperous life.”
A long and prosperous life has realized itself in Dr. Balters, despite a seemingly relentless series of valleys. With his renewed perspective through the lenses of fellowship, family, and faith, he says that he feels blessed.
John H. Calhoon, MD
STS News, Summer 2022 — Just a couple of months ago, I was sitting in my office thinking about the importance of leadership during crisis and trying to make sense of the latest tragedy within our borders and the ongoing conflict thousands of miles away in Ukraine. So much violence and so little sense.
The Uvalde shooting hit very close to home as the school is located approximately 80 miles from where I live, work, and raise my family, and some of the victims were treated by the trauma team at The University of Texas at San Antonio.
And not as close, but just as devastating, are the war in Ukraine and its terrible consequences. Major powers have been unable to stop the fighting, and the war continues with an ongoing loss of life and mounting strife realized by the entire world.
Where do we sit in all this, and what should we be doing?
Leaders Everywhere, Every Day
We are leaders in our communities, our institutions, and our departments and teams. In these times, it is especially important to do our best to serve as wise and measured voices as we keep in mind the duties beyond those of our careers and professions. There are moments in life—like this—when people depend on our leadership to reassure those around us, build connectedness, and inspire confidence.
Building Community
Importantly, we must recognize the importance of CT surgeons and our professional associations collaborating with and supporting one another. We all have skin in the game and are working toward a common goal of advancing the specialty and providing quality care for our patients. Of course, we all are enthusiastic and excited to return to in-person meetings and resume live learning and networking.
Thankfully, once again we are experiencing the power of face-to-face interactions—deeper, more meaningful conversation, handshakes and hugs, a joyful respite from our phones and computers.
Meeting Successes
The inaugural in-person STS Coronary Conference in Ottawa, Ontario, Canada, was a great success, with nearly 150 attendees gathering from 18 countries last month to discuss the latest techniques for coronary artery bypass surgery. The sold-out, hands-on Workshop on Robotic Cardiac Surgery in Atlanta, Georgia, this spring was another highly regarded success.
Right around the corner is the Critical Care Conference in Denver, to be held Sept. 8-10. Boot Camp, scheduled for Sept. 29-Oct. 2, will provide 60 residents with an experiential foundation and hands-on practice in basic cardiothoracic operating skills. Other upcoming meetings include the LatAm meeting in Cartagena, Colombia, being held Dec. 1-3, in conjunction with our colleagues from EACTS.
The Society also recently organized a leadership retreat, attended by Drs. MacGillivray, Romano, and Szeto, key STS staff, and me. Together, we began to map out critical initiatives and discussed future opportunities, including a variety of quality education programs that will ensure STS has a clear direction and purpose for years to come.
Modernization of the Database
During the AATS meeting in May, Dr. Vinay Badhwar, on behalf of his multidisciplinary co-authors, presented an invited landmark paper on mitral valve repair that used data from the STS National Database. This paper, along with several others, showcased the value of the information from the Database.
Overall, the Database continues to get stronger, although it has not been without some hurdles as we evolve to a fully digital platform. The Society is continuing to transition data capture and data analytics to internal STS staff, eliminating the need to rely on outside vendors and giving us more authority and responsibility for accurate and timely reports. We are very resolute in this goal.
Important Advocacy Work
On the advocacy front, the cardiothoracic surgery specialty remains under attack with the possibility of additional cuts to clinical reimbursement.
As a founding member of the Surgical Care Coalition, the Society continues to work with the American College of Surgeons and other associations to find longer-term solutions to Medicare’s broken payment system, while also protecting access to necessary surgical procedures and high-quality care for all patients.
The STS Government Relations team also remains focused on other important regulatory and legislative issues that are relevant to cardiothoracic surgeons and our patients.
There remains much to do—in the ORs, in our institutions, in our communities, for our specialty, and for each other. But I am optimistic that with the help of wise and selfless leaders like you, we have a much better chance.
Stay grounded, and do not fall prey to the quicksand around us all.
More to come, John.
By Steven J. Yakubov, MD, and Steven B. Duff, MD, from OhioHealth Physician Group in Columbus
STS News, Summer 2022 — Valve replacement technology has focused on solving the challenges of lifetime durability, excellent hemodynamic performance that is persistent, avoidance of anticoagulation, and providing access to coronary arteries.
Approximately 80% of surgical valve implants (SAVR) are bioprosthetic valves, despite the concerns of long-term durability. Since the advent of transcatheter aortic valve technology (TAVR), some of the durability concerns are lessened due to the availability of TAVR in SAVR.
Newer designs in surgical bioprostheses have focused on the ability to enlarge the aortic surgical valve at the time of TAVR in SAVR, as well as newer leaflet treatment techniques to enhance durability of the initial implant. Surgical techniques to enhance hemodynamics have concentrated mostly on root enlargement techniques to allow for implantation of larger surgical valves, thus minimizing the chance of patient prosthesis mismatch and allowing best possible residual gradients.
The Tria valve technology is designed to enhance durability and hemodynamic performance of aortic valve replacement. The Tria valve is composed of polymer leaflet technology using proprietary biomedicalgrade siloxane-based polyurethane-urea—LifePolymer (LP) from Foldax, Inc. LP has undergone extensive in vitro and in vivo testing.
Surgical aortic valve prosthesis
The aortic valve is composed of three flexible LP leaflets solution-cast onto a radiovisible polyether-ether ketone stent with a polytetrafluoroethylene felt sewing ring. This is performed using a robotic manufacturing process, which is highly precise and obviates the need for direct human contact. The valve is prepared in a dry state and requires no preparation prior to implantation.
The initial surgical experience or early feasibility was performed as a single-armed clinical study in patients with severe, symptomatic aortic valve disease, evaluating 15 patients at five clinical centers. This demonstrated excellent and sustained outcomes with regard to effective orifice area and hemodynamics, transvalvular gradients, and improvements in New York Heart Association functional classification with a 1-year follow-up. Two postoperative deaths (60 and 90 days) resulted, one related to an unplanned surgery on a renal carcinoma and another not well defined.
Surgical mitral valve prosthesis
One patient experienced coronary thrombosis at day 92 with thrombus possibly related to the valve sewing ring. The specific leaflet design with linear closure and diastolic inward flexion of commissural posts contribute to the excellent hemodynamics.
The early experience was continued for a total enrollment of 40 patients, the results of which are not yet available. An early feasibility surgical aortic valve study has begun in India. An early feasibility study with a surgical mitral valve is underway in the US.
The latest iteration of polymer leaflet technology is the development of a transcatheter aortic valve replacement system. This consists of a nitinol frame designed for accommodation to coronary reaccess and a suprannular leaflet design for optimization of hemodynamic performance. The initial experience with this valve system consists of implantation in six ovine subjects for assessment of feasibility.
TAVR prosthesis
Long-term outcomes with polymer-based leaflet technology, including freedom from anticoagulation and leaflet tearing, will not be known for many years. However, it holds the promise of durability without anticoagulation and hemodynamic performance comparable to transcatheter valve technology.
These ideas, as well as improvements in supply chain/production (i.e., fully robotic production and no need for animal products) hold tremendous promise for the advancement of valve replacement technology
Varghese Accepts New Quality Role at Huntsman
Thomas K. Varghese Jr., MD, MS, MBA, has been named associate chief medical quality officer at Huntsman Cancer Institute (HCI) in Salt Lake City, Utah. He also will continue to serve as HCI chief value officer, chief of the Section of General Thoracic Surgery at the University of Utah, and professor of surgery at the University of Utah School of Medicine. In addition, Dr. Varghese recently earned his Executive Master of Business Administration degree from the University of Utah. An STS member since 2009, he currently chairs the STS Council of Meetings and Education and is a member of the Workforce on Media Relations and Communications. Dr. Varghese also is the Deputy Editor of Digital Media and Digital Scholarship for The Annals of Thoracic Surgery.
Carpenter Named Assistant Dean
A.J. Carpenter, MD, PhD, has been appointed assistant dean of graduate medical education for health science systems within the Long School of Medicine at University of Texas (UT) Health Science Center at San Antonio. She has served on the faculty at UT Health San Antonio since 2002 and was appointed director of the residency program in 2014. Dr. Carpenter has been an STS member since 1998.
MacGillivray Leads Cardiac Surgery at MedStar
Thomas E. MacGillivray, MD, this fall will assume the position of physician executive director of cardiac surgery at MedStar Health and chair of Cardiac Surgery at
MedStar Washington Hospital Center in Washington, DC. For 5 years, Dr. MacGillivray has served as the chief of the Division of Cardiac Surgery and Thoracic Transplant Surgery at Houston Methodist in Texas. An STS member since 2003, he is the STS First Vice President and serves on the boards of The Thoracic Surgery Foundation and The Annals of Thoracic Surgery.
Kachroo Directs Thoracic Aortic Center
Puja Kachroo, MD, has been named surgical director of the Center for Diseases of the Thoracic Aorta at the Washington University School of Medicine in St. Louis and Barnes-Jewish Hospital in St. Louis, Missouri. She also will continue as cardiac surgeon, with expertise in aortic dissection and thoracic aortic aneurysms. Dr. Kachroo has been an STS member since 2010.
Bowdish Assumes Full Professorship
Michael E. Bowdish, MD, has been named professor and vice chair of the Department of Cardiac Surgery in the Smidt Heart Institute at Cedars-Sinai in Los Angeles, California. Previously, he worked as an associate professor of surgery in the Division of Cardiac Surgery at the Keck School of Medicine at the University of Southern California in Los Angeles. An STS member since 2012, Dr. Bowdish serves as chair of the STS Adult Cardiac Surgery Database Task Force.
Reddy Oversees Surgical Innovation in Michigan
Rishindra M. Reddy, MD, MBA, has been named director of the Center for Surgical Innovation at the University of Michigan in Ann Arbor. Dr. Reddy, chair of the Comprehensive Robotic Surgery program and associate director of the Thoracic Quality Collaborative, will continue his research in lung and esophageal
cancer, medical education, and health disparities. He has been an STS member since 2011.
Guy Is Vice Chief in PA
T. Sloane Guy, MD, MBA, has been appointed vice chief of the Division of Cardiac Surgery and clinical director of cardiac surgery at Jefferson Health in Philadelphia, Pennsylvania. Dr. Guy adds this position to his current roles as professor of surgery and director of minimally invasive and robotic cardiac surgery at Thomas Jefferson University Hospitals. He has been an STS member since 2006.
Gunn Takes Helm of ECMO Program
Tyler Gunn, MD, has joined the Department of Cardiac Surgery at Cedars-Sinai in Los Angeles, as assistant professor of cardiac surgery. He also will serve as director of the Extracorporeal Membrane Oxygenation Program (ECMO) within the Cedars-Sinai Health System. Dr. Gunn has been an STS member since 2014.
STS News, Summer 2022 — As the world around us becomes increasingly digital, so does the way we communicate, connect, share, and publish scientific research.
The Annals of Thoracic Surgery recently launched Annals Short Reports—the new fully open access companion journal. This e-only publication provides a contemporary venue for authors to present their research in a digestible format, while also making it available immediately, permanently, and universally.
“Annals Short Reports is a great way to publish and access concise research, reviews, feature articles, and videos—all peer reviewed by The Annals Editorial Board,” said Joanna Chikwe, MD, FRCS, Annals Editor-in-Chief. “Our expanded digital platform will allow readers to combine content from both journals to reflect their interests, with much more frequent updates and mobile access.”
Annals Short Reports welcomes a wide range of short-form original research related to clinical advances, current surgical methods, and controversial topics and techniques in the following areas:
Adult acquired and congenital cardiovascular disease
Thoracic surgery
Cardiothoracic transplantation
Mechanical circulatory support
Perioperative medicine
Education and training
The “short report” article type requires:
< 2,500 words
< 4 combined tables/figures
< 10 references
Also featured are engaging editorials, focused mini-reviews, educational and impactful case reports, “how to do it” technique papers, and images in cardiothoracic surgery. In addition, Annals Short Reports includes a special emphasis on digital media and supplemental content, designed for easy and open sharing of data, results, and content across social media and other channels.
According to Dr. Chikwe, this format facilitates a more efficient review process, with a shorter time to decision. All published articles are expected to be indexed in PubMed within the next 6 to 12 months.
Annals Short Reports follows the high standards of The Annals and is supported by the same expert Editorial Board team. The open access journal now is accepting submissions.
For more information, visit sts.org/annals.
STS News, Summer 2022 — While the fighting in Ukraine rages on, global congenital heart surgeon William M. Novick, MD, can be found in the operating rooms of hospitals throughout the war-torn country, saving lives of the littlest patients.
These operations are considered challenging; they are complex, dynamic, and often time- and resource-constrained. Not to mention the additional risks that result from the fighting and life-threatening danger on the other side of the hospital walls.
“When I hold a child’s heart in my hands, I experience an extremely scary, humbling, and challenging series of thoughts,” said Dr. Novick. “Scary, because that child might die. Humbling, in that God gave me the ability to do this. Challenging, because we want to save every child no matter how bad the defect is.”
Dr. Novick, from the University of Tennessee Health Science Center in Memphis, and his team from the Novick Cardiac Alliance have traveled to Ukraine several times over the years, and they’ve committed to four visits in 2022. So far, they have completed three—traveling to the country in January, March, and, most recently, in June.
“The physical damage being caused in the country is going to set back medical care in Ukraine years, maybe decades,” he said. “We were in the country during the last week of January and the first week of February. While our team was there, there was a developing threat of a Russian invasion, with troops already staging on the border and in Belarus.”
Dr. William Novick champions the expansion of pediatric cardiothoracic surgery in under-resourced countries, both operating on children and training others to do so.
Then, while the team was in Lviv this spring, the far western Ukraine city was bombed, said Dr. Novick. Even so, they worked day and night, desperately trying to complete as many surgeries as they could in a short amount of time.
“They put us up in the hospital,” he said. “There’s no room anywhere in the city, in any hotel, because of all the refugees. We took a nap, I talked to the administrator, and then we got started.” Dr. Novick and his team operated on six children: three newborns, and another three who were just days old.
Each year, 1 million children in low- and middle-income countries are born with congenital heart disease, according to Dr. Novick, and most do not have adequate pediatric cardiac care.
The most challenging place in which he’s operated was Tashkent, Uzbekistan. The conditions included ancient equipment, unclean operating rooms, and dangerous power supplies.
“There was a bypass machine—unplugged—on a counter,” said Dr. Novick. “Sitting on the floor next to the machine was a pair of heavy rubber gloves and rubber boots. Our perfusionist went to plug in the bypass machine. Simultaneously, six Uzbeks screamed, ‘NYET! Put on gloves! Put on boots!’ So he did, and when he plugged in the machine, sparks flew.”
Dr. Novick explained that many of these countries don’t have any options for heart surgery unless it’s charitable. “And, what makes this work special is we are doing it in places where no one else wants to go,” he said.
So Much More than Surgery
In addition to their surgical skills and expertise, Dr. Novick and his team in March brought to Ukraine 14 massive bags of supplies to support pediatric heart surgery and pediatric cardiology, and for the trip in June, he shipped 12 pallets of equipment and materials. This is important to note because the Cardiac Alliance works to save lives, but also helps local teams assemble and sustain cardiac centers. In fact, the centers that the Cardiac Alliance builds typically are sustainable within 3 years.
“We do pediatric heart surgery, but we also train pediatric cardiologists, and nurses in the ICU, respiratory therapists, those who run the heart-lung machine, and the catheterization lab technicians. We try to get all these people trained up to improve their diagnostic skills, or work on catheterization or anesthesia, and we do a lot of it in conflict zones,” said Dr. Novick.
Dr. Novick and the Cardiac Alliance team visited Lviv, Ukraine in June 2022.
‘You Protect People…That’s Your Job’
Dr. Novick is not only doing much of the surgery himself, but he’s also gathering donated supplies, lining up financial contributions, and organizing training programs.
Described as the undisputed leader of the Novick Cardiac Alliance, he’s known to run the team with a “thundering hand.” And his work in these countries—especially in Eastern Europe—holds personal significance for Dr. Novick. His grandmother, who is Ukrainian, and his grandfather, who is Russian, escaped Soviet Russia many years ago to settle in the US.
With these roots, Dr. Novick credits his father for his “Russian temperament, tenacity, and persistence.” From his mother, he learned “all the soft things” such as his concern for children regardless of where they are in the world and his deep desire to repair children’s hearts.
Just as importantly, his parents taught him, “You never, ever intimidate anybody. You protect people that are intimidated or bullied by other people. That’s your job. You’re big enough to do it.’ So that’s the way I was brought up: help those who are not able to help themselves,” Dr. Novick said.
Over the years, he has done just that—made saving and protecting lives his life’s work, helping more than 10,000 children in 30+ countries, including places like Libya, Iraq, the Democratic Republic of the Congo, Russia, and China.
“I’m very passionate about this work,” Dr. Novick said. “Unless you go to these places, I don’t think you can really grasp how desperate the situation is for these kids and their parents. Our team showing up, and their kid getting operated on—they truly consider it a miracle. I’m very humble about what we do, but you’re in a country of 85 million people and there’s no heart surgery for kids, and your child is one of 18 who gets operated on? I mean, holy moly.”
For more information about the Novick Cardiac Alliance, visit cardiac-alliance.org.
Described as an experienced leader with “exceptional maturity” and a reputation for “respectful and thoughtful engagement,” Dr. Chen generously shares his personal experiences and insight.
