Joseph S Coselli (Baylor College of Medicine, Houston, USA) speaks to Vascular News about his career to date. Despite initially planning to follow in his family’s footsteps and attend law school, a summer internship at the Texas Heart Institute in Coselli’s native Houston changed the course of his career forever. The internship sparked an interest in cardiovascular surgery that would culminate in his current roles as professor of Surgery and executive vice chair of the Michael E DeBakey Department of Surgery at Houston’s Baylor College of Medicine, among others. Coselli has received widespread recognition for his work in cardiovascular and aortic surgery, and credits his success in large part to the important role of three celebrated mentors—Michael E DeBakey, Denton A Cooley and E Stanley Crawford.
Why did you decide to pursue a career in medicine and why, in particular, did you choose to specialise in cardiothoracic surgery?
I did not take the conventional route to medicine and cardiothoracic surgery. In my first year of college, I planned to become an attorney and attend law school, as practically everyone in my family had done. Between my first and second years of college, I needed a summer job. I met Dr Denton A Cooley, who offered me an internship as a college student at the Texas Heart Institute, here in Houston’s Texas Medical Center. Except for my family doctor, I knew no other doctors. That summer, I witnessed pioneering and dramatic cardiovascular surgery on an epic scale. Following this experience, I made the decision that I would become a cardiothoracic surgeon and, and I have never looked back.
Who were your career mentors, and what was the best advice that they gave you?
My mentors were giants and trailblazing experts in cardiovascular and aortic surgery: Dr Denton A Cooley, Dr Michael E DeBakey, and Dr E Stanley Crawford. Dr Cooley (who is also a native Houstonian like myself) was my first mentor, giving me a summer internship as a college student at the Texas Heart Institute. His advice was to “be the first one in and the last one out,” or to work harder than the person next to you. Dr DeBakey, my next mentor, was the programme director for my general surgery, vascular surgery, and cardiothoracic surgery programmes. His advice was to pursue excellence in every effort and goal in life. Dr E Stanley Crawford, a pioneering aortic surgeon, a southern gentleman from Alabama, and the godfather of the thoracoabdominal aortic aneurysm, was my third mentor. His advice was to treat every patient compassionately and as an individual. Additionally, he instilled in me the concept of keeping track of all my cases and data, reviewing them regularly, and learning from them in order to improve and teach.
What has been the most important development in cardiothoracic surgery during your career so far?
The development of numerous minimally invasive and endovascular procedures has been the most significant advancement in cardiothoracic surgery during my career thus far. Abdominal endovascular aneurysm repair (EVAR), descending thoracic endovascular aortic repair (TEVAR), replacement of the aortic valve with a transcatheter aortic valve (TAVR), and most recently, hybrid open and endovascular aortic devices such as Thoraflex from Terumo Aortic.
What has been the biggest disappointment? Something you hoped would change practice but did not?
I have not had any major disappointments, but in the 1980s we pursued the use of laser therapy to open occluded arteries (such as the iliac, superficial femoral, and tibial arteries, among others). It did not evolve into the spectacular development that we had hoped for at the time. Although more recently, similar advancements have been made in opening medium and small vessels.
How do you anticipate the field might change in the next decade, and what development would you most like to see realised?
I believe that minimally invasive and endovascular therapies will continue to evolve and advance. Although the descending thoracic and abdominal aorta have been well established for endovascular therapy, similar therapies to treat the thoracoabdominal, ascending, and arch are still under development. I suspect that over the next decade, technology will solve the issues these specific areas present, including the development of an endo Bentall, in which the aortic valve and aortic root are endovascularly replaced.
What are the biggest challenges currently facing cardiothoracic surgery?
Cardiothoracic surgery has several substantial challenges. First, there is an educational challenge. The complexity of cardiac surgery is increasing, as has its pool of related information. Simply put, the fountain of knowledge has exploded. Organising this into an educational format to prepare future cardiothoracic surgeons remains a daunting task. Cardiovascular research has been underfunded, for many decades. There is no question that there are enormous needs in the area of research. Clinically, cardiothoracic surgery is becoming increasingly challenging due to extensive pathology such as infection (i.e. endocarditis), advanced age (i.e. our population is ageing), and increasing patient morbidities. Particularly from a standpoint of minimally invasive approaches, partnership with industry will be necessary to address these concerns.
What are your current areas of research?
Our present research interests include the continued development of cardiovascular devices including aortic valves, particularly TAVR, endovascular therapy for aortic surgery, and evolutionary improvements in mitigating the risk of thoracoabdominal aortic aneurysm repair. In the laboratory, we are studying the influence of fluoroquinolones on the development of aortic pathology in mice.
Recently, I was co-author of an important paper titled “Staged repair of extensive aneurysms of the thoracic aorta by using the elephant trunk technique,” published in The Annals of Thoracic Surgery 2022. This study evaluating 363 staged elephant trunk repairs followed by 203 second-stage elephant trunk repairs concluded that treating extensive aortic aneurysms by using the elephant trunk technique is associated with notable morbidity and mortality; however, this is driven in some part by those who present with acute systems, who are the ones with a greater risk of developing postoperative adverse events. This paper is particularly useful as it serves as a benchmark of traditional open elephant trunk repair, which is being replaced in many centres with the frozen elephant trunk approach.
You have a number of professional society presidencies to your name. Could you list some of the highlights of these roles?
I have served as president of the Texas Surgical Society and the Southern Thoracic Surgical Association, which are fantastic organisations. Regarding the Cooley and DeBakey societies, it was an incredible honour to be the only individual to serve as president of the Denton A Cooley Cardiovascular Surgical Society and the Michael E DeBakey International Surgical Society. However, the most significant position I have ever held was being president of the American Association for Thoracic Surgery, which is the oldest and most prestigious organisation of its type worldwide.
What has been your most memorable case?
I have decades’ worth of memorable cases. However, I would have to say the top two most interesting were, 1) an open cholecystectomy of a severely inflamed gallbladder on a woman who later became my mother-in-law, and 2) I removed a lung tumor from one of my mentors, Jimmy Frank Howell, a renowned cardiovascular surgeon in his own right, and he lived an additional nine years after having the procedure.
What advice would you give to someone looking to start a career in medicine?
First and foremost, study hard, work hard, and keep an open mind. Medicine is a discipline that is continuously evolving. One should never be dogmatic about any particular issue and equally important, one should always maintain a healthy work/life balance.
What are your hobbies and interests outside of medicine?
Golf and reading are my two most important hobbies outside of medicine. Although I am not particularly good at golf, it offers an opportunity to be outside for an extended amount of time, and the collegiality and social aspects are quite enjoyable. The other is reading. I read everything from history, and novels, to current events. I have always believed that instilling a love for reading in your children, then their quality of life will be immensely enhanced.