In this interview, we spoke to Dr. Alexander Marmureanu, a thoracic and cardiovascular surgeon, about his day-to-day role and responsibilities as well as his career highlights.
What inspired your career into thoracic and cardiovascular surgery?
It's a very good question, but it started a bit earlier than that. I grew up in Romania, and my parents were physicians. My father's a radiologist, my mom was doing internal medicine. I grew up in a small town, it's called Baile Govora. There are some old villas and old clinics and nice hotels from the 1920s. My parents were working there as doctors, and I grew up there playing sports and playing tennis as a kid.
But, every day was related to the medical profession. I was visiting my parents in the clinic and the hospital. Everything was within five minutes walk. So, I grew up seeing what they are doing, and I really wanted to be a doctor.
I was in the army first, but then once I got into medical school, I wanted to be a surgeon because you are being exposed to different things. When you walk into a hospital, you look around and see someone in pediatrics, someone in cardiology, they fit the profile. I thought that my profile would fit in surgery, rather than something else. It is the way you are built, the way you are wired, and also the things that you want to do and the people you get along with.
Now, once you get into surgery, you realize that there are different options, from orthopedic surgery to heart surgery, to thoracic and lung surgery, even to neurosurgery, and so on. I like general surgery, which everybody starts in, and then I specialized in cardiac surgery because again, I thought that operating on the heart is the ultimate task.
You look at people. Somehow, they take half of their brain off and they still live. You cannot do this with the heart. Everything has to be perfect. Also, we do operations that, for example, you have to replace the ascending aorta, you go into a circulatory arrest, basically cooling down the patient to less than 20 degrees Celsius, and stop the heart-lung machine and take the blood off. Where is the patient? Is he alive? Is he dead? It is cold. Then, you finish your operation, fill them up with blood, warm them up, and they are good to go.
There are fantastic privileges at the end of the surgery, that you have done things that, in reality, almost nobody else can do other than your mates, colleagues, and other trained specialists. The satisfaction of basically, I don't want to say giving life, we are not God. But helping those patients is tremendous, more than doing a hip replacement or a knee replacement when you do orthopedics.
What are your main responsibilities in your current job?
First of all, we all believe as cardiothoracic surgeons, the first responsibility comes to the patient.
I teach people, I travel extensively throughout the year, I give lectures, and operate pro bono in charity. I always say the first responsibility is taking care of the patient. That is where it starts, that is where it stops. While all those things are being taken care of, we have other responsibilities.
First of all, I am the chief of cardiothoracic surgery in a few hospitals. So, I have to be sure that the operation runs smoothly, the patients are properly selected, the results are reported, the nursing staff are properly trained, the intensive care unit works properly.
You are as fast as the slowest person in your team, so if we do a perfect operation and nobody can take care of those patients, patients die or they don't do well. Obviously, this reflects badly on patient care, and at the end of the day, surgeons. We cannot afford those things.
You have to be sure that the practice runs smoothly in terms of pre-op preparation, operation, and parked reports, as well as post-op, discharges, and following up with the patient on an outpatient or outpatient basis.
Another point to mention is that it is a team approach. I've done this for 30 years. Many years ago, there used to be this theory that the surgeon is the captain of the ship. That doesn't exist. It's a very interesting situation because the surgeon is not the captain of the team. In other words, each member of the team has to do their own job. But somehow in a nice way, you have to keep them in line and you have to run the team somewhat from the top without doing that.
You have an anesthesiologist that has to do his job. You have a perfusionist that has to do a heart-lung machine. You have nurses that are scrubbing as you do surgery. You have nurses that work with you. You have to direct this without being technically the one in charge, so it's a fine balance. It is working quite well, but yes, there is a team approach and there are always interesting issues related to how homogeneous the team is.
What does a typical day look like for you?
That's an easy question. There is no typical day. We will go CABG, coronary artery bypass grafting. It's a fairly common operation. You bypass a failing heart, and sometimes there are lesions, there is stenosis, and you put grafts, arteries, or veins.
For example, on aortic valve replacement and a bypass operation, it sounds the same. You've done three, or you've already done a replacement this week, or ten. I have done a hundred last year. None of them are the same. Every single one is different. It's like driving from your home to your office and every day taking a different route, different weather, different car, different street, or a different scenario. That's the same thing with those operations.
Daily, I wake up around 6:00 to 6:30 am. Sometimes work out, sometimes I don't. It depends on how busy you are. I then get to the hospital and see the patient you operated on the day before while they are getting your patients ready for same-day surgery. Usually, it is one or two cases. Some days have three, four cases. They could be lung surgery, heart surgery, vascular surgery, or all of the above in the same patient or different patients.
I currently practice in Los Angeles in six hospitals. I don't operate every day in six hospitals, but there are days when I operate in two hospitals on the same day. There are days when I have to go to a third hospital after I finish my cases, which gets me back to my home around 1 or 2 in the morning.
Routinely, you probably do one to two cases in one hospital, perhaps two hospitals. Then, you go to visit your patients. Then, there are new consults that have to be seen. Some of them will have surgery the next day if they are an emergency and others will get scheduled. At that point, if there are no other issues, fires anywhere burning, you go to sleep. That could be anywhere between usually 9 pm and 2 am.
I am also on call for the thoracic surgeons at a few hospitals. Not all at the same time, but one week in one hospital, one week in the other hospital. On top of my regular practice, you have emergency surgery, sometimes gunshot wounds, stab wounds. This is on top of everything else. But not every day is like this. Sometimes you have time to play tennis on the weekends. I race cars, I play tennis, I ski a fair amount, but that is whenever you are available.
What is the most rewarding part about your job?
It is taking care of the patients. Every heart surgeon thinks they are the best, and they should think that because if they don't think they are that good, imagine how comfortable we are going to make the patients feel. The reality is that almost all heart surgeons are very, very good just because of training. If you are not good, then you just don't last in this line of work.
The most rewarding part is seeing your patients doing well through the surgical part of the procedure, post-op going home, living their life, and doing better than before. Or, in case of trauma or stab wounds to the heart, you fix the heart and they just go home and they are alive. It is this feeling that the mission is accomplished, and you can move on to the new task.
What do you find most challenging about working in surgery?
There are few things that are challenging. First of all, it's nobody's fault, but it is the patient population and the fact that we see some of the patients really late. There is a lot of red tape and logistics in terms of transferring patients from one center to another where the surgery can be done in a timely fashion.
We have no control from ambulances to paperwork to helicopters and so on. There are also challenges related to the fact that I work 24 hours a day. However, the staff in the hospital work nine to five. So, sometimes there is a lack of staff, lack of available operating rooms. Again, I'm not blaming anybody, but when emergencies come, it could be the old surgical theaters. The operating rooms are busy so you have to wait a little bit. There is a lot of frustration at every level. It is like a puzzle that you have to work around to do the best job possible.
Throughout your career, what has been your proudest achievement?
That is a good question, but I have achievements daily. Sometimes they are small, sometimes they are big. Like I said previously, it all comes down to taking care of the patients. I just did a double valve on a patient who nobody wanted to operate on. Now, five, ten years on, I still see him. Once in a while, he is on Facebook or Instagram sending me a "thank you," that everybody thought he would be dead. He did spend three months in the hospital, but clearly, he is doing very, very well. Once in a while, he puts a post that he is still alive and so on. I remember vividly how hard I had to work on this patient, so that made me happy.
Now, that was a big task, but on the other hand, just small things like one wire gets infected in somebody's chest or it's sticking out through their skin and they can't an open blouse because of the wire. You take the wire out and they are equally happy. There is no more wire in there.
I write papers, I do research, I travel, I train surgeons. As I said, we do a lot of things that run hospitals and clinics, but it comes down to taking care of the patient. At the end of the day, you are a surgeon and my parents are physicians. You want to help them, and when you help them, they're happy, you're happy. That's the way it is.
What has been the most exciting project that you have worked on?
They are all exciting when talked about differently. Now, I do heart surgery. I used to do heart transplants, lung transplants, and very fancy cases, cut nerves in the chest that go to the heart, and intubate the heart. Sometimes, the heart has crazy arrhythmias. It is called ventricular tachycardias or arrhythmias, and they could die from them. You use video cameras and fancy kit. You cut the nerves, they do well. They are all nice operations.
However, a few weeks ago I carried out vascular surgery. I wasn't even on call. There was a lady who got a hip replacement, and they tried to measure it to figure out the metal part from the femur and from the bone to the hip. They moved it forward too much and they ripped the femoral artery and the femoral vein. They ripped everything. Not only did they cut them, but they ripped. They were all gone.
They called me and it didn't look good so I had to open the groin immediately, and doing this for 30 years, I am good at what I'm doing, but I could not find the artery. The leg was blue, and I couldn't find the artery because when they ripped it, it retracted, one up, one down. It kept on bleeding, one part toward the belly, one part toward the leg, so time was of the essence to find the two heads of the artery before she totally exsanguinates.
I was then left with a gap like this, so I had to put a graft in between and save her leg. This was very challenging, and then the next day there were other issues and so on, but she is okay now. But that happened a few weeks ago. There are always interesting or odd cases that need our attention, and then you keep thinking about it.
How do you think thoracic and cardiovascular surgery has changed with the advancements of new technology?
First of all, there are a lot of technologies. To reemphasize your point, there are a lot of new achievements from percutaneous valve placement, percutaneous valve repair, percutaneous stents, and placing stents into coronary or carotid arteries.
However, there is always going to be a role for open surgery, so you have to have two options in your armamentarium. It comes down to the surgeon to fully evaluating and recommending surgery to the patient.
Here, it becomes the patient's decision. It is what we call shared decision-making or patient-centered care. Although things are to be considered, we have a lot of technology available from robotic surgery to thoracoscopic, but there is a clear role still for open surgery.
What advice would you give to people who want to pursue a career in thoracic and cardiovascular surgery?
I think Richard Branson said that you hire for aptitude, I think, and you teach them the skill. You have to be sure that's what you want to do. There is no way back. If you are going to become cardiac, and it's not what you like, you will be miserable and you are not going to do well.
First and foremost, it's a glorious profession but it's not an easy thing to do on a daily basis. I like it. I like what I'm doing. I wake up happy and it's something I deal a lot with, and it's in me. I'm very happy, but not everybody feels the same way.
First and foremost, you need to get into medical school. The medical school just goes through all your rotations, all your courses. You have to figure out if you want to be a pathologist, family practitioner, if you want to be an OB/GYN, ophthalmologist, etc.
If somehow surgery is for you, then go through your surgery step-by-step, baby steps. While you do this, you realize that perhaps urology, orthopedics, or cardiac surgery might be for you. Then, don't just try to dive into something because it sounds right, it sounds fancy because there is no way out. Again, you have to figure it out. Trust your gut feeling. If that works for you, just go for it. If you have any doubts, you are not 100% sure, probably you would d be happier doing something else.
Also, another point to mention is that you cannot expect to become a surgeon overnight. I think the training is 10-15 years to become a cardiothoracic surgeon. My medical school was six years and I have done my general surgery residency twice, but that's a bit unusual. I have done it in Europe and the US, but if you do it only here, it would be anywhere between five to seven years because we have to do one or two years of research. If you add these 6 years, it would be 12 years. Then, the cardiothoracic surgery training is anywhere between two to three years. It is 15 years of training.
Is there anything else about your career that you would like to share with our readers?
It is a rewarding profession once you do it right. If it is done right, it is like a perfect racecar or like a perfect tennis racket, perfectly lined. If it is perfect, it will go well. However, if it's not perfect by 5%, it could be a disaster. This is not something you can do at 50%. You can't cut corners. You have to have 1-100% commitment, or you don't do it at all. You cannot be a part-time cardiothoracic surgeon. That's something that I always tell people that look into this, that they need to think about.
Again, once you are in it, there is no way that you can practice two days a week or three days a week. We can't take a vacation. Let's say I have a vacation on Monday, but if I have cases on Friday or Saturday, which is quite often, I cannot let anybody else usually take care of those patients that are sick. That vacation is gone. I am totally okay with it, but again, people have to understand that it is a very demanding profession, it has got high stakes in terms of rewards. However, there is no margin for error.
I personally don't drink alcohol. Obviously, I don't take drugs. I don't smoke. I don't do anything. I just play sports and work. That's it. This is because we anatomize one-millimeter vessels. If this is not perfect, if that one millimeter is not, anastomosis gets to half a millimeter, well, that vessel will close in six hours, six days, or six weeks. When it closes, the patient is dead.
Athletes at the Olympic Games have to have one good day, one good final, or two good weeks to play the tournament. As a surgeon, you always have to be on top of your game, period. Every game, every match for the rest of your life. That is something that needs to be considered.
Where can readers find more information?
About Dr. Alexander Marmureanu
Dr. Alexander Marmureanu is a prominent board-certified thoracic and cardiovascular surgeon, with special expertise in the field of minimally invasive surgery where he pioneered and developed several techniques and procedures. In his 30 years of practice, he has been able to successfully treat some of the most complex and challenging heart and lung conditions with high rates of success.
Dr. Marmureanu completed his General Surgery Residency and a Research Fellowship at New York University Medical Center (NYU) in New York City. He then continued his surgical training at Mount Sinai Medical Center in New York City, where he was actively involved in the field of thoracic and cardiovascular surgery research. He completed his Cardiothoracic Surgery Fellowship at the University of California Los Angeles (UCLA) in 2002. He continued to practice as UCLA Faculty, before joining Cedars-Sinai Medical Center and also becoming Director of several Cardiothoracic Surgery Programs in Los Angeles.
Dr. Marmureanu is nationally and internationally recognized in the field of thoracic and cardiovascular surgery and has authored numerous research papers and clinical publications. Active in both local and international charitable causes, Alexander donates his time by traveling around the world to train local surgeons and perform pro-bono procedures.
He has appeared as a guest speaker on numerous TV and radio shows, where he discussed the benefits of cutting-edge surgical techniques as well as the advantages of minimally invasive surgery for thoracic and cardiovascular patients.
Dr. Marmureanu maintains a busy and active cardiothoracic surgery practice in several hospitals, where he performs over 400 surgical cases per year with outstanding results. He is a member of well-recognized organizations, boards, and committees, as well as an invited speaker/visiting professor both nationally and internationally.