Inspired by a passion for nature, Jolanda Kluin began her career in medicine in Africa, before returning to her home country, The Netherlands, to specialise in cardiac surgery. Today she is the head of the department of cardiothoracic surgery at Erasmus Medical Centre in Rotterdam and chairs the European Association of Cardio-Thoracic Surgery (EACTS) Women in Cardiothoracic Surgery Committee. She tells Cardiovascular News of her work and life outside of medicine.
Why did you initially choose to become a doctor, and what was it that made you decide to specialise in cardiothoracic surgery?
As far back as I can remember I wanted to be a doctor, though I do not come from a family of doctors. When I was beginning my career, I had a particular interest in working in Africa, which was also something that nobody in my family had ever done. Originally, I wanted to specialise in tropical medicine, which led me to Ivory Coast, where I stayed for seven months. After spending some time with other specialists in tropical medicine, I realised that if you choose that specialism you are away from home for the rest of your life, unless you want to undertake a teaching role.
I then considered paediatric medicine, and upon gaining some experience in surgery, I knew immediately that this was something I wanted to do. I did my PhD in general surgery, but by that time there was already something appealing about cardiac surgery. That is when I began my training as a resident in the cardiac surgery department in Rotterdam.
Who were the biggest influences on your early career and what did you learn from them?
The entire group who trained me in The Netherlands, especially the head of the department Ad Bogers, a fantastic paediatric surgeon, and also A Pieter Kappetein, who worked as a cardiac surgeon in Rotterdam and is now at Medtronic.
From a technical point of view, Bogers was a fantastic surgeon, who I learned a lot from. Kappetein taught me a lot about the specialty, including the importance of taking other people with you, building a real team, and also making the young ones enthusiastic for the specialty. It can be difficult as a young surgeon to get involved in societies like EACTS without having someone to introduce you. That I learned from him, the importance of having a mentor.
You are known for your part in the development of the soft robotic heart, HybridHeart, for the treatment of patients with end-stage heart failure. How did this idea come about, and what is the latest status of the project?
Around seven years ago, I was reading the weekend science section in the newspaper, where there was an interview with a Dutch researcher who had just returned to The Netherlands from Boston, USA, where he had developed a soft robotic octopus. I was struck by the picture, and I thought that if a soft robot could move like an octopus, it could also move like a heart.
We began working together and wrote a proposal for European Union (EU) funding, from which we got a little over €3 million to start the research five years ago. We recently got €11 million from the Dutch government to proceed with the project.
We are currently writing what we have learned and hoped to have this published in Nature, but this is a once in a lifetime chance for me. We just did an animal experiment in which the heart was implanted. We were able to completely wean the animal from cardiopulmonary bypass, and it lived with this heart for one hour.
There are more and more people living with heart failure now, and the therapies we have—left ventricular assist devices (LVADs)—are life-saving but result in a rather low quality of life. Heart transplant is the gold standard, but there are not enough donors. For some specific diseases, such as pulmonary hypertension patients or congenital heart disease patients in which there are no options, hopefully this heart can be an option.
What are your other current research priorities?
I have worked for a long time on tissue engineered heart valves, or synthetic, pliable heart valve development. I am also interested in using large databases to improve results, in areas such as aortic valve repair surgery, mitral valve repair surgery and aortic surgery. Collaborating with other institutes is the way to go. Single-centre retrospective studies do not add much to our knowledge, you really have to have a combined effort.
What are the key unanswered questions in cardiac surgery that you would like to see prioritised in future research projects?
To me it is fascinating that we can put a man on the moon, but we do not have a valve that lasts forever without any anticoagulation, for example, or that we are not able to make a total artificial heart with little complication. If you look back over our specialty, though, it is only 50 years old, and you see what we have achieved since the start, it is incredible.
What has been the technological advance that has had the biggest impact during your career?
Although it is not really cardiac surgery, I think the answer is transcatheter aortic valve implantation (TAVI). There are surgeons that are feeling bad about TAVI, but I would have loved to have invented it! It is really important, we can help a lot of people that were not healthy enough for surgery, so that is a fantastic invention and it shows we should really collaborate with our cardiology colleagues. However, I also feel that this is very industry driven, and that is difficult.
In cardiac surgery, it is the arrival of minimally-invasive procedures. Doing mitral valve repair without sternotomy, robotic-assisted coronary artery bypass grafting (CABG) and those kinds of things. Though the incision is small for mitral valve repair, you still have to put the patient on bypass and arrest the heart. That is the big difference between TAVI and cardiac surgery. On the other hand, also with sternotomy, I think most people can cope with that very easily. In the end, if you get a perfect repair with a sternotomy, it is not a big deal.
What does the heart team look like in your practice?
Interestingly, in The Netherlands we have always had a heart team. When it became a big topic, I thought it looked very familiar! Then, I realised that in other countries it was not like that at all, patients were referred to the surgeon, others were referred to a cardiologist. In the Netherlands we discuss every patient together with cardiologists.
To have a successful team, you should not be afraid to lose out on patients. That is not what our job is as physicians. You should aim for the best solution for your patient, and not the best solution for your practice. Never look at it from that point of view. For me it would be interesting to see more patient involvement in the heart team. A lot of patients want to have a conversation with you, a lot of them want you to make the decision, but I can imagine that younger people are keen to be a part of the discussion.
Has there been any recent research that has had a major impact on your practice?
Research that shows that building a team where you have a sense of belonging is connected to the quality of your work has been important. It is not only about new technical issues or learning that one technique is better than another, but when you have a really good team where everyone feels that sense of belonging, then you have higher efficiency, but more importantly higher quality. I put a lot of effort into team building and people management, so that everyone goes to the hospital with a smile and delivers the best that he or she can.
How did the EACTS Women in Cardio-Thoracic Surgery Committee come about, and what are the committee’s key aims?
It is around three years since EACTS first installed this committee, of which I became chair. I think it was really time, as there were already similar committees in the USA. We are 50% of the population, but not 50% of cardiac surgeons, so there is some work to do. I would prefer to focus on diversity, not just for women, but it is a good way to start.
In the past three years we have focused on awareness. Awareness of unconscious bias. Awareness of inequality. And in this last year, awareness of the importance of the sense of belonging.
I have to step down by the end of this year, because my term is over. I am enthusiastic, and I would really like to thank EACTS for their commitment. I always approach it from a very positive and proud attitude. I am proud that I am a cardiac surgeon, I am a head of department, but I am also a mother and a woman.
What we do not want to see, and this was often the case in the past, is that women are chairs in sessions about the soft issues and not in the plenary session on surgical techniques, for example. I mentioned this topic of unconscious bias, and we all have our biases. We as female surgeons also have biases.
What can be done differently to attract the next generation of physicians into the field of cardiothoracic surgery?
This is an interesting and important question, that I really struggle with. There is a real difference in the expectations of young people today than in previous generations. Generally, they do not necessarily want to be in the hospital during nights, they do not want to be on call, they do not want to work for 80 hours. The generation before mine, especially, lived for hundreds of hours in the hospital every week, and that is not good. The change is very fast. But, I do not see how you can become a very good surgeon when you only work 30 hours a week.
We have to involve the next generation when we have these discussions. I sometimes sit around the table when we ask how to make them enthusiastic for the job, and there is often someone missing, and that is the new generation. We think about them, but we should involve them to know what they need.
Outside of medicine what are your hobbies and interests?
I am a mother of four children, and a lot of my time at home goes to the children. On Saturday I am at the hockey pitch or the football pitch the entire day. My husband is a nature photographer, so photography is my biggest hobby outside of work. I cannot do something for any less than 100%, so when we are on holiday I am fanatic about photography, because I really love it. If you do that you enter a completely different world, when you enter this small environment with, for example, butterflies, it is fascinating.