Join David H. Adams, MD, Marie-Josée and Henry R. Kravis Professor and System Chairman of the Department of Cardiovascular Surgery, in discussion with icons of the field of cardiac surgery during the "Legend Series" lectureship for the Department of Cardiovascular Surgery at the Icahn School of Medicine at Mount Sinai. On January 27, 2021, Dr. Adams welcomed Tirone David, MD, Professor, Melanie Munk Chair of Cardiovascular Surgery, University of Toronto sharing insights on life, career, and the evolution of cardiovascular surgery. the welcome. We really appreciate you coming today. Thank you. So in honor the I'll just tell you to start with A few uh candidates and entire tell us about this one I think. I don't remember. They do. But this is uh back in the 80's when there was a very long queue for heart surgeon Canada and I started, you know, I was giving you a new job. Pretty tough job. Actually one unit in Toronto was closed because I put outcomes. And of course the professor went down to the most senior member of the group and asked him to move and reopen the unit Professor University Back in the 80s. And you know, bad things flow down here with the five of them, none of them except the job. So I, he came to me and said you have no choice. You are the new recruit, you're gonna move to Toronto Western Hospital. I was horrified because of I'll finish my training six months earlier share with their, I went and I reopened this unit. I literally live in a hospital for the first few years. And uh, and after all I hear too, I had established my, my the unit goes up, you know, very good results. And the problem was the cube patients are coming from everywhere. And I had a six months to wait months waiting list. But you know, I I showed this because I wanted to just, you know, highlight for some of the younger residents and and team members that, you know, cause everybody has heard of the david procedure. We're gonna talk about that in a little while. But I think it really, really shows the the sort of, you know, stature that you were developing very early in your career, um, you know, really in North America and I think that the, you know, pinnacle really. And I'm sure you agree with me. the pinnacle of this specialty is to be the president of the Yes, this is is Tyrone. We had a nominating call last night. I mean, that has got to be the heart, that that is a tough ticket. And I think this is a recognition again of your, you know, incredible influence on the, on the field. And I'll just show one last one, which is this one, which is the order of Canada, which is not not only being recognized, that like the 80 s pregnancy being recognized by peers, but this is the, you know, the highest honor you can get from the nation for service. So, tell us a little bit about this one, and then we're going to start from the beginning. Well, that's linked to a produce picture. Did the cover of a national magazine. I was fighting for more resources to a you know, we needed more money into cardiac surgery to be able to do more cases. And I and I got national attention and suddenly From three or 400 cases a year, was doing 1100 cases a year in two surgeons, which was quite, quite a remarkable and of course not only three cases, but publishing and and moving myself upward academically developing new things. So I end up getting the order of Canada 19, I think it was 96. Uh it really isn't, you know, I think it's a testament when you look through the sort of years of trying to get not only pure recognition, but just this global recognition. So I think that we're in for a treat today to train sort out exactly how this, how this happened. And I think we should start at the beginning. And I want you to tell us a little bit about where you grew up. Oh, God, yes. Uh, it didn't look as gorgeous that there are pictures showing. This is a one of the pretty large river. They create a water them, uh, hydroelectric and inundated a very large area, which is brilliant. Now it's beautiful actually. But my town is very, very tiny, some 200,000 people. It was born my father, however, not being Brazilian, uh, being an immigrant, a jewish immigrants in a small town. And the last he thought that the only way you're gonna succeed, this threw up education and and pushed us to up to be the best we could. Yeah, it was a tough man. But, uh, help me a lot. I think it worked out. Yeah, I guess, yeah. Hours when I was about to here, six months old or so haven't changed very much now. I see you've still got that full head of hair even then. That's very impressive. The, I'll show you a picture of your family. Tell us again, a little bit more about your family. My father is a businessman, uh, a bunch of kids. And the, I apparently my brothers tell me that was always the, uh, the oddball as you can see everybody's looking the camera, but me looking airplane flying by. Uh, what? Yeah. Short life. The only in brazil, I'm the only one that left and never came back. They all left for a period of time for education but returned to brazil. Why I decided to stay here the, and this is your elementary school west elementary School. I learned to write the first awards in Portuguese, I guess. Oh, they, uh, And again, now this must be junior higher. So I'm all about 10 year old. I wasn't basketball that was already pretty tall from an age and I guess was an off tournament. That was lydia deliveries or, or I don't know what they recorded their and you're continuing to grow and your continuing to get taller and your continued continuing to have all that hair. I'm very jealous. Well this there is falling out not your old white but falling off as well. Getting thinner I guess at any rate. So, so I would say like, like a lot of us on this call fairly humble origins with with a family structure that was very supportive that makes a good summer. Yes. My, my my to be quiet, my mom is there loving italian mother who want to give me her arms all the time. My dad is when they pushed to our try to be better than you are and it's never good enough for him actually. He when I was trying to get the medical school, this one here very impressive building. I uh to lure me toward see if I could get in. He offered me a car said if you take the exams what it was like a national exam and and they said if you get in or give your car, the car was a Volkswagen of course this back in the in his sixties and I came in second in a I can petition over 2000 students For 100 positions. So I went home and said one of my car. He said, you know there's one guy out there better than you are. You are not very good. Really. I mean this kind of man who was wasn't very nice to me but he helped. Yeah, I would say so. I would tell us did you always want to be a doctor or how did that come about? Pretty much, yes I had that uncle as a pharmacist. Um Here talk to me a lot of chemistry. Gabriel Gabriel David. And here he was the most scientific and family read extensively and his frustration was a stopping pharmacy not being a doctor. So as I grew up in the first came to out here's my life. I live next to his door next to his pharmacy. And in those days Farmer Self like now you prescribe antibiotic. He comes ready cough syrup, can't ready. In those days the doctor prescribed the composition the medication and the pharmacist mixed with different things. So very early on I started learning about the importance of far chemistry in the human body. And he's the one, it was the link they inspired me to us to become a doctor. Um And I like this. I like this off. That's uh I don't think we can get away with this today, but that's right. So just get the medical school there was you were there to see if you got accepted. The more senior ones will shake your hands and spray with tar everywhere. I mean after they got better gasoline afterwards to uh to clean look how skinny I was. I mean I'm too skinny now. But I guess you have to study so much. They don't have time to do anything else but books to be able to get in. Look at the concentration camp. Yeah, I know honestly. It looks it doesn't exactly look like a group of young medical students that are celebrating getting into school out of 1400 dozen. Um And then you're gonna finish medical school. Any idea of what you when did you decide you like surgery? We'll do the medical school less uh in brazil the european system we don't have like here college and then four years medical school, all the eight years of seven years are together. So when you finish high school you applied for pre match and then after two year basic science should go to medicine, dentistry or some other biological sciences. I was a medicine from the gecko. and by the 30 years start to work in the hospital and the by working the hospital weekends and at night I beginning clients to surgery. And then of course my mentors start saying you've got a good pair of hands. It should be a surgeon. So that I discovered very early on By the age 2021 that I want to be a surgeon. I just didn't know what kind of search is going to be. But. And where were you influenced by a surgeon there? Did you meet anyone? Oh, God, yes, I helped you figure that out. It's very influential. I mean because you're artigas, I think you trained at Mayo clinic and came back to brasilia in his sixties and brought a lot of new things. More importantly, he's the one that told me if you not learn medicine, you better go tonight. States you're not gonna learn medicine here. Remember this back in 1970 when I finished medical school? Yeah. And yeah, usually I was gonna say a medical school most of the time it's a surgeon are or two that really gets you interested in get behind you. It sort of starts that way and it sounded like it did for you. And then of course you met one of the icons frank spencer. So tell us about this early experience here. It's quite as I apply to french cancer program because I knew a frank spencer as a Brazilian medical student. But I ended up with Claris Dennis in downstate interested in is it was very good to me. I spent my ear in his unit and I try again to get Dr spencer. But he had a pyramidal system perimeter system. It means it took 28 straight surgical intern. Only four became our uh huh senior surgical residents. And he had no place for me unfortunately. So that's when I went to Cleveland clinic. And uh tell us about those early early times. Don't worry is what made me go to Cleveland clinic. But I never worked with Cavallaro. But the man the right side is a head and neck surgeon. And he and I became very good friends with Ur believe or not. 45 years later we should talk to each other as you see each other from time to time. The federal surgeon, he married George Primrose, a daughter. You probably know who George prior is. Cry from the club, cry from the mastectomy tarot deck to me. So I started at Cleveland Clinic in July 1 to work with George Cryo and caldwell Association, spent two months in his service. Was the best experience in my life because I knew how to operate already. And as he pretty much as he was, the way we called him pretty much left me out. Do what any case I'm going to do was quite a great experience. You know, it's a different different era. We were a little bit like that at the Brigham back there was a little bit different era, wasn't it? You were able to uh yeah, you were able to uh, do things to your ability much. There was a lot less sort of oversight and reporting like there is now. Absolutely they do pretty much whatever we Uh to be quite honest uh I think I finished my general surgery training in 40 years with over 2000 cases. I mean when I applied to American board you have to give the list of cases. I mean mind you we will work every second day For the whole seven year training was on call 36 hours or off 12 hours in those 36 hours about half the time in the outbreak room. It's very different than they are more. I know if you're not like covering emergency more you're right I was gonna say uh yeah the hardest thing you told me about doing those 500 cases at at a in Toronto your first few years out was that you had to take care of them too. And they weren't exactly as healthy as they are. They were healthier patients, but they were a lot sicker because we didn't know as much about protecting the heart and things like. Absolutely, absolutely. It was a lot of work. Well, something good happened during these uh 70 or 36 hours in the hospital. Everything low cardiac output was a routine those days you have to adversely. We talked to me and they decide that And you learn about protecting our cardio and bleeding. You know, it's interesting when I came here, we still had a room upstairs in the icu that was that was basically the reactor bleed room. It was so prevalent that people thought they really needed these sorts of and then we also had a balloon tech that's only 20 years ago. So, but Dave, I think bleeding has not been resolved yet. It bothers me. I put a patient a pump for 45 minutes to repair my to evolve and very seldom more than 45 minutes and the fiber in ocean drops, platelet drops. Why I mean, makes no sense. Yeah. I don't know if that's plastic or I don't know whether it's artificial blood with 40 surface, but we certainly have the means to dissect bleeding out like we did before before we had no sort of operate. You know, we just sort of guessing to throw the bag at everybody. There wasn't really an opportunity to sort of dissect it like it was now. But one good thing happened during all that time. Tyrone, which was you met Jackie while you're in that hospital, the best thing happened to me, they're seeing from Cleveland clinic as well as a I'm very happy days. I met these young women and I I thought that she was it and she has been In the past 45 45. More than 45 72 means what? 28 years? Yeah. You you chose very well to Iran. We've we've really in Mariana. I just adore her and we're so happy that we got to know her as well. And I feel like she's she's done very well for you. And this is a this is a great picture. It looks like you're she's not sure. I don't think your daughter is sure yet who you are because you were living in the hospital with some of, most of the people in this call had been there. Well, we haven't designed this back to our to be able to carry her with me. And to be quite honest on my study, she was against my chest wrapping my neck. And so these are custom made. Uh ouch there. I carry my daughter ruth. I really liked that picture. And here's a picture of the Of the three girls later. three daughters. Yes. Yeah. So you guys have a very good, I've done have done well and just before we move on, tell us about your three daughters. Tirane. Well did they are The eldest 1's is in business. She travels extensively. The second one from the left Caroline. She's a nurse and she does research with me now and my colleagues one on the right side. Uh she's a computer expert and she does coding in the it's just does very well. Ah She has two little boys that that become the eurozone death of my life. There they are. A wonderful, I mean leo and over there fabric to kids. How old is Owen? Oh and there's three and louis five. Okay, that's great. Yeah, I know that. I've heard many, I've heard from Jackie many times. That's become a very important part of your life. As green as they come. Not now because of the pandemic, the oldest will literally live with us. They pretty much every weekend, step in your house with he has his own bedroom and Darren remind me what he what his nickname for you was. No, no there's not a nickname. Use our, he calls Jackie granny and calls me Volvo who is the morning during grandfather in Portuguese? Yeah, I remember, I couldn't remember the phrase just data because five years later its value very outspoken when he meets her friends and meet my Volvo Volvo. His grandfather. Well I really, I think that was fun. I guess we'll just, we'll start moving into some of the other things to tell us a little bit about this. Uh My first mentor in Canada for Bigelow, I uh I was his resident in a and july and august and he are here in Canada. The thing is everybody has a college. So he took up his college the weekend and he taught me to fly fish, which is quite a fascinating game and I enjoyed it, so enjoy and once a year is one of my best time is flying fly fishing for salmon. But dr Bigelow is the one that taught me the importance of uh academia in your life. And uh it is a master clinic investigator. He inspired me to our develop a database where every single patient I update on. I kept tab on I those days money didn't seem to be a problem. And was hiring an imprisoned number of nurses to follow my patients. And that's how you learn to follow up and care of documentation what you didn't operate room to know what works, what doesn't work. Of course, it's not all glorious along the way. You make many mistakes. I'm working on paper. The president how on reconstruction, the basic heart after radiotherapy treatment in the Mostly for Hodgkin's what you have to do 30, 40 years later. And when car makers came operating 10 12 paste record matrix, every single one fell apart. But that's, you know, it is painful, but that's how we learn. I'd say there were more victories than defeat on your absolutely resume, my friend. But we don't publish enough. We don't publish enough on a on a mistakes we make. We published mostly victories that works. But for the residents and trainees and young surgeons, there are many, many failures along the way. So tie, right? I've heard I've heard this story, but I want you to tell the story that involves uh Goldman because it's fun for the residents that haven't heard it. Any dogma is one of the attendings. When I first came here. Bernie is retired now. So july 1st that comes in. I've never been to Canada before in my life. I come in. I got the hospital 8:00 July vs a holiday in Canada. This Canada Day just like four July the United States. So the resident was, there is a logical Lorraine rubies and I had an intern, a guy from Quebec. Uh, and she says, you know, I'm gonna take the month of july off. I'm a senior to you. I worked very hard the whole year. I'm gonna take the whole month off. You don't call for the next 30 days. I said what? Yes your uncle for 30 days. Yes. So often. What? That's what can I do. The new boy on the block. So three or four in the afternoon and making rounds trying to learn about the patients. I got a phone call from the emergency room our speech and they said until the patient's name for privacy. But a well known Canadian doctor. Yeah quite famous actually. 82 year old he's in shock. Has a ruptured abdominal aortic aneurysm. So I go to the emergency room and took a look at the guy freshly 60. I put in a stretch of the intern in our world. You got to the operating room, arrive in the operating room. The nurse starts screaming at me what the hell you think you're doing? I said this guy's in shark unless you cannot pregnant right away he's gonna die. So I called Bernie Goldman this urgent call and I said Bernie, we have a doctor. Gordon? Of course we have a patient here who has ruptured abdominal aortic aneurysm. Uh He said well go ahead and start and I'll be there as soon as I can. So he said go ahead and start to the internet. Open the guy's belly. Time to buy the but he died for him, revived. The old man replaces the aorta. And it is he survived. We started closing the belly burning Goldman walk in Bernie Gold market and said what's going on? Did you die? I said no we we we replaced the you have gone to war with the tubes. And he said what do you mean you replace it? Yeah what's done? You told me to go ahead. I did. It wasn't shark. Okay. The other story that I've heard about you is the time that he ruptured liver doing. I forget what operation you were doing. And they called the hepatic surgeons. And by the time they got there, you prepared that you've got a liver resection and repaired that as well. But that's the beauty to have been a general search before they become a heart surgeon. We don't have this anymore. Unfortunately. No general surgery changed you and I drained the days. We've got to lock the fuck barely a chance before he became a heart surgeon. Now, it's all endoscopic. Yeah. I always chuckle that uh back in the day we were doing five years of general surgery and 11 months of adult cardiac surgery to be an adult cardiac surgeon. You're turning an adult cardiac in five years to in general surgery. So, I don't know. It was it was clearly a different way to do it now. So you mentioned that you were the young surgeon that was put over at Toronto Western. That's that's when I started practicing independently. Yes, I know no one to help. I was it? I mean no consultants don't bother to give you a hand if you got in trouble. Very stressful. You must have had a good fallback plan though. I had called fred Loop fred Loop was the chief of Liberal clinic. He had tried to recruit me. So I call him back. I said I think I have to go back to Cleveland. So I talked about the opportunity and he told me a very important lesson. He said every time there is chaos that are opportunities. If the hospital closed because of put outcome, you're not going to do badly. You're gonna do very well with that. Try if you fail come to Cleveland clinic when you cheat you all over again. Okay, never left. And then those are the happiest years in my life. Honestly, 10 years of Western I worked like I'll never work in my life even more. Then when I was arrested My record was 14 Operation 24 hours once nonstop the other night was fun. It was great fun. And then and then you went on to this center combined with Toronto General. Is that what happened? No, there was a separate hospital. Now they emerged from the Universe health network. So they just became really transplant and cardiac center only the front of the hospital. Western. They do orthopedics and neurosurgery mostly. And cancer. Is that a princess Margaret? When the hospital across the street from Toronto General Hospital. Yeah. And this, this really was the, the uh, I would say the um one of the many pinnacles locally for you. Right. I mean, you really were the driving force behind the establishment of the, of the month cardiac. So, peter munk is uh Being was benefactor from since 1989. And he uh really helped a lot. Uh nobody does anything alone, there's a group of people but he was the force behind all this and dr ella Hudson. Uh it was then the ceo of the hospital and he was bold enough to a borough mm $300 million dollars Some 20 years ago to put a building only for transplantation at the Kayak surgery. Well, that's it. We are by the way, the largest transplant center in the world today. I think you probably heard from shop to shop today take away enormous amount of transplants. Yeah. And shop has really led the way in terms of organ preservation. So there's been a lot of absolute contributions there from your team. Well, I think the uh, you know, the, the journey in Canada of course led to a couple of other things I want to talk to you about before we get to some of your papers. Um, and that is, I just want you to give me an estimate how many, how many invited lectures you think you've given around the world? No, no, 10 20 a year. So Times 40 years. 500. 400 No. Yeah. I was going to say that. I don't think there's ever been a m I don't think there's ever been a surgeon certainly in our, our career that that has been, has been, I think more, um, a more, you know, sort of constant figure on the international scene, tire and that's big and small. Right? Because you've done a lot of trips to smaller places. Not just all the big meetings. No, but remember I travel a lot to operate as well to show people how to do operations. Oh, I know, you know, I had the honor of being with you and Shanghai a few years ago. This is that picture when whenever there and I did some cases over there. So I was gonna ask you that because I know you've spent a lot of time also visiting your former trainees and operating with them in their own communities around the world. Absolutely. We, we, we helped many of them to establish their programs when they finish their training and it was a great opportunity. Uh, and if you take a look at some of them, they became global authorities in the areas that they learned here and took back home. But which one when they asked me, I was there for a week or 10 days operating with them day and night. So what they request every time is to collect 10 15 patients so we can do in a week all those cases. And uh, so what's fun? And uh, and Tirana, I have to ask you this one question about, I enjoyed reading a summary. That vivid route that row there row had written about you um, a few years ago in J. T. C. B. S. And he said that probably the most common phrase that that I remember that the residents that train with Tyronne remember is you would say it is my fault but it is your fault. I don't know that. He said, I'll just tell my residence when then he goes on to say it is my fault. I thought you could do this operation, it is my fault. I thought you could tie those nuts that deep in the chest. It's really my fault that I thought you would be more prepared for this for this to take care of this patient. And they said that it is my fault is probably the most common phrase they ever heard you say, you know we we haven't had the multiple and raise your dance in Toronto and then row is probably the best one of the best speaker every time is a able to make jokes from something very serious. Like it's a great read. And it's one of the ones on my reading list for the fellas that having got ready for this with the mice that were going to. Everyone has to read that because it is quite a it's quite interesting. But it's all right. Tell me one other thing before we move on to these papers, that's about your about the nurse, the assistant that you've worked with for so many years in Toronto. Well before physician's assistant was popular I was very short and residents because remember I used to have one senior resident when in turn and one junior resident when I went to Western. What was the 300 cases a year to case a day, that was okay. But when I started doing five or 600 cases myself, you cannot do alone. And the where have you put to help? So I I who trained Joann boss who used to run my lab. She's done the I used to work in ship in those days and pigs and she used to help in the lab and showed a very good nurse in the operating room, subscribe. There's but she could put up a ship on bypass to replace their valves. Work some bob operation ship and I'll tell you if you can open a ship chest to put on my past without breaking that record. You are a good surgeon. Much more difficult than humans. So I I brought you in boston the operating room and then I hear to later we train somebody else florida. Uh So we had to nurse is helping me in the operating room take those days have the operation or bypass surgery so they could take a beautiful vein. Why I was working at chest. Take the memories and from the beginning I guess fred loop influence From the 80s I was doing Balala memory are most of my patients. So it takes a while to take to memories. And the Third and 4th country came from the leg. We have no residents. So you work with the nurse gigantic the vein I was taking the memories. Once we finished, we all come to the chest and down to the bypass and finish the operation. Joann boss has been running for 35 years. She still help me operate through now. All right. It's a major difference. You have a stable team in the outbreak room particularly for very busy When I go 3, 4 days a day. I completely concur with you. Yeah. Uh my my own story tyrannis is that when I came here, I think you know I was sort of the new new person coming in and there was a lot of grumbling about boston and new york and all that. One of the ways that I think one of the ways that we're going to test me was to give me the youngest nurse on the on the staff, someone that had just been recruited because you know that would be another way to sort of test me. And that happened to turn into mary joy, who you've been with. And yeah, and she she's been the same kind of person for me. So I understand these things. I I there are certain things about walking in rooms and seeing familiar faces that uh give you the confidence to really, I think get the results. You can get last two more questions to Iran about this phase and that's about your travels. To give me a couple of places that you've really remember visiting, that you've really enjoyed. Well, this is Thailand's Bangkok. I I broke my arm and uh for six weeks I could not operate after a week, I started going crazy at home. So I contact a bunch of former trainees like held up, I'm to rid the world lecturing and talking could not break anymore. If you take a look at my left hand and it's like gas him on at the end. And in Thailand, Bangkok was interesting because the queen had died when I was there, which was you met him job in the heart, you took us, you know, went for june It described the club in Bangkok once. There was a great experience of this picture here, but I I don't know, Dave I I have had some quite spectacular experiences for fun, perhaps has always been italy. I mean, there's no place like in Italy to work all day and eat all night and the engine good wine or gargle with. Yeah, I had only tableaus week in bordeaux was with Francis, invite me there to show you how to do your work involves sparing involved repair some 20 years ago and exposing to all the great wines of bordeaux. That's quite a treat. I think it's really in Thailand but they're going to be near the top of my list. I think so too. Will we agree with you? And um I just say this picture with uh I found this along the way and I just love this picture. I've told so many stories about dr Cohen and my team, Here you are, having a dinner with him. Yes. Uh Larry invited me to join his club, was a traveling club. They were up 10 years my senior, but jake and I loved it. We we uh was the group of that was Larry fred loop several miles from the south And there's like 10, 12 surgeons for my club and once a year they will travel somewhere to watch you operate and then there'll be a social part as well. Uh we are thinking nice ski resort somewhere, I don't remember where, but as you can see the, the amount of booze is more, anything else. Yeah, but it was fun your generation, I think even more than ours really uh made trips like that and really kept up. There really was a small group that there really were pretty much everywhere, different parts of the world Now. I I remember all of the stories back then. I was home holding the fort now while you guys were out there doing all those trips at any rate Tyrone, I want to move on to a few, a few papers with you districts for a little bit about your some of these contributions that led to all of the things we've been talking about at the beginning And I noticed one of your very first papers was actually a technical paper. So I guess it's so I was gonna say it always sort of fits that everything is technical. Of course. I'll also talk about that in 1976. I think it was maybe it shows you how the field is sort of grown. I'm not sure we can get a paper in on brain to search. You're not city more, but here you are. It's a fun fun sort of beginning. And you were also doing vascular surgery for the first five years. Yes. You used to do a hard, brilliant day vestment at night. What's fun to do? And I and then and then this is the one of the very first papers that you were an author on involving valve surgery, which I guess at that, you know, of course, at the time it shows you sort of where the field was. It was really at the very beginning, wasn't it? Because absolutely, this was, you know, just a paper talking about how the how the cuff on a prosthesis can help you in annular calcification on a micro prosthesis turned upside down. So it sure, it shows you the very early days of what surgeons were struggling with. But this sort of portrayed are always a hint of what was to come and um, but everything that we are here to cut the heart of the if you don't live in a cash anymore, today doesn't matter if you myself jobs classified to take everything out and the pension, What was going to say that in the 80s, 80s were afraid to do that? I think the most uh, impressive thing I think of of your Career as I think about your appears that you've, you know, sort of like been around over this journey the last 30 or 40 years is that I don't know anyone that has pioneered. you know, different fields and and so I wanted to break up these paper is not in chronological order that by um uh inches in the heart. So I wanted to start talking a little bit about Aortic Surgery 1st. And you obviously we're getting exposed early on um two aortic root surgery. And and you of course then had experience with stent lys prosthesis and this is the toronto about. Tell us again about. And then obviously at the same time you were also doing some ross operations. You were interested in the ross procedures. So you were doing these, you know, some of these aortic reconstructions in the ross procedure and that really is that that that was the foundation for the David procedure. These are really experiences. Look at the title of this uh address when I was invited to be the the honored guest speaker of european Cardiothoracic Association. Uh huh. I spoke about the importance of anatomy, physiology, and heart surgery and that's where the foundations that you know you can take a pulmonary valve. There has a caliber of 22 23 millimeter Transit 20 A watch of 30 35 and expect the pulmonary to work normally. Mm. So what was the first wanting to do? The notion that if you transfer a permanent evolved from the preliminary to the arch position. The preliminary has to work with its own that functionality in our position. So we have to fix their watch position to the anatomy of the pulmonary. And this all gave them the lessons learned from hama graphs first and then a stent lys person involved. They told us the importance of functionality. Yeah, I think that and it's interesting when you go back and look at your papers then you really were sort of building experiences to get to here. Absolutely. It's a stepwise logical way to a improve opponent techniques and Tyrone. It must take some courage to do these sorts of first and man operations. Well known. Dave I, I watch you develop micro valve for the best was 15, 20 years now You don't operate today. Do you operate 20 years ago? You introduce your own things because it developed certain level of understanding and comfort on what you're doing and you move to the next level. Here is the same way. It was a stepwise logical progression was not like a comeback, an operation one day work in the operating room and did that. So, uh, that's why I don't think it takes much Parisian. What it took, however, is the 36 hours on 12 hours off. It's very difficult to develop things like this. If you work two hours a day only for three hours a day, Uh it worked 14 hours a day. You might be exposed to much more and have more ideas. And also and also reiterates one of the points you made in your presidential address about, about repetition. In about again, the sort of technical aspects that that build on themselves. And that's why if you, if you're really a student of cardiac surgery, you're always learning and you're learning, watching and doing, you're just, you know, the anatomy, you know, you really have to get the anatomy to be intuitive to really be a good heart surgery. I think you've always made that point. Absolutely. And your your work here really shows that. Um and then of course there also was the valve sparing world that you are also helping to lead and and and started to work on leaflets, bicuspid valve. I mean the whole the whole route became a major focus and continued to be and continues to do it even today. So you really have, you know, I think more than anyone pioneered that, that field and continue to do it. We'll have been fun. So bombs pairing is likely one of the best uh pressure performing all We now have 32 years experience with it. It is amazing if you continue following our patients, what you see, it is gross. Have been normal to implant a normal charged, evolve into a rigid conduit like a dark room graft But works very well, surprising for 15 2030 years. But many of them now I began to fail at 25:30 years and guess what they're classifying I think is too stressful for our torch evolved to be into a rich counterweight and out Mark Moon, invite them to give a talk at the H. S. Yeah now he may and I'm just collecting the data for their presentation that more you follow your patients locally, follow them more, You learn about what you have done, any outbreak rule, what are you going to operate through? Has measured long term implications to the patient. You certainly have shown that better than anyone. And well I was going to discuss that with you and you're my troll experience. This issue of follow up and this is really where I you know I sort of remembered the you know the very first sort of memories I have Tyrone of you at these meetings and and in some of these discussions was around this idea of Kordell Sparing and preserving, preserving the Corday and replacements. How they, how did you start getting interested in that as well? Because I, when I started practicing 1979, we uh, I was repairing my travel was already. And remembering those days low cardiac output syndrome was a major problem falling heart surgery. As a matter of fact, my partner's published tens of papers on low cardiac output output following heart surgery. But you know, clinic observational gay, if I replace, I might evolve was one type of patient as you, if I repair the mitral valve, very different patients. Well, what's the difference between a replacement and repair is that you maintain the native valve? In other words, mitral valve repair was not followed. Buy low cardiac output syndrome might have our replacement wars. The difference was the severance. And that's one of our first paper on showing that if you preserve most of the attachments, you preserve the medical function. Not only a Q. three but the long term to and and Tyronne. Let me let me just ask you about that, does it right now. I just want your understanding your latest sort of theory when you do a mitral valve repair doesn't matter. I mean mitral valve replacement, it doesn't matter how many chords are preserved or that a papillary muscle remains attached to the annual US. In other words what you're sort of standard approach. I don't think they got went a little crazy tyra. And then everyone was like now there were all these technical papers coming out about how I save every single chord in the heart and re implant every bit of the anti relief. But here you know it got to be a little bit crazy because in my world of thinking when you cut out the post, if you can maintain the poster leaflet, especially if you can maintain fan cords. Both papillary muscles remain connected to the to the to the to the annual is. But what's your sort of current? I agree. He maintained the whole possibility from commercial to commercial remember prosthetic valves are reasons. So whatever angry mechanism you have between the intra lateral and it costs a lot of tri grams is gonna be the same on the prosciutto part. So as long to preserve the positional leaflet. We are preserving attachments. This is done by the prosthetic about Yeah. The other lesson I learned from from you and that weather reasons I guess I was so interesting. This is because I had a couple of patients that had uh huh. They ventricular rupture in the days when we were cutting everything out because that was you know still there and there are some patients that you had to and it really is. I think it's not only protective in the long term for the ventricle but it probably lessens the risk of mid matricular rupture in patients to have some attachments. That's right. I think I think it's really really it was an interesting, you know, again, another sort of behind the scenes seminal contribution in terms of mitral valve repair. I noticed you were early. You you you you figured it out much quicker than most of us that there might be some. Ah So some advantages to not having completely closed rigid rings in the mitral position. That's papers were the very first one. Uh huh. But then again, this is early. It is a three months of the operation. We brought a patient back into an exercise test on them with a nuclear angiography. Now that it was an echo of course, for the same thing, likely a year later. Doesn't matter anymore. The ventricle must have adapt achieve mechanism to overcome a rigid what a flexible uh in the low plasticity ring. And I do think that most of these rings, the flexibility part is fleeting versus having an open component. Absolutely. A flexible ring here later. This as real as it comes. You take out a cosgrove five or six years later, it's pretty tough to do. Absolutely. Of course, you don't stop. You really are a bit of a hog in this, in these, in this pioneering space. I mean, I don't know what it was like to be a colleague. Like every year you go to the 80 S and you have a new idea. I mean, it really is. You know what I mean? Like, oh, I know what you're talking about spirit. What you know about this year. Oh, he's the first person to start pioneering micro valve repair with gortex corny I mean like I don't know how you survived all this, but as I step more as you keep learning, keep you know, learning is a dynamic process, it doesn't end. So because now Tyrone you really were also you know really the first, I would say major adapter and pioneer in terms of the accord. People forget this now. We sort of talk about the loop and people think it all started with the loops, but it started much earlier than that. Didn't Absolutely 1985 actually, yeah, so you enjoy that really started to re suspend leaflets, it all fits that reconstructive brain. But this this was another really important contribution I think it would he He allow microbe are prepared to be close to 100 of change. 25 honest, if you're patient enough to off to spend the time now that room creating your corridor and I I truly believe that more court of the benefit the patient. Yeah more stable there in tyre in you also again don't stop now you start getting into more complex mitral valve repair and you are the person that taught a lot of us the whole idea of of of augmentation and you and Carpentier were the only two surgeons I know that really had the courage to do right annular reconstruction at the beginning. I don't think there was I'm all of the discussions about this really involved you and Carpentier early on. Yeah we was Elaine used a different technique, he tried to take the eight room to cover the ventricle, I was afraid of that so I covered the area with autologous or later on movin pericardium and I tried core matrix as well, which was a mistake but moving pretty cardio works very well. Yeah. And I think you know there are times where sliding atrial plasticky really works well and there are times where you absolutely should just go to the patch. And do you ever fill the patch up from below? You know, one of the lessons I learned was filling the patch up with with some glue and and and and gel foam or you know, some sort of material on the inside surges cell just to give it a little more jump when you put your future story. Do you ever do that or you just put them straight through the patch straight to rather go deeper in the event recorders, healthy muscle. Don't try to put any glue or anything. And do you run that? Do you run that patch? I run with a large three Oprah lean from normal analysts all the way to Dakar Diem until normal handles about what is inside. Eventually if the typical patients, if it's a mitral stenosis patient and then you princess if you got a mitral stenosis patient you've got a small ventricle. So rio needles hard to maneuver inside the metrical, isn't it? It is but not impossible. You full thickness or partial think at least 2 30 thickness. You don't go to the Picardo surface. That's the coronary arteries run. Yeah we get at least half an hour cardio hold those close as you can now tyra. And the other thing that of course you know it goes on because the other thing that you were starting to buy and this is where the follow up is so important. And one of the lessons that I one of the many lessons I learned from you was the issue of fault because there were very few people that were really presenting longer term data. And you were one of the first to really I think and the mitral space really talk about long term data. But this particular paper it really helped influence guidelines for years and that was this recognition that when you dissect out the survival it really did depend on functional class. Yes it was very dependent. But remember they are older as well, they're five years old. So but you know people forget that early on microsurgery was such a high risk procedure that cardiologist would sit on them as long as they look. They didn't want to send them because the patients had a four or five mortality one in 20 people. Yeah, so and that was gets back to the cordial sparing and it gets back to you know but they all were sort of coming together, mitral valve surgery was getting safer And then it was time to start talking about what are the other things you can influence. And one of them was not waiting till patients were so sick. This paper really said there were only two papers that really moved the guidelines toward toward earlier surgery and this was one of them. So that this was a really important paper in terms of guideline evolution for mitral valve surgery. In this paper. Special uh impact on our program. But tell us a little bit about this paper this paper is going to have to be rewritten because I think the best 10 15 years we change that. You got that. Yeah, of course I I do not. I don't believe that my pace, our practices and our energy from the P. Two A. two or both. Little prolapse is the only one. There are a bit complicated that I believe is those who bet advanced make some of the generation, the metro bob is huge. I mean uh four or five millimeters signified analysts, those if you leave those patients outside, uh this graph now will be a single single line. There's no originally those patients and those patients fortunately are usually not the youngest ones. But I was gonna say Tehran, is that I still, I think by leaflet and poster enough to be the same because you've got access to agree into your leaflet. I still, you know, one of the things that we do with the anti relief right now as we tend to downsize the ring if its primary and relief. What we're trying to really force co optation because trying to take tension off the into relief. But I do think one of the mistakes that I've made early on was with if I was sort of between sizes I go up as opposed to down like I do with the post relief and post relief when I go up. But interleague but now if we're not sure we go down we try and make it a little bit tighter to try and improve the addition to take tension off and also belts and suspenders. But I was gonna say the reason this papers went on and you just joined me um And I came back from the 80 s that year and I said and I like many people look at that data and I said and I looked at that 10 year plot and I said gosh look you know there are those are a lot of failures and what can we do differently and better. And that that's where the home front we started on me we were in I forget what room now we were in one of the rooms and and and and and he said and he got an ink marking, we started marking the valve then to try and understand depth of co optation. So this really this paper completely changed our brand very early on on depth of co optation on the length of co optation depths. That's one of when I always remember. And it also again highlights the incredible importance of following patients and reporting longer term outcomes and particularly if you're going to do something other people don't do. For example if you're going to go after and trying to repair everybody, understand should you have repaired everybody and you we learned that lesson from you. I think one of your most important contributions that aren't talked enough about it is the lesson of follow up. Yes, Yes, but Dave, let me tell you go back to previous lines. Yeah, isolated until leaflet with the entirely normal posterior. I don't think it's the same patient. Oh, the patient, This patient usually more than half of them and very large over dominant and your leaflet and the diminutive promotional leaflet. I agree those cases. I think you're absolutely right. Any prolapse and reduce the diameter maximally because because of the Bush era leaflet that's too small a margin. But well, we got to write that down together. We're gonna make a note about that because I don't think that. I think that concept has to be developed and I don't think that the average person changes their angioplasty strategy or recognizes what you just said that if you've got a true large anti relief, what prolapse most of the time you have a diminutive poster leaflet. It's not the normal height. Yes, yes. I think again, it's just it shows you how papers like this. You don't think you're not gonna tell you. This was probably one of the three or four papers that changed everything for us here, which is why I showed it. And then just getting back to the point of reporting really long term outcomes with relatively new procedures which you've done. I can't leave without this one because this is my favorite things. This is by the way where you and I really became very close friends back when this whole discussion was going on about track us because we were really go out and have some good times. We will give me the response for this fun here. But I love this. The eric toronto Rochester in Cleveland different from London, Monica, Leiden, gig velocity for all of you that weren't in cardiac surgery yet. We were having a very big discussion about functional try customer irritation at the time of microsurgery and whether we should do that and I don't have time because this could have been the entire discussion and I could, I think people enjoy it when we do that. But um I just want to say that we I think to I think this discussion really was useful for um for the field, right on one more paper which you continue to teach is this is this is the paper if you want to read about long term follow up with mitral valve repair um that you need to read about it on. And I read an editorial about this, this paper again sort of changed the paradigm for the future. And what I mean by that tyrant is that, you know, when you looked out the longest follow up patients were, had really actually very stable results perspective and I always make the point particularly considering when these patients were operated on for a much better micro appears that Yes. Yeah. But I think this paper showed that patients that were not done, patients do develop atrial fibrillation. Um They do they if they do they can develop recurrent trikus are new or or exacerbate, try custard eradication. Then we talk about the atrial appendage and I think that this paper really highlighted to me some opportunities for the long term which was to treat all of the diseases associate potentially associated with with mitral valve disease, not just focus on eliminating them are but I think again you're sort of work just you know, it continues to lead the lead the way towards new frontiers and new ideas for us to pursue. And this is another example of it. It's a really, really important paper I think. And you can tell it's important by the journal that is published in. Um, and then we're just finished up. Of course, you know, again, any of these topics could have been the entire tire discussion Tyrone, but you also were the person that taught a lot of us how to take care of ventricular aneurysms, particularly a posterior part. This will transform the outcome of his patients. I, I think it was, I mean luckily don't see this very often anymore, but mortality was very, very high and by not doing it for tech. To me the way our friend Bill Daggett suggesting the uh, in his seventies by student in fart, opening in part put a pitch inside the heart, enclosed in part Making much better you transform a patient in cardiogenic shock to one who has allowed guarding function. And uh I think we are able to reduce mortality 10 20% in stations. And I remember these days very well at the Brigham because we were doing and for protecting me until you really it's shown these techniques and this completely changed the the dynamic and also just made the operation more more understandable. Exactly renewable particularly in post your infarction. So this was another yeah really big contribution. And of course the whole idea of uh skeleton reconstruction was also one that you find me. I think your status operation now too often. Unfortunately for patients learn patients who have the Hodgkin's treated successfully 30 40 years ago. And now they come with extensive classification of the base the heart. That that very humbling. Yeah. I uh and I don't know if radical operations the way we propose is the answer. But I don't know the answer to those patients. We are exam the results now. Yeah. It's a it's obvious it's an operation that we've been fortunate that we can offer because paul and Robyn specifically. It's sort of pursued this. But I think it's a very select group of patients. But again just highlights again the sort of for all the frontiers you pushed in your career. Yeah. I wanted to put this up again to remind everyone, especially the residents that I think this is really um yeah, mandatory a mandatory paper. If you really want to understand Dr David, this is his presidential Address and it's it's just again, we could have talked about it for 15 or 20 minutes, but I want to read one um phrase that really summarizes. I think one of the things that you know I really learned from Tyrone and that we all have and rep there is evidence and that repetition leads to perfection and is one of the reasons high volume surgeons have better outcomes than low volume surgeons. And this is a message Tyrone. We continue to present that we've got a super specialized in and work as a team and do things together and here you are. This is 2000 and five. Again, 15 years ago, you never have an original idea that this was something that you were really, you know, sort of proposing another message, I'll give the residents which I've told you before. However, there must be an innate component of dexterity that explains the variability of technical skills and outcomes even among high volume surgeons. And so volume is not enough. You still have to practice practice practice and build up your dexterity. The other thing I read is the next paragraph, caring is crucial and the delivery of patient care, caring involves a genuine interest in the patient's well being, as well as a conscious effort to cause no harm, honesty, openness and compassion enrich the quality of patient care, ignorance, indifference, and carelessness do the opposite. Attempting to operate without adequate knowledge is a display of poor work ethic and lack of caring. I believe the caring is the most important component of work ethics and the practice of medicine. And I think that really really summarizes what what Yeah, your career is is all about. I've been so blessed by your mentorship and especially your your friendship. I will tell everyone that that my greatest friend during my my two greatest friends during my presence of the 80 s were Taira and David and David Jones. And I wouldn't have gotten through that without both of you. And it's just such an honor to have you with us today, Tyrone and I really appreciate you letting us walk through some of some of these advancements in your career. It's it's really been a personal honor for me, and I'm sure everyone's really enjoyed it. Thank you very much. Dave was honored to be with you.