SCTS Ionescu Traveling Fellowship – Early Thoughts on the Cleveland Clinic Way

Dr Lars Svensson and Dr Adam Daly

Adam Daly

The day had finally come. It was 5.30am, the sun was beginning to creep over the horizon. I couldn’t have been more excited, albeit somewhat apprehensive, to start my fellowship in the world-renowned Cleveland Clinic. This was the culmination of years of work.

Early in training, I developed an interest in Aortic Surgery and attended the AATS Aortic Symposium. While there, I plucked up the courage to introduce myself to Dr Svensson and Dr Roselli, as well as many other “Giants in Aortic Surgery”. Over the next few months, I visited eight different Aortic Fellowship programmes worldwide. Cleveland Clinic instantly became my first preference for fellowship. It left such an impression that I couldn’t shake. To me, doing cardiac surgery in Cleveland Clinic was akin to golfing with Tiger Woods or playing football with Ronaldo. Everything about the Clinic represents the top level of performance. Thankfully, Dr Svensson and Dr Roselli agreed to me coming to do an Advanced Aortic Surgery Fellowship over two years. Also thankfully, the SCTS Ionescu Travelling Fellowship supported me to come for it.

The days are long but the weeks are short, I find it hard to believe I am just over three months in. While initially daunting, I am settling in well. The residents and fellows (nearly 40 of them!) are very welcoming. Fellows are paired with a mentor who helps guide them through their learning experience and with Dr Svensson as my sponsor and Dr Roselli as my mentor, I am certainly in excellent hands. There is a friendly environment and a huge focus

on teamwork with each other and allied professionals. Being on fellowship is an education like no other. With over 100 CVICU beds, 20 dedicated operating rooms in action daily, there is a huge amount from which to learn.

The complexity of operations performed is unparalleled. What I considered complex cases before are simply the routine here. In one theatre there may be a redo frozen elephant trunk procedure and, in another room, a bicuspid aortic root reimplantation ongoing. Down the corridor there may be a revision homograft, an LVAD implantation, robotic mitral repair and radical pericardiectomy. Later, on call, there’s not an unrealistic chance you’ll cannulate someone for ECMO. I sat down early with the faculty, identified technical areas for development in which I had limited experience, such as revision sternotomy and dissection (anywhere from 5-10 revisions per day) and axillary cannulation, and now perform these independently, in addition to exposure to an array of complex cases. We have threemonthly assessments and now are making plans for the next period.

The system in Cleveland Clinic is designed for success. It is evident the focus is that of excellence, patient safety and quality outcomes. The Clinic provides world-class experts with the teams, resources and equipment needed to get sick patients through complicated operations in the safest possible manner. Teamwork is key and resonates through all levels. It is not uncommon to see Dr Roselli scrubbed helping a new faculty member with a challenging aortic pseudoaneurysm. Surgeons have their own highly trained scrub team who work in unison daily. Each person is fluid with every step of the operation. The team approach extends to both pre- and post-operative arenas and what becomes apparent is all these elements of patient-care have been fine-tuned, work in concert and are required collectively to deliver a premier service.

There are multiple fringe benefits to such a fellowship, many of which I only see now. The crux of any fellowship is to become a clinical and technical expert in your subspecialist area and with a case-load of 1200 aortic surgeries per annum, it is a given that I will be competent in performing valvesparing root replacement, Branch Stented Anastomosis Frozen Elephant trunk procedure (BSAFER), endovascular aortic surgery or any other aortic procedure. The benefit of being able to ask Dr Svensson the granular detail of bicuspid valve reimplantation, discuss a complex arch problem with Dr Roselli or hear directly from Dr Gillinov “The five techniques for 95% repair rate in Mitral Valve Surgery” cannot be underestimated. Once here, you become a member of the “Cleveland Clinic Family”; you operate with, talk to and know these worldleading authorities, who otherwise are infamous names that you quote in your FRCS exams or who have instruments and procedures named after them. The membership is lifelong it seems. You have a direct contact point with a world-expert when you encounter a challenging case in your future career. Furthermore, your nearly 40 resident and fellow colleagues are some of the brightest upcoming

“The system in Cleveland Clinic is designed for success, providing world-class experts with the teams, resources and equipment needed to get sick patients through complicated operations in the safest possible manner.”

5.30am, day one at the Cleveland Clinic

stars – the future leaders in cardiac surgery – who will remain within your network for life. You will be friends with the stars of cardiac surgery from all corners of the globe; Canada, Israel, Turkey to name a few. Furthermore, you benefit from the nourishing environment here – Cleveland Clinic wants you to succeed! There are endless research opportunities with a full complement of support staff, a robust database and a massive case volume. There are Leadership Development Programmes, Quality Improvement projects and more, all of which contribute to the success of the Cleveland Clinic.

A few thoughts on considering a fellowship. Establish exactly where you want your area of expertise to lie. Know what you want to learn and seek fellowships that will support your goals. Visit centres early. Come well trained – fellowship is not the time to learn to perform routine AVR but rather the opportunity to develop your subspecialty expertise, learn to do complex cases safely or learn a particular operation. You would undoubtedly know how to do a phenomenal septal myectomy for HOCM if you spent six months working with Dr Smedira who does two or three every operating day. Plan financially.

I am extremely grateful to have been awarded the SCTS Ionescu Travelling Fellowship, nonetheless, the costs are significant; USMLEs, visas, flights, moving and living expenses. Fellowship is truly the opportunity of a lifetime, a marvelous chance to live abroad and experience a new culture and lifestyle. Plan some enjoyment for your free time, I have certainly made the most of mine having visited Niagara Falls, celebrated the 4th of July and even attended a Cleveland Browns football game to name a few. I’m looking forward to the next year or so and will certainly keep you posted. n