The Surgeon Who Saved My Heart | Mr Toufan Bahrami & the Elite Mindset

Speaker A: We cannot stop the heart beyond four hours already. Three hours is a lot.

Speaker B: Meet Mr. Tufan Bahrami, the cardiac surgeon that repaired my heart and the leading surgeon in endoscopic mitral valve surgery. We go inside the operating theater, inside the mind of an expert who is operating in one of the highest stakes environments imaginable, where calm, precision and the hand holding the knife can mean the difference between, between life and death. Uh, never in a million years would have thought I'd be interviewing my heart surgeon.

Speaker A: The whole operation, from beginning to closure in my head, I do it not only once, sometimes two, three times. Sometimes standing next to the patient in theater when they're sleeping, before even doing the incision, I do the whole operation again. That's why I'm saying when I do the operation, I've done it already three times.

Speaker B: You're in the operating theater, you're imagining what's going to happen. Do you see yourself as, ah, a scientist, a savior, uh, or an artist?

Speaker A: Medicine is science, but surgery is more an art.

Speaker B: Mr. Toofan Bahrami?

Speaker A: Yes.

Speaker B: Welcome to Anatomy of a Leader.

Speaker A: Thank you very much for inviting me.

Speaker B: Never in a million years would have thought I'd be interviewing myself, my heart surgeon.

Speaker A: And also for me, it's not easy because that's the first time I'm sitting with a patient after the operation talking about cardiac surgery.

Speaker B: How does that feel?

Speaker A: It's bizarre.

Speaker B: Yeah. Because I have thought about it, how it must be strange for you because there is the person and then there is the body. And when you're in the operating theater, and, uh, we will talk about that because I'm so curious about what goes through your mind when you are in the operating theater and there's a, a live being, but yet you have to be so focused on that very important organ in the body, the heart. But we'll get to that. We'll get to that. First things first. Heart disease is called the silent killer, and that's for a reason. For people who are at home, who've never maybe even thought about heart disease or heart issues, and they just think that maybe it's something that old people get, you know, like old man, you know, working in finance that gets, you know, heart attacks. What is the one red flag? What is the one thing to look out for when it comes to your heart?

Speaker A: Think the first, it is true the heart is a silent killer and is the first cause of mortality. Um, the problem is people are not, um, going to their doctor to do the diagnosis during the checkup, and they discover it when they have symptoms, at that point, often it's too late. So it is important to see the GPS or also in asymptomatic patient. We always think it will happen to someone else and never to us. To do a stereo routine, test blood pressure, heart rate, oxygen saturation, and if there is a minimum symptom, which is not as usual, like you go up step stairs or you're running and you're more breathless than usual, then doing simple tests and then either they're normal, then you're relaxed really, or they're abnormal, then you can discover nasty things which are treatable because some of them are life threatening. But with treatment, the risk is gone and you're back with normal life expectancy. You leave your normal, um, lifetime, which is 81 for men and 83 for women. So it's important to, for anyone who wants to make sure they don't have cardiac disease to do either an echocardiogram or a CT scan, something which will, uh, if it's normal, you are sure for the next 10, 20 years you don't have any heart issue. If it's abnormal, there is always a treatment.

Speaker B: Yeah, because it is silent. Because from my experience, I had the tests, but, you know, it didn't show up in the blood tests. The GP didn't seem to be so worried. I had to be. I had to push to get, you know, the right diagnostic tools to be used on me to even see if there was an issue.

Speaker A: The issue with the GP is after

Speaker B: my heart surgery, I thought recovery meant lying around reading books all day. I could not be more wrong. Recovery is movement. And that's where CP&R, uh, cardiac rehab completely changed things for me. One thing I found out later is that they don't call you, ah, a patient internally. They call you an athlete. They don't treat you like you're broken. They treat you like somebody who is capable of far more than they realized. And this approach makes the world of difference to how you see yourself and how you ultimately recover from something as complex as mitral valve repair. I had three sessions a week with a personal trainer who monitored my heart. And every 12 weeks they'd measure everything from blood pressure to glucose to psychological health to body composition. So I can see the progress. Even on the days where we didn't have a session, they check in, they'd message me, they make sure that I was doing okay. Some days I felt strong and on other days I was literally crying, just going for a walk. And they understood both more than anything. Cpnr Made me trust my body again. Honestly, this isn't just for people recovering from heart surgery. If you have a heart, you should be training it. You don't have to be a patient. You can be the athlete.

Speaker A: The issue with the GP is we can't do echocardio for heart. We need to see the heart inside the valves. That's imaging. Echocardiogram or the structure of the muscle plus other organs around it with a CT scan or to see the arteries. We can't do that to everyone otherwise because of the, ah, financial issue. So. But if people have an echocardiogram and a CT scan, we can rule out artery, coronary artery issue, which can cause cardiac arrest. We can rule out muscle issue, and we can rule out valve issue. So it's ruling out nearly 95% of the heart disease. Uh, which one can have. The fitter patients are the less symptom they have, so they think we are fit. It will never happen to us. But they don't have symptom. And that like someone, um, who had surgery recently. Very fit. 90%, 95%. The main artery of the heart was narrowed. Uh, he could have been running and having a sudden cardiac arrest, but he just went for a checkup and he found that it was narrowed. Although asymptomatic, no symptoms. Uh, he had a bypass and his life was saved. So he's back to, to normal activity. So, um, another one I remember had a tumor inside the heart. A small tumor, not malignant, benign, which could cause a stroke. We discovered it, we removed it, and back with normal life expectancy. So it's, it's important to check. Um, and knowing that it can happen to anyone, at least you know it's normal. And for the next 20, 30 years, you have nothing to be worried about with your heart.

Speaker B: So say you're fit and healthy. You know, you are not 60 and you're like, I want to check my heart. What do you do?

Speaker A: Uh, I, I, for the heart, I think an ecg, an echocardiogram to check the valve and the heart contractility, and a CT scan to check your arteries of the heart.

Speaker B: And what is an ecg? An echocardiogram and a CT scan.

Speaker A: So an ECG will be looking at your heart rate if it's too high or too low. And that can indicate also if it's too high, you might have other underlying disease like valve or muscle. So then we go to the next step and we request other tests. Um, the echocardiogram is like ultrasound. They put it on the chest and they look at the contract. It's a dynamic picture of the heart. We check the contractility of the heart muscle. We check the valve. If they are leaking, if they are narrowed, if they're functioning normally. These are like doors opening, closing. Ah, we have four and each one can have a problem. And the CT scan will look at the amount of calcium into the arteries of the heart. And we give a score. If the score is low, which means coronary arteries of the heart are normal. So you won't have a heart attack. If there are too many, too much calcium in it, then we get worried and we're going to do the next test which is an angiogram looking at the arteries to be how much they are narrowed. But we don't do angiogram to people unless there are there is evidence of artery disease. So basically ecg, echocardiogram and CT scan of the arteries of the heart will cover 95% of the heart disease. M In younger patients, I would say there's less artery issue is mostly the valve issue. So the valve disease such as aortic valve leak, mitral valve leak or mitral valve being narrowed, they are more frequent in younger patients uh than older.

Speaker B: With your practice what's the average age of patients you see and like what's the youngest and what's the oldest in

Speaker A: the youngest I've seen was uh, 18. Um and the oldest I operated. I go on both extremes. Had surgery is 90, was 93 and that was about eight, nine years ago. So uh, 18 to 93. At that time we didn't have for older patient the techniques which are now available. So now for example the same operation he had would be treated with a different technique. But now I would say I would go from 18 to, to age 80. Over 80. Usually cardiologists can implant valves or open the artery otherwise. And what's the average age let's say in the 60s.

Speaker B: Mhm. Is that because that's the time that they have discovered the condition or is it to do with just. That's what happens when you.

Speaker A: It depends age which disease we're looking. If someone has coronary disease is more frequent in older patients because it's aging prevention process of the coronaries. If it's an aortic valve, it's also between 60 to 75. Uh because the valve degenerate and calcify mitral is usually younger patient I would say average 50 of age. Uh so it depends which disease they have.

Speaker B: Mhm.

Speaker A: So usually valves are younger and coronaries are older.

Speaker B: Patient because you operated on my mitral valve. That was the condition that I found you for. Is that the most common surgery you do? Uh, mitral valve repair or what's the body of surgeries that you concentrate on?

Speaker A: Out of nearly 3,000 operations I've done, I operate on coronaries. So the bypass, aortic valve and mitral valve at one point. So when I was younger, I was operating, I wanted to do the maximum possible and doing a bit of everything, including aorta. Uh, but at one point you understand that and when we are young we think we have to do everything and a lot of everything. Uh, and the idea of concentrating in one specialty wasn't accepted.

Speaker B: Is that what you wanted to do? You wanted to specialize or you didn't?

Speaker A: No, that came afterward.

Speaker B: Mhm.

Speaker A: So then I moved toward minimally invasive. I said let's start, start doing minimally invasive. Instead of opening the breastbone, let's do it through smaller incision. It's not that easy just to bring a technique and say I want to do it. We have to prove to the hospital it is safe, it's is feasible, it's reproducible and we can teach it to other surgeons. Uh, we can't be in an institution, just one person doing one procedure, uh, and then at the same time doing bypass and aortic valve. So I develop minimally invasive for coronary bypass surgery, minimally invasive for aortic and minimally invasive for mitral. So automatically I move toward less, uh, invasive procedure for these operations. But then there are too many things to do so that, so by doing so more patients were coming. And when there are more patients, uh, we can't treat them all. It creates a waiting time which is not right because in heart surgery if the waiting time is too long, patient can, can die from the, from by waiting. So m. Then I decided to specialize more on one area than others. So I went toward the mitral valve. Um, because the mitral valve includes mitral valve, tricuspid valve, which is next to involves rhythm issue which have, which often patient have irregular heartbeat and ah, develop that area. And I thought by sub specializing in one area, my number of recruitment of patients will go down. And in fact it went up because more patients were coming. So it's a very positive thing. Not only we get better in what we do. Also more patients are uh, coming for that operation. And mitral to me would be two area. One is the approach and one is a technique of the repair. And at the end of the day to me, when patients Come without knowing. They often come for less invasive, but for me, they come for the repair. Good repair. Good repair is first. If we can do it through, minimal access is better, not the other way around, but, uh, at the same time. Then I have developed aortic, but not having time to do aortic regularly. So I do more mitral. We do aortic and they bypass as well. But bypass is easier.

Speaker B: Is it?

Speaker A: Yeah, it's much easier.

Speaker B: Why is that?

Speaker A: Uh, bypass is easier because it's more superficial. The arteries are on the surface of the heart. So you, you reach the heart. It's like motorway on the, on the heart muscle. You can see them. So you don't need to stop the heart. We do it on the beating heart. You don't need to go deep inside the heart. You don't need to have an unrested heart. You're unlimited by the time to do the procedure, and that makes it easier. So the bypass, minimal access technically is much easier than mitral.

Speaker B: Well, let's get specific. I came to you precisely, well, for two reasons. One, because you're the only surgeon in the UK doing completely, totally endoscopic repair surgery, which is what I needed through a very small incision. I think it's 3cm. And also I felt that you were the expert in that specific repair surgery. So these were the reasons why I've come to you. What's the difference between open heart, minimally invasive, endoscopic, and then let's throw robotics into there as well.

Speaker A: So the one which is what they call open heart surgery is when we open the breastbone in the middle. So we open the breastbone in the middle, and we use a retractor to push on each side. So the opening is about 10 by

Speaker B: 15, 20 centimeter, which is what I wanted to avoid.

Speaker A: And that open about 10 by 20 centimeter area, uh, exposes very well the whole heart. And we can do anything in that way. In fact, there's many, many heart transplants. We can, uh, take the heart out, putting a new one in, uh, and that for years has been the approach of choice by surgeons.

Speaker B: And is that because you can see better, that you have more access? It's easier to maneuver, it's safer.

Speaker A: So, uh, all these are subjective. So we can see better. We see because in front of us, but with the endoscope, we will come to that. You can have a, uh, magnified image of the valve, which you see much better the details than direct vision. Sometimes direct vision, the valves are right in the middle. You have to twist the heart. And it's not always easy to see the whole valve with the camera. You have it right in front of it and outside on the screen is magnified so you don't need to bend to go and look at the valve. The um, safer, I would say for any procedure, something you do regularly is safe. Something which you don't do often is not safe to do.

Speaker B: On that note, if you are choosing a surgeon, is it better than to go to somebody rather than focusing on the procedure? The way you access the. Whatever you're operating on, the number of that specific, either method or specific surgery that they've done versus just going for,

Speaker A: you know, it is important when you see a surgeon there are a few questions to ask. How many operations they've done before, how many of the specific operation you're going for they are doing every week, every month, which hospital they are working. It is important to work in a NHS hospital, which is uh, a very busy one with a big number of specific procedure and if that hospital is specialized in that area specifically is even better. So the surgeon might operate in other hospitals as well. But it should be. Attachment should be to the, a very good hospital. What is the mortality rate, their success rate again, how many of that procedure are ah, they doing every, on a weekly basis? Every surgeon, obviously they are known to say, I do a lot. My mortality rate is low and my success rate is high. But this data is available online for how many operations these surgeons are doing and the mortality of the procedures. If you ask people, it becomes obvious which surgeon in which area is doing more of the procedure.

Speaker B: Going back because we started off with, you know, what's the difference between open heart. Minimally invasive. So what's minimally invasive compared to open heart?

Speaker A: Open heart surgery because we open the breastbone, the ribs are moving. So patients cannot lift everything, cannot sleep on their side or driving for about six to eight weeks. Any movement on one side can make the sternum moving and if it gets open, then there is a need of major surgery. If it gets infected is a nightmare. The less invasive technique is to do. The idea is to do exactly the same procedure through a smaller incision between the ribs and to avoid opening the breastbone. It's more demanding technically is we need specific instruments which are not the usual instrument we used for many years. They are much longer. Only the end of the instrument is moving. It's like eating with fork and knife and one day they give you chopsticks. They, you have to eat with that. It's exactly the same. If you give my instrument to a surgeon who's not doing endoscopic, they won't be able to use it. So it's less invasive to the body because we don't open the breastbone. So patients can lift anything. They can sleep on their side and they can drive earlier because the sternum is intact and they are much more mobile. And more than anything else, when you have your chest open in the middle, your breathing, deep breathing is affected. You take a deep breath, it's painful. You stop midway through a small incision. Your ventilation is preserved so your breathing is normal. So oxygenation being better, your cells receiving good amount of oxygen, you will feel less tired, you have more energy, and your recovery is quicker. I always, uh, put the aesthetic aspect aside. The biggest difference between minimally invasive and sternotomy of breastbone incision is the recovery time that we will not see it in the hospital because both nearly going out of the hospital at the same time, maybe one day less for minimally invasive. But afterward, when you see patients two weeks after surgery, there is a massive difference between the one who had minimally invasive and the one who had, uh, through stem atomy.

Speaker B: Uh, what's the difference?

Speaker A: It's more energy, more stamina. Ah, uh, um, back to normal activity much quicker. And uh, they don't have the complications such as wound infection, sternum which is moving, is clicking. The back pain, pain, uh, on the side of the ribs on both sides. All this, they don't have it. But mostly is that they are more energetic, they can go back to normal activity and back to normal life. The other advantages is less opening inside is less risk of bleeding. Um, I think the surgery is more accurate because we can magnify the valve and doing a more accurate operation. Obviously it's a slightly longer operation. And also there is a learning curve because we have to learn to operate through a screen and our hands are working somewhere else and that is not easy. Is like I am. I have. There is a glass and I'm writing on it. I shouldn't be writing in a way I can read it because I want you to read it. I should write it the other way around for you to be able to, to read it. And mitral valve is the same, uh, the. On, um, the screen. My right is left, my left is right. So I have to, uh. There's a learning curve how to use the screen in order to do the proper job inside the chest. But it's more accurate again in the hands of those who are doing enough of the operation and, and There are a handful of surgeons who are doing minimally invasive and there are two sorts of minimally invasive. One is, we call it a small thoracotomy is the opening is about 6 to 10 centimeter and they spread the ribs because they have to look through the incision. So that is already better than sternotomy, but still is looking through the screen through the incision. Um, they put a camera called Endoscope, but it is used mostly to provide light inside and on the screen. You can see uh, but is mostly for others to see what, what we're doing. And it's not a bad thing. I, I did it between 2010 to 1516 until the new camera came out, which is the 3D camera. And uh, a 3D vision is very important because.

Speaker B: And this is for endoscopic, for endoscopic

Speaker A: that will allow you to, to run through the screen, you see the depth of the, of the organs. So without 3D is all the organs are at the same level.

Speaker B: Mhm.

Speaker A: And as soon as you have the 3D you see which one is in

Speaker B: front because that's the difference between what you will be able to see with your eyes versus having to use technology to. And what reimagine that for you.

Speaker A: They, they reimagine that for us. And in fact robotic also is using the 3D images.

Speaker B: Mhm. So what's robotic compared to endoscopic?

Speaker A: So while in US the robot has been developed in the last 10 years, we have developed in Europe the uh, endoscopy, um, robotic did pick up earlier for other operations and it's very interesting and very good urology, general surgery, uh, thoracic lung surgery. But for heart didn't pick up because there was some issue and the whole program stopped. The particularity of the heart is we cannot go beyond maximum four hours. From three hours onward, the heart start getting damaged. We can't go behind uh, beyond four hours of cardiac arrest. So when we operate we have to stop the heart. And stopping the heart is not that the heart stops, uh, and never picking up. We are sending a very cold fluid with potassium inside the heart and the heart getting cold, stops beating. So like hibernating.

Speaker B: And you have to do that for every heart surgery, for the valve, any

Speaker A: surgery where we need to go in the middle of the.

Speaker B: And that's what you did with me.

Speaker A: That's what I did for the valve. And why we do that at the end of surgery we send warm blood inside and the heart is waking up and beating.

Speaker B: That's so crazy to me. Uh, that is crazy to me to think about that. Your heart is literally like it stops.

Speaker A: Stopped.

Speaker B: Yeah.

Speaker A: And they, we cannot stop the heart beyond four hours and already three hours is a lot. So the reason we couldn't use the robotic because robotic surgery takes a long time and in cardiac surgery is very different to others. In general surgery they can work on the, operate on someone's abdomen for hours without any issues. The lung surgeon can do it the same way we cannot do it with the heart. So we have, we have a limitation of the, by the time and ideally we have to be between two to three hours. Arrest it hard. And so that's why in for heart surgery robot didn't pick up and we have developed endoscopic and endoscopic is working very well. And currently robotic surgery is not accredited for cardiac surgery.

Speaker B: So um, in the UK or globally.

Speaker A: So the current robot, if I go into the detail, it's called xi. The current robot is not accredited in the UK or even US for uh, heart surgery. So like we bought it in our institution, we can't use it. Uh, in US there is exception. The surgeons who use the previous version, which is a very old one, they can continue to use it with xi, but other surgeons who never used the previous one cannot. So in fact in Europe the robotic surgery for valves, uh, even some surgeons I know which had the robot and they do endoscopic, they say I feel much safer using endoscopic because you're sticking to the patient. If there is any problem, you can't, you're in control where robotic, you're sitting somewhere else. If there is a problem on the patient's side by the time you come it can be catastrophe and you have to open the chest.

Speaker B: So just back up again because I thought I had an understanding of what robots within heart surgery are, but what exactly are robotics when it's used, what are we talking about?

Speaker A: So robot is we is we open similarly to endoscopic surgery about ah, three 4 centimeter on the side of the chest. Then we add three extra or four extra holes and the robot comes with four arms and each arms is putting an instrument and the camera inside the chest. Then the surgeon removed the sterile um, uh dressing we have and go and sit outside an sterile and put the head on the camera. We see immediately the 3D picture and operating and cutting uh, the tissue and then suturing, putting stitches.

Speaker B: So the surgeon is operating the robot or is the robot somewhat autonomous?

Speaker A: No, the surgeon is, we have the um, we put our fingers into the robot um, area for the finger and by our hand movements are translated via the robot inside the patient with the instruments. And um, the difficulty is so surgeons like thoracic surgeon, they don't do stitches so they use stapler. So they just cut and suture at the same time. It's a device is doing it, doing an operation. I counted with the 250 stitches. So doing it with robot takes hours. So that's another reason for cardiac didn't, didn't happen. But usually we are sitting with our fingers, we are moving our hands, we're looking into the screen and at the same time on the other side the robot is cutting, putting stitches. But the way I see it is with robotic surgery we cannot do exactly the way we um, do the repair through endoscopic or minimal access because of limitation by the time limitation of suturing, stitching. Um, we need to simplify, we need to jump some steps of forgetting them. And that to me is compromising quality. So as I said the day I ah, moved to endoscopic I, I translated the whole technique of repair through sternotomy into endoscopic. So whatever I do as technique of repair through endoscope is the same as open with robot. We can't do it. So I have to simplify and jump some steps for getting them in order to make it happen. But currently the mitral valve repair with the robot, uh, anaortic valve repair, uh, and suturing for the bypass is not allowed in the uk.

Speaker B: So after the surgery when you came to me and said hey, do you want to look inside your heart with the videos? And I couldn't look at it for, for a few days, I'll be honest. But I was very fascinated. I did watch it and um, for those of you who don't want to hear about what it's like being inside the heart like turn off. But for when I looked there were like tiny little, almost like tiny little metallic hands. What are those?

Speaker A: So they are clips. So when we put the sutures we used to tie them.

Speaker B: Mhm.

Speaker A: Ah. And with endoscopic where fingers cannot, our finger cannot go inside. So we have either we do the knot and we push it with a knock pusher inside. But that doing 25 sutures, each one with 12 knots is a lot of knots and it takes time. So there's a very clever surgeon in us invented a clip. So it goes and clipping both stitches together. And uh, so those clip, we are using it too but we can only use it on specific type of sutures. So those clips are those metallic uh, uh, parts coming out of the ring, they are the, the clips.

Speaker B: Mhm. Talk to me about the. I call it mitral valve. You call, you say, you pronounce it mitral valve. I don't know if I'm saying it incorrectly. Uh, what is the correct way mitral valve. Can you explain to people who don't know what it is, what is that and why is it an issue when it's not working?

Speaker A: The valves, whether it's mitral or aortic, they, they have, they are like doors opening, closing. So a door which opens, allow the blood coming in the heart and when, while it's coming in, the other door is closed, doesn't let the blood going out. As soon as the heart contracts, the original door gets closed so the blood doesn't go backward and the other one opens, the blood goes up. So this valves, when the door doesn't work very well, then the function is disturbed, the blood flows, blood circulation is disturbed. So if a valve is narrowed, the blood cannot go into the heart. So the amount of blood circulating is less. If the valve is um, floppy. If the, like mitral valve, they are cord holding the valve. If the cord are ruptured or getting longer, the valve is floppy, the door doesn't get closed and gets open through the other side. So blood goes backward instead of going forward. So that also is causing trouble. So in general for all valves, either they're narrowed or they leaky. And in both cases, when they reach a certain limit, you have to repair or change them.

Speaker B: What other issues do you deal with when you go in?

Speaker A: When I do an operation, I try to make that day of operation, uh, as if I've already done it three times. Uh, by that I mean I try to do all the tests. Like we do 3D reconstruction of the chest and heart and everything inside with the CT scan, um, we do with echocardiogram. We put an echocardiogram to check behind the mitral valve, the whole structure. So I try to understand before even going there, the mechanism of the leak, the area which is affected, understand where to open, where the heart is positioned. So the day I do the operation, every step I do, every area I open, I know what is behind, so there is no surprises.

Speaker B: So in my case, having all of the, what is it called, the toe echocardiogram, uh, the CT scan, I think there was an MRI as well. So what do you do with it? Do you put that all together and do you almost practice doing it or you just have the information and anticipate what it's going to be like to.

Speaker A: So, uh, before every surgery, so all these tests you had, I look at all of them one by one. So the angiogram will show me where the arteries are, how far it is going through the next to the valve. Because if it's. Sometimes it's too close. If we take it in, a stitch can be causing trouble. With the CT scan, with the 3D reconstruction, I know where to open, how far is the mitral valve and which direction I have to go. Uh, and with the echocardiogram, I check your valve to see which area is affected and what technique I should use. Once I had all these tests in my head, I'm doing your operation without even. Even.

Speaker B: Is it like a subconscious?

Speaker A: Yeah, it's just I'm doing the operation without being even in theater, I might be in front of my computer, I do the incision, I put the camera in, I put, I do the incision here, camera here, I go that far. My troll is like this. I put this stitch, I do this test and at the end the result is this. So the whole operation from beginning to closure in my head I do it not only once, sometimes two, three times, and sometimes standing next to the patient in the other when they're sleeping, before even doing the incision, I do the whole operation again. And then that's why I'm saying when I do the operation, I've done it already three times or four times.

Speaker B: That's interesting because this is a technique that many Olympic athletes use where it's the visualization of like, how is it going to go? And like literally like we're playing it blow by blow. Is that something that happens within like a minute or is it, do you literally, do you take like 50, like what's the time frame for that?

Speaker A: I think after looking at all the images, the whole operation in my head takes about one to three minutes.

Speaker B: Mhm.

Speaker A: Uh, obviously the second, third time, the last one is very quick, is maybe 22nd, uh, incision and, and the whole procedure. But always I think when I take the knife to skin and starts opening, uh, already three times the operation has been done in my head. If I don't do it, then I can expect a surprise during operation. And I don't like surprises. I think to have an answer, I like to have an answer for every possible complication. And it's only when you do it in your head that you might say, oh, at this point something, this might go wrong. So what do I do? So you have an answer for not only I do the operation. I imagine also at every step there is a complication on how I deal with it. So even during operation, if it happens, I have an answer for it and we act quickly. And that's the reason we don't have comp. I mean complications. The uh, it is because everything is. I always say to my assistants, to my registrars, I can predict every complication. And in my head the only thing I cannot predict is how my assistant is going to behave. That's the only one I don't know. But otherwise the every step of operation M For any operation, mitral, aortic or bypass is all been done two or three times.

Speaker B: How often do you have where you open the patient so you've visualized it, you've taken all the data in, you know, you've prepared for it, you open the patient and something unexpected happens.

Speaker A: Is very. Nowadays with all the tests we do, with all the reconstruction we do is exceptional. Uh, the only time I say I cannot predict is someone come had previous operation and they want minimally invasive. So after the first operation, for the first time, organs are not sticking to each other, they are free, there is a virtual space and they, they move close to each other. Second operation, second time, organs are sticking to each other. So we spend time to separate them. So the longer you are from the time of the first operation, the less we call adhesions they you have. So on those patients I say I put a camera. If organs are sticking to each other, we go head minimally invasive. If not, we open the chest in the middle. That's the only one I cannot predict because CT is not strong enough to show us if there are additions or not. And it's only by putting the camera we can see. So in some patients I did minimally invasive, not much adhesion. And I did the whole operation. Some others I thought there wouldn't be additions. And I found addition. And at the end of the day what is important is the safety. So uh, a good repair patient leave the hospital again. If all this, you can do it minimally invasive, it comes first. So safety before anything.

Speaker B: You said to me on the day of the surgery that I gave you a hard time. What does that mean? Was it something happened that was unexpected or that. What was that?

Speaker A: Mitral valves are difficult.

Speaker B: Mhm.

Speaker A: Uh, you know an aortic valve, you want to change it, you just, you take the valve out, you know where to start, you do your stitches regularly, you know where to finish. Everyone does it, everyone gets good results. Mitral is a repair you give the same mitral to three surgeons. Each one will assess it differently, they use different technique and they will have different outcome. A, uh, mitral valve has eight segments. In some patients, one segment is affected, and some others, two, Some others, the whole valve is blowing and yours was, the whole valve was below it. So I didn't have any reference to adjust the other parts. So very often we have the segment called P1 that is our reference because that never, that's never affected by the leak. And we adjust the height of every other part toward uh, compared to that one. And when that P1 is also affected, then we have no reference. So we have to go by experience, how, how much we should go down, how we should position the valve, which size of the ring to take. And um, it took long time because I had to adjust every segment, testing them and then making sure not only is not, uh, is coming together nicely, it's not leaking again, it's not narrowed. Now and then after we have the. Once the heart starts working, the anesthetist is doing the echocardiogram. And that reminds me of the exam. At university or school, you do your exam and you just, you're waiting for the teacher to give you the result. And they are the one judging because astronaut the heart works. I'm, um, sterile next to the patient. And they look at the valve, how much contact they have, how much is the valve functioning well, is there any leak remaining? And they are basically judging our work. And if it's good, operation is finished. If it's not, we have to go back and correct again. So it is the, the mitral valve. I said it gave me hard time because your mitral valve was prolapsing in all the segments. And the difficulty was to find a, find a reference to repair it. Um, and that is not, uh, always predictable. They even, I think the same surgeon, you operate on the same valve. I might not use the same technique today and I would do tomorrow. Uh, and that can affect the outcome. But in general is the same, but definitely between different surgeons. The technique used are, uh, if your surgery is done by me or other surgeons in London, hundred percent the technique used, the size of the ring used, uh, everything will be different.

Speaker B: Yeah, I know it's obviously not the same, but the way I relate to it because I used to, uh, sew and also knit. And so they're, you know, when you're working with like a very delicate sock that has a hole at the back, we don't do that anymore. But back in the day, you Know, I still experience of that. Whereas like how would you, how you would put that together? Everybody would have a different technique and also you know, delicate material having to like work around that. That's the closest like example that, that I can relate to. So I can see how you say that different surgeons would have a different approach to it.

Speaker A: Uh, and also we are limited. When the operation is complex, it takes longer uh, time to do the repair. And I said we are very limited in the, how much, how long we can have the heart arrested. So if you have three hours left and you spend two hours doing your first repair, the heart beats and there is still some leak, you go back, you don't have much time left to, so you have to, you have to have a good knowledge of where to go and what technique to use for that part which is still leaking. Otherwise if it takes too long, either the heart doesn't work or you say I take the valve out and to do a valve replacement. And in young patient it's not good to do a valve replacement. The valve should be repaired as much as possible. Valve replacement should be just for narrowed valve. Uh, but many surgeons, the Barlow valve, which is the complex valve which is leaking everywhere, they just go and replace it.

Speaker B: What's the difference between repair and replacement?

Speaker A: So the repair, you have your, your, your valve and the physiology, the way the valve is moving is a natural one. Doesn't uh, affect the blood flow. An artificial valve is a circular valve where your valve is an oval shape. So you are changing the basic, initially the base, the shape of the base of the heart, you make it circular. It's an artificial valve made from cow. So uh, or sometimes metallic valve, um, they, the way they move is different. The how much orifice is open is different, how much blood goes through is different. Uh, but also the valves via uh, the cord at the end of it, they are attached to the end of the heart muscle. So which means not only the valve, the heart is holding the valve, but also the valves are holding the heart muscle. When we replace the valve, we cut all this cord and the valve, we put a new valve and this, there is nothing holding the valve to the muscle. So although the door is working well, the heart muscle, nothing holding it will happen. It gets bigger and bigger. So it affects the heart function. It's always better to preserve the valve. We preserve the physiology. The way the blood is moving the, and the contractility of the heart and valve repair avoid the heart getting bigger, ah, and going to heart failure in the future. So we have to Avoid it maximum. And trying to repair the valve. Repairing a calcified valve is not easy and even when we do it it doesn't give a very good long term result.

Speaker B: That's the one concern I also had which was not having to have the valve replaced because also depending on the blood thinner. Exactly. So having to you know, essentially live on medication for the rest of your life.

Speaker A: Young patient, they normally get metallic valve. Then you have to take blood thinner forever every day. If you don't take it, the valve can have. Blood can clot, the valve will stop working and it's a disaster. So it's uh, lifetime commitment. Lifetime commitment to a drug. Uh, every day. Uh, and also the valve can be noisy. You can hear click, click, click, click. And. And I had patients where I had to take the valve out because they couldn't tolerate anymore.

Speaker B: It's like Captain Hook and the clock that the crocodile swallowed.

Speaker A: It's a big valve so it can be, it can be not always but it can be noisy. So there are. And they get, they are more prone to infection but they last much longer than the tissue valve. We, you know, some patients are mistaking also cardiologists put clip also on the valve. They call it mitral valve repair I think. And some patients come to me also they say what about the clip is a repair? By clip they put it through the groin, they go and clip the edges of the valve together. This is not truly repair, this is reducing the leak. And we keep it for patients who are not ah, surgical candidate. By that I mean too old, frail, coming on wheelchair, they have too many comorbidities. So we um, think that through surgery the outcome will be poor. Any patients who is active fit below 80. Normally the gold standard treatment remains the surgical repair. And I think for patient it's important to not to go toward what is less invasive. Always less invasive. I don't mean by that a minimal access sometimes um, uh, the most important remain again a good repair because that would keep the heart healthy. And uh, also the durability is very important. A good repair which lasts many, many years is better than a small approach with a poor repair.

Speaker B: Mhm. I didn't really, I mean I, it was obviously like I want to have the job done well. But I also anticipated that the way you approach the surgery so whether it's open heart or minimally invasive, that that was such a big deal in my mind that it almost overshadowed the fact that you know, you still need to get the actual surgery done. Well, so what you're stressing is that it's. Well, first you need to have the expert in that specific procedure. Uh, and then the second is how you approach it, because that is secondary.

Speaker A: That's definitely secondary. I know a lot of surgeons or colleagues are putting minimally invasive first, which. That's because people want minimally invasive. I think the most important, uh, is it's funny because I am promoting minimally invasive and I think it's better for patients. But still I say in the hands of those who are doing enough, if someone is not doing enough, it's better to have a good repair through sternotomy than a bad repair through minimally invasive. Just because, uh, patient wants minimally invasive. And I know a lot of surgeons say they do minimally invasive because patient wants it and they don't want to lose the patient. But then complication happened, didn't work well, then they had to do sternotomy. Then again, farther issue, then again, uh, on and on with very poor outcome. So it's always better when we can't do it. Just say to the patient, I don't do it regularly. I shouldn't be doing it. And there is no shame to that. Is, uh, or the other option is to learn how to do it. But that's a way forward. And, you know, a lot of registrars are learning it. I'm teaching next one of Imperial. Uh, I had from different countries came and learned and they went back and they're doing it. So it's something which is we use always the same technique, is reproducible, uh, is safe. And thousands of patients had the operation and they're doing very well. So, uh, and again, if a repair doesn't work sometime after a few years, that doesn't mean I have to say that also to defend myself and my colleagues. That doesn't mean the operation wasn't done well, because if it's not well, you see it straight away, it's not working. Sometimes the heart doesn't remodel. It doesn't because patients came too late. So the heart doesn't shrink because when the heart is leaking, the valve is leaking, the heart is getting big.

Speaker B: Is that what you mean by remodeling? That it's shrinking back to its normal size? Right.

Speaker A: And if it doesn't, it keep getting bigger. Therefore, it's pulling the valve down. And after a few years, the valve starts leaking by different mechanism. Before it was coming up floppy. Now it's going down and restricted and the valve leaks. And that is because the heart hasn't remodeled, didn't come back to its normal size. And that's why we push patients with even asymptomatic to have surgery at early stage when the valve is severely leaky. Because if you wait too long, I always say it's like an elastic, you stretch it, you release it early, it come back to normal size and shape. You stretch it for too long, you release it, it doesn't come back.

Speaker B: Is that why it was recommended that I have my surgery now rather than wait?

Speaker A: Uh, yes, I would say between one and three months rather than uh, waiting six months or one year or two years. Because you know when the heart function is down, your operative risk is high because at early stage your risk is lower, your heart can remodel and uh, your ability to recover is, m. Recovering from the operation is, is, is better. Uh, and uh, but there normally we should operate an asymptomatic patient only if we guarantee over 90% success rate of repair with the risk less than 1%. And if we do by the guidelines, more than 25, I think is not enough number more than 25 repair a year. Uh, I think less than 50 repair a year. We shouldn't look for another surgeon because like any profession, when you do a lot, your results are better. And uh, that's why I think we are moving towards sub specialization and, and staying in, in, in one area.

Speaker B: How many have you done?

Speaker A: As far as I remember, my cardiac surgery first one was 1994 and with Carpenter, so that I was in the mitral since 1994. Uh, during my training in six years of cardiac surgery, 94, 2001 I've seen about, and I participate to about 150, 200 mitral a year. Personally I've as a consultant since 2002. I was consultant. I've done about 2000 mitral valve surgery. And um, out of this 2000, maybe a bit more 1500 were minimally, uh, invasive and endoscopic. And that is without counting aortic, minimally invasive. I've done about 8, 900 coronary bypass, minimally invasive. So overall minimally invasive is more than 3,000. Uh, but that is dedication to the technique. I was doing a lot of transplantation, heart and lung, and I had to give up because although I love heart transplant, I think we can't do everything and is for endoscopic surgery you have to be fresh in your mind in the morning. This is not an operation. You start at midday, um, and you have to concentrate, uh, for hours into the operation. I'm wearing 3D glasses, so for three, four hours I'm looking on a 3D screen. So at the end of operation I have headache, uh, and you can't do transplantation, which is so much demanding. And often it's during the night, so it affects your operation the day after.

Speaker B: Why is it during the night?

Speaker A: Transplants always happen during the night because the hospitals, um, the organ donate retrieval when they go to bring the organs. It happens during the night. Where the theaters are usually, uh, free during the night. During the day they are, they are taken so often the uh, heart, lung transplant or kidney, liver, they always during the night or very early morning, at 3 o' clock in the morning, 4 o' clock in the morning.

Speaker B: Interesting. We're going to come back to the. How you stay fresh because I'm fascinated by your approach. And that was one of the things that really stood out to me about that. But before we get, before we talk about that, you're in the operating theater. You're imagining what's going to happen. You're running through it. Do you see yourself as a scientist, a savior, or an artist?

Speaker A: I'm not purely a scientist. Medicine is science, but surgery is more an art. Uh, as I said, get the example of the valve is like teaching three people painting. You have three different person, same master, same period. One year training with the same master. After one year you put an apple on the table. Each one will do it differently. So it's more of, I, uh, think surgeries and art. Technique. Uh, you learn it, but technique is. Might be a bit of science. Management of the patient afterward in intensive care and on the world. That is science. That's medical science. Technical aspect in the operating theater. That's an art classic.

Speaker B: Interesting that you say that savior.

Speaker A: Definitely not.

Speaker B: Um, I'll get, I'll get to that as well. Because my husband calls you the artist. That's what he. He. That's the name they call you. Some of the, Some of the staff in the hospital call you the Godfather. Apparently it's not a known nickname, but I have, I have heard it when I was there. So there is this element of the, the technical aspect, the biological aspect of a human body. And then there is the artistry that comes with acting on the spot and figuring out how you're going to deal with it with something that is alive.

Speaker A: I think during operation. I'm completely disconnected anyway from the uh, from a person which is there. You can't have a feeling about a person and all people surrendering that person, their family, their husband, their wife, their children, and at the same time operating Is not possible. Uh, you become too much emotional and you lose your logic and the way of thinking. In order to do that, you have to disconnect and not imagining that you know there is a person. So you're careful. But in order to do the job properly, you have to concentrate on the disease you're going to treat and controlling your operation. Controlling the 10 people in theater which are doing their job, making sure they don't make a mistake, and at the same time keep watching the time because you know every second is, uh, uh, is important. So it's a mixture of everything, but you have to keep in mind all of them. But the one I try to disconnect the most is to think that, uh, someone is there and they are family around, and that we do it beforehand and after that, when we are into the operation, is just technical.

Speaker B: So is it part of training? Is it something you do deliberately or does it come with practice?

Speaker A: I think it come. It's coming with practice. And um, that's what I teaching my trainees is how fast you do the operation is not important. Is, is how. Is how good you do it and how much passion you show into it is. Every step is important, even closing the skin. Because at the end of the day all you would remember is how your skin is. Uh, maybe not you, but every patient. For most patients, the skin is. And the skin is the part we pay the least attention. At the end of operation, everybody's tired, let's do the skin. We did the important part inside. But patients always remember the skin. They often forget what's been done inside. And that's why I'm telling them every step is important, including how we close the skin. Um, but that comes with experience, with, um, the, how much commitment we have to our job and responsibility, commitment to the patient. So you know it is true. If I know you, I see you in the outpatient clinic. We basically had a contract, verbal contract. You agree that I'm being your surgeon and you are my patient. Um, I have some sort of accountability toward you to provide a good result. And sometime in the NHS we say no. They, so you have too many patients, or this patient goes to someone else, that connection disappears. Suddenly you move to another one which you don't know. And I think the way you do an operation is always better if the trust exists between the surgeon and their patient. Astronaut that trust is going, the quality of work might be affected.

Speaker B: So isn't that a bit of a contradiction then, because you're saying that when you're operating you are disassociating from the person. But yet you're saying to me that that is the most important thing.

Speaker A: No, it's important when you see. Because there are different steps that is

Speaker B: it different stages of the process of meeting the patient, operating.

Speaker A: It's completely different. Meeting a patient is accountability for giving the perfect result to the patient. I need to see the patient, to know the patient and to get the trust of the patient. If I don't have the trust of the patient, there is no reason that I do the operation. Uh, but while in theater, uh, so some operation like opening the breastbone and doing three bypasses, that doesn't require the same concentration that I need. For endoscopic procedure, it's routine. Uh, but some more delicate operations, such a valve repair, uh, complex reoperations, three valves, operations, um, those require. That that's an art. Not everyone can do it. And that is true for everything. It's just, uh, you can have many cook. Not everyone become a Michelin star. So it's, uh. That's how nature is. And some people are good in that. Some, um, less good. So it's. But that is, uh. That's not up to me to define who's good and who's not not good. But it's not only the surgeries, how people behave with the patients as well. Um, I had surgeons which were technically very good, but connection with the patient were awful. And some others, they are very. They have excellent communication skill with patients, but technically, uh, not that great. We learn by experience. I mean, I had the advantage to have. I had three of the greatest surgeons in the world. And as master. One was Magdiaku, one was, um, the carpenter, and one was Capel, who did the first transplantation in Europe.

Speaker B: And tell me what was unique about them because they were, they were.

Speaker A: They were pioneering cardiac surgery. They, uh, Cap Ontier created the operation for mitral valve. He invented the aortic mitral tissue valve we are using worldwide. So he, uh, at that time, I mean, he was the best micro. Best cardiac surgeon in the world. Cabral was great in. They were pioneer. They have new ideas. They, they were bringing new techniques. They. The outcome was less controlled than today. Today you make, uh, you have three or four complications. Immediately you investigate it. You have to prove that you did nothing wrong. So there are more, um, uh, you have more accountability toward the outcome. At that time, it wasn't like that. I mean, I'm pretty sure that if the same surgeons today were practicing, they couldn't do what they did at that time.

Speaker B: Today, um, because they had more freedom to.

Speaker A: They had more freedom to do. I don't know if sometimes it was experiment, but they had more freedom in order to do new things. Today is much more control over everything. You have to prove that it's effective. You have to, uh, prove the safety. You have to start doing it on a few patients, then presenting it into the committee that it's working and then expanding it so it takes longer. At that time it was going much faster. I don't think that was good because, you know, the outcome. We never, we always know about they did it. We don't know about what happened to the patient today. We know the outcome is better. But the, the. If you want to do the same technique, it takes longer to put it in. In practice. You have to find the balance between. Between both.

Speaker B: And you've studied directly under them.

Speaker A: Oh, yes, all three.

Speaker B: What did you learn from them? Apart from obviously the, the technique. But what is.

Speaker A: I did learn a few things. One, um, so I've been under surgeons who were very tough, so shouting and like in an army.

Speaker B: And Gordon Ramsay style, let's just say. Right, okay.

Speaker A: Similar to him because. Yes, the, uh, exactly similar. So shouting, screaming, insulting. And uh, some other, like Carpentier, who was extremely soft and called all of us son and, uh, called you son, My son. Come here and let's, uh. It's very polite, very polite. And, uh, he treated us like, uh, trainees, which. And that's why we are always. We are very respectful toward him. Some others were very tough. And, uh, I always remember them not by their skill, but how tough they were with us. Operating theater started at 6am we were in theater at 5am it was 10pm we were tired. We had to go to, uh, bring organs for transplantation. Doesn't matter if you don't sleep the day after, you have to come to theater and operate. And you couldn't say no, otherwise they would have stopped your carrier. So there was a training like in a row, three days in the hospital, sleeping on the floor and all this. So that was this kind of a training I had. So seven days operating, uh, on call, nearly every day. But now it's not possible anymore. So now the trainees, they are trained two days in the operating room. Uh, if they do a long call the day after, they shouldn't be working. So obviously the training is not the same because the amount of time I spent in theater during my training for the trainees today, it will take three times more to have the same experience.

Speaker B: Um, but was it better to be trained that way. I mean, what happens to a surgeon or a trainee who is underslept and stressed and tired?

Speaker A: I don't know if it's better or not, but it gives you more exposition. You see more operations, you see more complication, you get more confident in a shorter space. That was too much. And I think today, two days in the operating theater, that's not enough. So something between both, maybe three, four days in theater would be. Would be better. But, uh, I think in Europe, because I wasn't trained here, I was trained in France. Still in France and Germany and Spain and Italy, the training is about. In theater, four days a week. Here is two, uh, days a week. Which one is better? I think, as I said, surgery is an art. The more you are in theater, that's where you're learning. Uh, the rest, you can always learn it, uh, out of hours or, uh, you take one year, you do intensive care and, uh, ward management. But theater is where we learn things. And the more we spend in theater, the more we learn.

Speaker B: So when you're in the theater again, I just want to get into your mind. So. So you're visualizing, you're disassociating from the person. Like, what are you feeling? Are you in flow? Are you, like, what. Describe to me what's going through your mind.

Speaker A: I mean, like this morning when I was operating. So during operation, when I'm doing a suturing an artery which is 2 millimeters. So I'm with a suture which is half the size of the hair. Uh, so the way you pull it a bit and it just breaks. So while I'm suturing at the same time, so I have to be disconnecting. My full concentration is into this future to be finished. Because the heart is beating and it can fibrillate at any time. Um, at the same time, my eye is paying. I don't know how, because I'm looking here, but I still, I can see on my right side everything the scrub nurse is. And still I can see in front of me everything the assistant is doing. It doesn't make sense. And at the same time, I can see the anesthetists on my left side. So although my full attention is on this future, still I can see all of them and what they're doing. Um, and I think because most of it is maybe because I learned their movement. And as soon as they move, uh, I'm just looking quickly to see what they're doing. But that's how it is because we are running the show. And if one of them makes a mistake, it will have an impact on the whole, um, whole procedure.

Speaker B: But is there. Is there fear? Is there calm? Is like, what. What are you feeling?

Speaker A: I'm. I'm calm, so I'm not. I'm never shouting. I mean, I've been trained in an environment where they were shouting alone. So I'm very calm. Even if something goes wrong, uh, I correct it without saying anything because I think as soon as in a theater, everybody's stressed, is about the life of someone. And if you start shouting, everybody is getting disconnected and they're not doing their best. So, um, never in theater, I never shout. It's just even really something which shouldn't happen, happen. I correct it. As I said, most complication. I know how to deal with it. I correct it. But afterward I can't take the registrar, the trainee, you know, and telling him, why did you do that? You shouldn't do that. Or saying it separately. But never in theater. In theater, the priority is, uh, is, um, finishing the operation. I remember one day the scrub nurse took the knife and the heart was arrested, Cut my finger. And uh, the, uh. I just say nothing. It's just immediately I came out, we put a stitch and, uh, closed it and gloves again, Washing the hands, scrubbing, coming back, finishing the operation. And that was years ago. And then, uh, then I had the chat with scrub nurse. But on the spot. We don't have time to do these things.

Speaker B: I've spoken to some of the people who you work closely with, and they described you as cool, approachable and caring. And they said that you're exactly the same person m In the theater as you are outside.

Speaker A: I mean, the. When they said, I come back to the previous one, the. The Godfather is just because there were other surgeons who are doing minimally invasive so called. But they always said, you know, there is a massive difference between your minimally invasive and the other one's minimally invasive, which is three, four times bigger. Uh, unless the patient don't compare them together, they don't see the difference. They have a lot of pain because when they spread the personality. In theater, I'm calm. I like music in theater. So. And the music is our, uh, music is not to listen to the music. I don't want to hear others. I want to be discorrected. I can have a music. I even don't remember what was the music.

Speaker B: So this is more for you to get into a certain state, like a

Speaker A: certain state and disconnect from. From everything. And often, you know, if most people are with me are Indian, I ask them to put Indian music. It just is to make everybody feeling comfortable and they do well. Their job and I can concentrate on. On mine. And outside of theater is the same because at the end of the day, the same structure. If you shout at nurses, if you talk to them badly or strongly or, uh, to push them, that they feel they are, you know, inferior to. To the medical body, that doesn't work because they are. They do their job and they love it. They are compassionate with the patients. They. And telling them off is not going to solve problems because we are. At the end of the day, we are human being. We are. We make mistakes. And, uh, making mistakes in a row, that's a different thing. But everybody can make mistake. The whole thing is that they understood it and they're not repeating it. But that can be said in different ways. I like to say it in a soft way. And maybe that's why I think when I have my patient, they. They look after them very well and they update me all the time for everything. Uh, blood.

Speaker B: Yeah. They said that you get upset if you don't get enough day. Like you really need to know.

Speaker A: It is. It is important because as I said, it's a contract. And I am fully responsible for anything happening to the patient. So I don't mind. They ask things and they take initiative, but they have to let me know, uh, what is done, what are the results. And, uh, otherwise I'm not in control.

Speaker B: So it's about being at a certain state. It's about like, tuning out the distractions or anything else and focusing on the moment. And it's about just creating this very calm environment.

Speaker A: Calm environment, everybody's. And always. I like working always with the same team, because you haven't seen in theater, but in theater, when I have the same team working with me, I don't talk to them because they know the whole operation by heart. So very often I'm at a stage I need to change my forceps to a thinner one. On the screen, they can't see I'm going for the thinner one. I just take this out. The scrub nurse will put in my hand, right. Without anything, and I'm back again. And that makes everything going more smoothly. So. And then I can concentrate on the. On the job or the perfusionist who's running the pump knows that once the heart is getting full and I can't see, he takes the initiative to empty it. And I can see straight away that he sees that he's full and, and immediately reacts. Otherwise if he's not someone I'm used to work with, I have to tell them every five minutes, can you empty the heart? Can you give me the right instrument? And as soon as I do that, I'm m. Disconnected from this.

Speaker B: Yeah, it's what I compare it to is in the, in the theater it's choreography. It's a dance where everybody learns their steps. And so the more you practice together, the more cohesive and together you are.

Speaker A: And I am the person in the middle who's doing the main dance. No, but it's just.

Speaker B: But they are doing the dance around you as well.

Speaker A: But I think it is important that everyone does their job properly. And uh, very often I have the same surgical assistant, the same scrub nurse, the same perfusionist who run the pump and same anesthetist. The only person which is changing every year is a M trainee. But I think concentrating on the job, a smooth atmosphere in theater. And once the operation is finished, everyone is satisfied because once the valve is repaired and they anesthetists say, you know, the result is perfect, is good.

Speaker B: And we look at, you've got your stamp of approval.

Speaker A: That is, that is really rewarding because uh, and sometimes it's not perfect, sometimes there is a bit of leak. I said I have to go back again and we stop the heart again and we just go and correct it. We come off bypass and now it's good. So at the end it is a satisfying uh, uh, profession at the end when we look at the result. But um, it comes with a lot of ah, concentration during the four hours of the procedure. I mean one mistake and the whole thing is changing.

Speaker B: How do you celebrate your success? Do you celebrate the success?

Speaker A: No, to me, uh, celebrating a success. Are there number of patients who come for the operation? Uh, you know, I, as I told you before, I don't have any personal website. I don't have a, I don't have a fancy web pages saying I do that, I do this. I've been to BBC, I've been to that. It's just the fact that despite that I'm operating on um, minimal access. Mitral more than anyone else is quite rewarding because patient manage to find the right person for the operation. And um, that is because you can't lie to patients. Uh, at the end of the day when they see a surgeon acting is one thing, but saying the truth is a different thing. The they find out easily who has done enough and who hasn't done enough. Uh, and that is not a Website will not change it. So, uh, as I always say, once I see a patient is very exceptional, that patient goes somewhere else. Uh, and if the patient goes somewhere else, they will come back for reoperation. I take it back.

Speaker B: Uh, no, no, no, But I mean, I felt such total confidence in you because the first thing I remember is like, going for a consultation with you, you're kind of, you know, you're arriving, you're looking at it, and you're kind of, you're not really saying too much. And I'm like, okay, I'm just gonna be patient because I always want to have the answer. And then you start sketching, you start drawing and explaining, like, based on my physiology, like, what's going on. And, um, and it's, it's something that I didn't necessarily put on my high priority list for a surgeon, for somebody who is, you know, approachable, like your, your team has said, as somebody who's easy to talk to. And you just seemed very calm and very confident and that, uh, the drawing,

Speaker A: now you mentioned it. I think when the patient come, you know what you have, but you don't know the, the severity of. You have, and you haven't seen it. So showing to patients their images is important. Then drawing it first to make them understand before showing the images what is what. Otherwise, I'm showing you an echocardiogram, which, that's the first time you're looking at it. You have no idea what is what. So I have to do a drawing to show the, the what is what, what area is affected. Then when you look at the picture, you see exactly the, the issue. And, um, I think explaining it, I suppose every patient, they are worried. Uh, they're very worried. It's heart surgery. They think they might not make it through. And, um, once they understand the problem and as I said, the surgery in front of them will very easily make them feel either comfortable or uncomfortable. But still, I don't know why you chose me. Because every surgeon can say we do a lot and our outcome is good, but, um, unless you know someone who had surgery, it is, it is difficult to understand why. I suppose the patients come and often stay because the way I explained their disease to them and maybe as you say, that provide a certain feeling that I've done enough and I know what I'm talking about.

Speaker B: It was a combination of factors. One is just the volume of surgeries you've done. I mean, that is black and white. You can't, you know, you can't take that away. And then it was the explanation you made about the open heart, the minimally invasive and what you do. And that is. That was, ah, One of the top criteria that I wanted is to have as least m. You know, invasive as possible. Possible. Um, and then it was your approach that you just come across as somebody who just really loves what you do. And you really wanted to do the surgery. That's the feeling that I got. Like you want you. I don't know if it was a competitive streak or. But you. You wanted to do it.

Speaker A: No, they. The thing. I mean, since age 7, 8, I wanted to do cardiac surgery. I mean, not only medicine, I wanted cardiac surgery. The, the reason when a patient comes, and I know that I will do, is a bit pretentious, but when I know that.

Speaker B: Very humble of you to say.

Speaker A: When I think, let's put it that way, when I think I can do it better than others, I. I prefer that the patient stay with me to have the operation because in some operations, I know that says the Barlow, they will end up with a replacement, but I can repair it. And, you know, even if the list is busy, there are patients still, you know, I prefer to do the operation because I know I can provide a good result and I should push the patient to have the surgery for that specific procedure. So if something is like coronary surgery, you do your bypass, everybody will do it with very good results. That's fine. They can have it done by someone else. But it's a very specific procedure. I think is important to. To make the patient understand that they're in the right place. And especially in young patient. You are young and having the valve being replaced is not good. Is better to have it repaired. And at that time I thought I would. Maybe I'm wrong. I thought I would do it better than others.

Speaker B: Well, that's what. That's what I got. And that coupled with the fact that everybody else, every other surgeon recommended you, that also was a full circle moment. Um, I'm a headhunter, so my, My expertise is putting together a short list of experts. So I decided to apply the same.

Speaker A: When you do about 3,000 operations over 25 years, people know about it. And the, uh, I think at one point, I mean, in the country they know when you talk about minimally invasive, there are not many surgeons and people will give a few names. Uh, but again, um, I think competition is good, is healthy, it makes things going forward.

Speaker B: So I agree. I didn't see that as a. As a bad thing. I saw that as a. That you're there's certain point in a person's career where you can get either disillusioned or bored or you're not pushing yourself anymore. And, you know, you still have that, like, I want to do this, I

Speaker A: think for the patient is good. So that's why I want to do it. Sometimes, you know, the, uh, I do two operations and I'm tired. And on a weekend, my wife said, you know, why do you do that on the weekend? But it just makes me relaxing. I mean, I get tired, but mentally it gives a, um, feeling of reward. Uh, and doing something good, uh, even for a simple bypass, that feeling is still there.

Speaker B: So you're saying that your work makes you feel relaxed?

Speaker A: Relaxed. And yes, at the end of surgery is good because. Because I don't think that way. Because now we're talking about it, I'm thinking about it. But when I operate, operation is done and finished. I see the family, which are happy, they relieved, and that I tell them everything went well, there was no issue. It's a good feeling for them. But it's a good feeling for me also because I gave some good hope and good feeling to the family of someone and made some people

Speaker B: thinking, uh,

Speaker A: that they will stay longer with someone in life. So that's a good feeling. I, I don't pay attention to it. It's just there. The same way if something happen is very stressful because patient post cardiac surgery can have bleeding. If a patient start bleeding, um, immediately in my head, all the complications which can go with it, it comes. And that's, uh, where we are getting stressed. We have to do things quickly. And, and that's why it's a very stressful job. Because even if everything is good, I know something can happen in the first few hours. So I'm getting ready for that. Um, it's like you're at war. And although everything is calm, you know at any moment something can go wrong and you, you get ready. Uh, but I think the overall is a stressful job. Stressful in a term that not only the life of the one we operated on is, is there, but also people around that person because we often ignore it. The family around. And, and, and what are the best moment? I like end of operation, going and seeing the family. It's really good.

Speaker B: Yeah. Actually, when I was talking to the staff in the hospital and I said, what got you into this? Like, why do you do what you do? And I said, I love seeing the patients go home to their families. Like, that's what drives them. It's like, see that they're gone and they're not there anymore. And that was actually. That was the reason why I was like, I need to get out of here. I need to just. I need to go. I need to get out. Um, how do you deal with stress? Because outwardly from. I've never seen you flustered ever. So I don't know you well enough to say, well he's just always like that. Or you're just very good on putting on a show of being calm. Like how do you stay like that?

Speaker A: I mean one is because I know what I'm doing. Um, anything which can happen and complicate this scenario of the. The whole scenario, I'm. I can basically predict it. And if it happens, I have an answer. But still removing this is stressful. As I said, it was the. I. I uh, drink a lot of coffee of 15 espresso a day. Ah. And I started uh, playing a year ago music instruments just to relaxing. So I come, I arrive home, I sit down and I play with my instrument.

Speaker B: What do you play?

Speaker A: I play tar and sitar. And it's, It's. It's a. It's a Iranian instruments music instrument is. Is really nice.

Speaker B: Why did you pick that up?

Speaker A: Because I operated on a um. I operated. I'm a famous sitar, ah. Player and he's. He's very famous in Iran and he came with his brother and I uh, operated on him and he. That was the setar. Was his instrument. He gave it to me as a gift.

Speaker B: Amazing.

Speaker A: And then for years he was sitting there in my uh, at home. And then one day I picked it up and there is no one in London teaching me that. So online I did learn it. How to uh, read the, the uh, the notes and then how to play it on the instrument. So I did uh, through Internet learn how to play this setup.

Speaker B: It's a wonderful.

Speaker A: And that's. And that is I come home, I start playing and in fact they are coming to London for the uh, concert. Ah. And I said to my wife, uh, never tell them I started learning. No, but it's. It's relaxing and uh. No, it's. And going on holiday. That's.

Speaker B: That's really. I was just about to say this is what I've heard that you, you like your holidays.

Speaker A: Yeah, I like my holiday. I just went two weeks in Mongolia horse riding with my son. That's. So if we did 700km on horse and uh, then uh, we did uh, in Turkey, uh, uh, the wakeboard and uh, water ski. So. But horse Riding, I think that's, that's my favorite.

Speaker B: Is it?

Speaker A: And skiing and ski twice a year.

Speaker B: Yeah.

Speaker A: So anything which can take me out of the normal situation is good.

Speaker B: When I've heard that you are going on those holidays and that's something that you make upon part of your ritual process, I was like, I certainly want a surgeon who will take their holiday who will like, forget about all the worries of the world and properly disconnect and to, you know, come back and feel refreshed.

Speaker A: Now it has to be a holiday. It can't be sitting, uh, around the swimming pool and under the sun. It has to be completely different environment. So skiing to me is just getting disconnected. Horse riding, we're already planning for next year, Kazakhstan or Kenya. Horse riding. So it's just, uh, it's doing things which are, uh, we don't do routinely is. But that is, that is part of. And the music, I mean, not the music. Playing, playing an instrument, I'm not perfect in that. But even the little one I'm playing is just relaxing.

Speaker B: Bringing it back to the fact that you've worked with pioneers who invented techniques. How do you see the industry evolving and what's your part in creating new techniques?

Speaker A: So in cardiac surgery, industries are not very much interested in. In industry as everywhere. They are interested in area which brings money to them. So in the cardiology, uh, the new technique of going through the groin, putting a valve into the valve, or to clipping the valve, the one I said is like a valve repair. So they are very costly devices, about £20,000. A ring for surgery is £2,000. So therefore industry is pushing into that. And also they are funding a lot of research which are, uh, industry driven, which means the outcome will be in their favor in order to have more patient having them. Ultimately, I think we come back to the fact that the gold standard, this surgery is just more invasive and we have to somehow make it less invasive. Um, but in surgery the problem is we don't have the same help the cardiologists they have through the industry. So we have to just be innovative and going step by step. Um, there is a limit to how much we can reduce the size of the incision. Already the devices cost a lot. A 3D camera costs about 250,000, instruments are about 80,000. So the whole setup is about 500,000. And the robot costs 2 million pounds. So the cost of having this for an institution is a lot. Um, so in surgery is going smaller and smaller. The step by step cardiology is because, uh, we Become surgeons less invasive, the cardiologists, they become more invasive. There will be a midline where we are meeting each other and the new generation of cardiology or surgeon is made where they neither like cardiologists who are not invasive at all, not like some surgeons which are very invasive, but something in the middle. They are a mixture of invasive cardiologist and less invasive surgeon.

Speaker B: What do you mean by invasive cardiologists?

Speaker A: So cardiologists, they usually mostly treat the patient with medication or they go through the groin, they put stent and open arteries in the last few years. So they do also valve replacement, but they don't take the diseased valve out and put a new one in. They keep the disease valve in and they deploy through the groin valve into the valve. It doesn't have the same durability as a surgical valve. And we keep it for patients who are high risk or over age 75, 80, or for the mitral valve, they put a clip in the valve so that work again for patients with life expectancy less than five years, uh, or quite frayed. So therefore the cardiologists who are just giving medication or putting stent now going through the groin and putting valves. So they became more invasive in terms of implantation of valve treating valves. We surgeons, we were opening a lot and we said, okay, now they're going becoming more invasive. They are taking our patients for treating them. Now we're going to become less invasive to attract patients because patient they again they just see the cardiologist advertising themselves as keyhole surgery for mitral valve repair. That is not surgery. They go through the groin, they put a clip that doesn't provide the same result as surgery. And surgeons say minimally invasive keyhole mitral repair for the patient doesn't know which one to go to. And uh, that's where the confusion come. They have to make the right decision. I think they have to be careful. They have to choose what is durable.

Speaker B: We're talking about, you know, what's the cardiologist and what the surgeon's job is. And once the surgery is completed, your job is technically done.

Speaker A: Yeah.

Speaker B: So what happens after? What advice would you give to patients to help them recover faster? Because I imagine that this is something that will also help, uh, a, reduce the risk of it returning and B, also, you know, is less expensive for hospitals for you to stay in hospitals

Speaker A: longer or for them to come back the after surgery. Usually we ask in hospital anyway. We are managing the patient, making them becoming mobile quickly because you need to expand your Lungs. And if the lungs are not fully expanded, you will get fluid accumulation between the lung and chest wall, and then we have to drain it. So in hospital, we tend to make patients walking, and they can go home when they can't take the shower, going up and down stairs and walking in the corridor. Once out of the hospital, they need to walk about four or five times a day, 15 minutes. So the more they do, the quicker they will recover. They also need to eat well because they lose their appetite. And if they don't eat, they are going to lose muscular mass. Therefore, they feel tired, they do less activity, and we're back again to square one. So the mobility, walking and eating well is the most important. Uh, and then after two to three weeks, then they can do static cycling. M starting running a little bit, but exercising, lifting, heavy things. I would say a month after surgery, um, full recovery. I think one month after surgery, they should be fit enough.

Speaker B: One of the cardio rehabilitation places that you have recommended or as part of the whole hospital experience was CP +R. Ah. What do they do that you feel is effective for patients recovering after?

Speaker A: These are, uh, because there are different sort of rehab. I think they are dedicated to cardiac rehab, um, uh, which is mostly static cycling and a treadmill. Um, I think the reason we work with them because probably because we send all the patients post cardiac surgery. They used to cardiac patients, uh, and that's a connection we have with them. As I say to patients, the best rehab, I mean, exercises would be walking every day. And if they can do seven to 10,000 steps, maybe more, two weeks after surgery, that's already a good target. Not everybody can do it, because some patients can get what we call a Dressler syndrome, which means you're not used to have air inside your chest. And during operation, air goes inside the chest and the lungs get inflamed as well as the heart, so there can be side effect. So some patients get what we call a Dressler syndrome, which is fluid accumulation, some discomfort, but that will go away after some time. Uh, and that's the only thing we are looking for after surgery. And the more patients are exercising, the less symptom they get. M. But those who are sitting in the chair after surgery, walking 10 minutes a day, and that's it. They will come back for tiredness, for fluid around the lungs, which we need to drain. And that only goes away by. By exercises. That's why young patients and fit patients recover much quicker.

Speaker B: Yeah, I mean, I certainly would not recommend a laundry to anybody. That was a special Kind of experience. But, um, yeah, certainly walking preferable.

Speaker A: Uh, in fact, the full recovery comes about two to three months because still is a big surgery. Still a pump works instead of your heart. The blood circulation in the whole body is changed from muscle cell, eyes, brain, gastrointestinal system. The whole body is disturbed and is reacting to that aggression, which we call inflammatory reaction. And the inflammatory reaction takes about two months minimum to go away. So in some patients, it's going away quicker. Some others it takes longer. The older the patients are, the longer it takes, the young patient goes away quicker.

Speaker B: I mean, I've had all my. My scans and I've spoken to my cardiologist, who is not associated with you. So, like a third party. I said, oh, how would you rate this surgery? 1 out of 10. Um, and then he said, it's excellent. And all the scans, like, everybody who's taken a scan, and it's like, that has been an excellent job.

Speaker A: The Barlow is hard to. The Barlow valve, that's the whole valve coming and leaking, is a difficult one to repair. And, um, that's. That's the. The valve I prefer because I know the technique to. To how to do the. That type of valve to repair it. But those who are doing the scan and they see the Barlow valve, they know, uh, when the result is good and whether it is not good. And I take it for 11 out of 10.

Speaker B: Oh, well, some call you the Godfather. Some call you the artist. M. I'm going to call you the Alexander McQueen of Mitchell Valve repair because, uh, you've done an excellent job on repairing my heart. And now I have a designer bespoke folk art, and more than that, just a second chance at having a much better quality of life. So thank you for both the. The work and also for coming onto the show and for sharing your expertise and just learning more about your mindset and your approach, because I think you are very unique, and that's what the people around you say, is that you're both very technically skilled, but also how you come across as a person. Just, um, a memory from the hospital. It was so calm and so quiet and almost like moving in slow motion. Ah. As though to, like, not spook the. The patient and just very calm, very quiet. And of all the surgeons and all the doctors, you were the only one who opened the door for a nurse that really stayed with me, and that's how I see you. So I'm genuinely very thankful that I've met you. And I'm making teary. Um, just. Thank you. I've really enjoyed this conversation and thank you very much. Could keep talking, so.

Speaker A: Thank you. I never noticed about the door after he told me that, but, uh, it's just automatic. That's is. I think that's natural, is they doing hard work and.

Speaker B: But I think this is where that's what I think is unique to you because you, you are at ease in one of the most stressful environments that you can possibly be in. Because to be able to have. Don't even think about it and you know, being gracious and considerate to other people. And a lot of, A lot of doctors are very, very stressed and that shows and in how they respond to patients, each other and like the whole room just goes calm and quiet in a. In a very good way.

Speaker A: So thank you. I never thought in that way of the whole thing, but, uh, I'm going to reflect on the whole discussion we had. But it is quite.

Speaker B: You know what it is because actually I didn't make this connection because in my head I was like, I'm going to use this for my solo episode that I will do about my experience. But it's like taming a wild horse. That's how you approach. It's like you've got a wild horse. And like, how do you approach a patient? And I say you don't look them directly in the eyes. You have to go. You need to be in the calmest mental space so that they can feel you. And then you don't make any sudden movements. You don't, um, like, spook them. You approach them slowly. You kind of like gauge it and then you assess and then they trust you.

Speaker A: On that note, I'm a speechless. Thank you very much.

Speaker B: Thanks for listening to Anatomy of a Leader. Hit subscribe and follow. Your support means the world to us.