Clinical Connections  –  Spring 2019

Interview with Dan Brockman, Professor of Small Animal Surgery, and Poppy Bristow, Fellow in Cardiothoracic Surgery

How many cases do you and your team handle now compared to a decade ago?

Poppy: Five to ten years ago, we were only handling congenital conditions – so only about three to five cases per year as these cases are much rarer. Now, on average, we do four operations a month and we plan to double this over the next couple of months.

Where do these cases come from?

Dan: We receive referrals from across the world, with a particularly high demand from the USA.
How has this team changed over time?

Poppy: The main difference from even two years ago is that we now have a dedicated team to help with these cases. Up until approximately a year ago people were doing this is in addition to their other responsibilities, whereas we now have several people whose main job is this.

Which roles now make up your team?
Our head surgeon is Dan Brockman, who leads the heart surgery programme and I am the other heart surgeon on our team. In addition, we have Alison Young and Sarah Carey, who are our heart surgery service co-ordinators. They provide admin support as well as co-ordinating our patients’ care. Nigel Cross, our perfusionist, who is involved with every case, and has been with us over five years. Tom Greensmith, our Perfusion Fellow is learning from Nigel. Tom is involved in aftercare during the first night after surgery. We have anaesthesia support – we have a minimum of one anaesthetist and one anaesthesia nurse per case. Our Cardiology team see and assess the cases before surgery, they are then on hand during the surgery to perform heart scans to assess the repair. They are also vital for our post-operative care.

We work with surgery residents and additional theatre nurses and the ECC team who support us immediately after surgery in our ICU. After the initial post-op period, the patient is cared for by surgical ward RVN’s. If there are neurological aspects to address, we have support from the Neurology and Rehabilitation teams. It is very much a huge transdisciplinary team effort.

What impact does the nature of RVC Small Animal Referrals have on the way you handle cases?

Poppy: These are obviously extremely complex cases, the fact that they go on the heart/lung machine can affect other organ systems, and often the cases are older pets who may have other comorbidities. Knowing we have so many specialists in so many disciplines on hand, who can give us advice and support for cases, is invaluable. It has been instrumental to our success rate and sets us apart from other centres.

How do you see your team evolving in the future?

Poppy: Right now, a previously part-time resource is converting to full-time. We have now hired an additional anaesthetist, additional ECC nursing support and additional programme coordination nursing support. We are hoping to train more people in the future as mitral valve disease affects so many animals. Expanding that knowledge base to help more animals is crucial.

Are there any examples of RVC students who have returned to become part of your current team?

Poppy: Yes! I was an RVC student, then an intern and a resident here and now a fellow in heart surgery. We have a lot of residents involved in these cases from surgery, cardio and ECC in particular, who have often been students here before. Our perfusionist joined us because his daughter was an RVC student. Tom Greensmith, our Perfusion Fellow, was an RVC student too. I can only see that crossover increasing over the next few years as the service expands.

Dan Brockman and Poppy Bristow with patient Lottie, who was successfully treated at the RVC

How do you and other global centres collaborate to progress the field?’

Dan: Collaboration is key to the whole global vet community, benefitting from the improvements and breakthroughs we are making on an ongoing basis. We are now in contact with a base in Austria to support their development in this area and collaborate closely with JASMINE in Japan, who have been instrumental in helping us to perform the mitral valve repairs.

What impact has collaboration with human medical institutions had on the growth of RVC’s service?

Dan: This is really where it all started – my inspiration came during my time at the University of Pennsylvania, where the veterinary college was next door to the human hospital. Throughout our journey, we have had the most tremendous support from places such as the Royal Brompton as there are considerable parallels between our work and advances in paediatric cardiac surgery. So much so, one consultant has even given up their personal time to assist me in theatre in the past.
How have survival rates changed?

Dan: With collaboration worldwide and a dedicated team allowing us to perform these cases on a regular basis, our success rates for dogs who are in stage C of degenerative mitral valve disease is now 87%, which we expect to continue to improve with further expansion.

What have been the biggest influencers on improving the success rate?

Dan: More research is needed to quantify the impact of different factors, but I would say the access we have had to high skill levels in perfusion has certainly had a positive impact. As with most skills, there is no substitute for direct experience, so the increase in caseload and the consequential knowledge that generates has a positive cumulative effect.

How have technical developments helped your team and clients?

Poppy: The key technical developments have come more from the support services we depend upon as part of the pre-op preparations and post-op care. Diagnostic imaging has come on leaps and bounds and this really helps prepare the team ahead of surgery. We now also use a 3D probe, which helps us assess surgical repairs more accurately and quickly.

What are the RVC’s future aspirations for this area?  

Dan: The demand for this complex service is high and growing fast. We want to continue to expand our team so we can handle greater case numbers. We also want to build upon our strong success rate so we can help even more animals live a much longer and healthier life. In addition to the benefits to dogs and their owners, we are also able to give our students an insight into mitral valve disease, advanced cardiology and
critical care.

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