​Building A Legacy

News goals for NUHCS paediatric cardiac surgery

PULSE Issue 38 | January 2022

“I think I had a very interesting start to this profession,” shared A/Prof Laszlo Kiraly, the newly appointed Head of Congenital Heart Surgery Division in the Department of Cardiac, Thoracic and Vascular Surgery (CTVS) at the National University Heart Centre, Singapore (NUHCS). 

He was nine years old when he was run over by a car. With a fractured skull, he had to wear a head bandage while he stayed home to recuperate. That was when he first saw a picture of Christiaan Barnard, the surgeon who performed the world’s first human heart transplant, gracing the cover of a magazine wearing a surgical cap. “I thought I looked like him, with my bandage,” said A/Prof Laszlo Kiraly, who then kept the magazine cover as a poster and declared that he too would become a cardiac surgeon one day. “And I only wanted to focus on babies and children. Never adults.” 

Unwavering in his determination, that nine-year-old boy has since accomplished much over the years. He graduated from Semmelweis Medical University in Budapest, Hungary, and completed his postgraduate medical training in the United Kingdom (UK), France, and the United States of America (USA), earning the Hungarian and European Board certification in Cardiothoracic Surgery.

He returned to Hungary in 1996, and in 2000, he was appointed the Chair of the newly set-up Congenital and Paediatric Cardiac Surgery/Intensive Care Unit at the Gottsegen National Cardiovascular Centre, a leading healthcare institution in Hungary dedicated to patient care, clinical practice, teaching, and research. As a new unit, A/Prof Kiraly led his team in redesigning the surgical service to focus on improving patient care and maximising hospital resources. Everyone had to pitch in and he proudly recalled working on the logo design. Following the success of the programme in Hungary, A/Prof Kiraly was invited to Abu Dhabi in 2007 to establish and lead a new tertiary-care paediatric cardiac service at the Sheikh Khalifa Medical City (SKMC) in the United Arab Emirates (UAE), which became the country’s leading paediatric cardiac programme. Before the programme was launched, children in the UAE had to travel abroad for operations. At SKMC, he built the paediatric cardiac surgery service from the ground up, including designing the operation theatre and outlining the care protocol from the prenatal to adulthood for congenital heart diseases.

The programme launched in 2007 with the unit performing just around 100 operations. When he left in 2021, his team completed almost 5,000 procedures and achieved a survival rate of above 97%. Most of the operations were performed on infants less than a year old, with the majority of patients being less than six months old. The programme has since expanded to serve patients across the entire Gulf region, keeping young patients close to home and their families. A keen adopter of innovative techniques, A/Prof Kiraly and his team in SKMC had completed several first-of-its-kind surgeries using the latest imaging and 3D printing technology to diagnose a patient’s condition and devise an appropriate surgical plan. In the case of a one-year-old Jordanian boy who was born with multiple cardiac malformations, 3D printing technology gave his surgical team clarity of his heart anatomy before proceeding with the procedure. After braving 11 hours of surgery and three months of post-surgical care in 2020, the boy is now able to lead a normal healthy life. 

Uprooting after 14 years in Abu Dhabi was not an easy choice for him. “I miss my colleagues the most as they have become close friends,” said A/Prof Kiraly. “But NUHCS made it easier because it was a chance for me to share my legacy.” Now 61 years of age, A/Prof Kiraly felt a moral responsibility to pass on his experience. He explained that paediatric cardiac surgery is a vocation that demands an extensive amount of training with a very steep learning curve, making it very challenging for a young surgeon to master the skills without proper guidance. “As a surgeon, I do not wish to take my secrets to the grave,” he joked, half-serious. “It would be a disservice to patients, my colleagues, and the practice as a whole if I cannot pass on my failures and triumphs for the next generation to learn and improve on.” For this reason, to train and educate the next generation of surgeons has been on his key agenda when he joined NUHCS in April 2021. Bringing with him video recordings of his past surgeries, A/Prof Kiraly is looking to build a vault of paediatric cardiac surgery knowledge where doctors will have access to a myriad of systematically documented surgical procedures for learning and training. This builds on the investment NUHCS has made in recent years to digitalise and equip operation rooms with high-resolution cameras as well as surgical training simulations where surgical teams can practice and rehearse before complex operations.

“NUHCS is well-known in the medical community for its high standards in surgery and adoption of advanced technology,” remarked A/Prof Kiraly, who hoped the vault will serve as a teaching tool for future surgeons as well as a resource for scientists and researchers developing new medical technology. He was impressed with NUHCS’ achievements in minimally invasive techniques, where the results have been published widely in several medical journals; particularly after reading the first comprehensive practical guide book on minimally invasive cardiac surgery authored by A/Prof Theodoros Kofidis, Head and Senior Consultant, Department of CTVS, NUHCS. These methods however, have limited applications in his specialised field where his patients are much smaller in size. However, if complemented with augmented visualisation, he believes several advantages could be achieved such as reducing the morbidity rate of patients without jeopardising the quality of heart repair and patient safety. To that end, A/Prof Kiraly intends to cultivate a learning culture to advance the standards of paediatric cardiothoracic surgical practice here. 

Research has proven that surgeons in solo practice with less opportunity to interact with their peers scored lower compared to surgeons in group practice. Surgeons need to learn from others to enhance their practice, consider various operative options and improve patient outcomes. They need to interact with their peers to share videos of different techniques, post questions, analyse data, and discuss to learn vicariously from one another. At NUHCS, he established multidisciplinary teams where hospital staff from related disciplines would participate in weekly cardiothoracic conferences including those from cardiac imaging, cardiac anaesthesia, intensive care as well as allied health professionals responsible for risk-stratification and public data reporting to international databases. Every operation is preceded by a detailed briefing package that covers details including patient pathways, scenario-planning, and continuum-of-care plan to ensure the team is kept informed on the patient’s condition. He intends to inculcate a strong spirit of team ownership based on transparent communication within the multidisciplinary team. He also introduced new avenues of training and education such as a journal club to cultivate the culture of continual improvement where various techniques surgical options could be analysed and discussed in a team. 

Performance reviews are held monthly where factors such as surveying patient outcomes, team dynamics, and other key indicators are monitored and tracked to ensure accurate up-to-date assessment of the case-mix, an essential element of outcomes reporting, quality assessment, and improvement initiatives. Aside from documenting surgical procedures, he is working with his team to review and introduce new protocols where procedures are formalised and standardised, including guidelines for patient management and care protocols for extracorporeal membrane oxygenation, post-operative care, and for hybrid procedures which could become more common in future. “NUHCS already has the elements of a centre of excellence in place,” noted A/Prof Kiraly. “My goal is to look for efficiencies and marry these elements in developing a long-term strategy where the outcomes of our paediatric cardiac surgery programme can be measured against international benchmarks.”

Ahead of this herculean task, A/Prof Kiraly is excited to be in Singapore. With the pandemic putting some of his surgeries on hold, he intends to get back to cycling which he had given up when living in Abu Dhabi. “I’m excited to meet new friends,” said the Hungarian, “and learn more about Asian cultures.”