Interview with ABEEL A. MANGI, M. D.
By Anjum Dawood Alden
I was fortunate to recently speak with Dr. Abeel Mangi regarding his ground breaking work in heart and lung transplantation. In a time when heart disease has become the number one killer of Americans, it is surprising that a large majority of heart patients are not even aware of all the therapies available to them. Dr. Mangi has made it his lifelong mission to help those who have heart or lung failure and are holding on to their very last hope, and to educate people about organ donation and all other options.
Dr. Mangi has worked at a number of fine hospitals in the country and currently serves as Surgical Director of the Lung Transplant Program and Co-Director of the Heart Transplant Program at Temple University Hospital. Mangi is also the Director of the Cardiothoracic Transplant Research Laboratory at Temple University. Previously, Dr. Mangi was a part of the Cardiothoracic Surgery team at the Cleveland Clinic. He recently spoke with us about his impressive work and aspirations.
Dr. Mangi: First of all, I’d like to thank PakUSonline for the opportunity to reach out to its wide audience via this forum. I think its critical that all of us, as citizens of the world, gain a deeper appreciation for therapeutic options that exist for those of us living with end-stage heart and lung failure, and that we understand the importance of organ donation when our loved ones pass on unexpectedly.
End stage heart failure is at epidemic proportions in this country. It is estimated that 5 million people in America alone are suffering from end-stage heart failure, and that number is expected to grow to around 20 million by the year 2025. At least an equal number of patients, if not more, suffer from end-stage lung disease. These numbers, in no way, capture the magnitude of suffering inflicted by these diseases world-wide. These are in no way diseases of the elderly – I have taken care of patients in their 20’s with end-stage heart and lung failure. I feel strongly that the vast majority of patients suffering from these diseases can be treated effectively and can return to being useful and extraordinarily valuable members of society.
What troubles me greatly, is that Asians make up a disproportionately small percentage of patients who come for medical attention with end-stage heart and lung failure. I think our role, as we collaborate moving forward, should be to spread the word about the fact that certain diagnoses are not necessarily “death sentences,” and that effective medical and surgical therapies are available for patients who have been given grim diagnoses.
Unfortunately, only about 2,200 heart transplants and 1,400 lung transplants are done in this country every year which means that the overwhelming majority of people die without therapy. The “rate-limiting” step in increasing the numbers of transplants in America and worldwide is the availability of donors. Certain communities tend to donate organs more than others and disappointingly our communities tend to be amongst the lowest organ donors. Its important to note that although rumors to the contrary abound, no major religion expressly forbids the donation of organs. This is something that I would like to work with PakUSonline to spread the word about.
Q. Please tell us a little about your background, and how you came to be where you are today.
A. I was born in England while my parents were completing their medical training and we moved back home to Pakistan shortly thereafter when I was three years old. I grew up in Karachi and attended the Karachi Grammar School where I completed my Ordinary and Advanced Level Examinations. I became interested in biology and biological processes fairly early on and can remember making plans about studying these further when I was 14 or 15 years old.
Also, my dad was a surgeon before he retired from clinical practice, and I was simply mesmerized by his stories about incredible aggressive interventions to save the lives of desperately ill people. I applied for college and medical school from the Karachi Grammar School and was fortunate to be admitted to several schools in different countries. The most compelling admission for me was at Brown University in the States. I was admitted directly to medical school and college and therefore had the luxury to continue to study the arts in addition to preparing for my studies in medicine. I would wind up leaving Karachi at the age of 17 for Providence, RI – making that the best decision of my life.
The Northeastern United States became my intellectual home. For me it became as it important to understand histories, cultures, literatures and arts – because those are expressions of humanity – as it was to learn about the technical science of medicine. Humanity, judgment and instinct are the cornerstones of the “art” of medicine.
The science of medicine is easy to learn - the “art” of medicine is elusive, and sometimes, impossible to teach a brilliant technical physician. Although I enjoyed every aspect of medicine as a student, I decided to pursue surgery as a career. In this, I was guided in large extent by the words of my father who reminded me that “a surgeon is simply a physician, who has one more diagnostic and therapeutic option at his disposal.” I really wanted to be at the apex of my chosen profession, and therefore chose surgery.
In order to become the type of surgeon my father espoused, I chose to train at the Massachusetts General Hospital (MGH) and Harvard Medical School. I was the first Pakistani chosen to train there, and was the first medical student from Brown University chosen to go there in close to thirty years. Those years were the physically most demanding, yet exhilarating years of my life. We worked close to 110 hours a week – often arriving at work at 2AM to begin rounds, going to the operating room at 7AM, doing evening rounds till 7PM, taking overnight call, starting rounds at 2AM again, going to the OR at 7AM and working until evening rounds were complete so we could get home by 9PM. The espirit-de-corps was phenomenal. There were eight of us a year, we worked incredibly hard together, and were like family. Most of the men and women I trained with remain best friends to this day.
My first exposure to cardiac surgery was at the MGH where I was awestruck by the surgeons’ command of cardiovascular physiology, and by their sheer technical operative brilliance. This to me, was the apex of medicine – cardiac surgery. The surgeons were brilliant, technically superior to any other surgical discipline; dealing with life and death on an ongoing continual basis; and demonstrating a grasp of cardiovascular physiology that was light-years ahead of any other doctor. I decided that this represented the ultimate example of “a surgeon being the ultimate physician” and decided to commit my life to this discipline.
I spent two years in the research laboratory as a resident with Dr. Victor Dzau at the Brigham and Women’s Hospital and Harvard Medical School in Boston. At the time, Dr. Dzau was the Chairman of the Department of Medicine (he is currently the CEO of the Duke Health System and Chancellor of the University). He charged me with developing a program for extracting and purifying stem cells from the bone marrow of adult animals, genetically modifying them to resist cell death, and then transplanting them into hearts damaged by a large heart attack. This program turned out to be very successful and we wrote a landmark paper in a very prestigious journal, “Nature Medicine“ that has anchored a lot of subsequent study about stem cell physiology. My commitment to the academic study of end-stage heart failure was therefore written.
After completing my surgical training I was recruited to Columbia Presbyterian in New York City by Dr. Eric Rose, the modern day “father” of heart transplantation and artificial hearts. He supervised my training in cardiac surgery, and then sent me on to the Cleveland Clinic where I spent two more years on staff learning about the nuances of how to take care of “the sickest of the sick,” and in developing new and novel techniques for the care of patients who would otherwise not survive.
Q. What drew you to specialize in lung and heart transplantation?
A. It was really the natural culmination of my interest in being the most complete physician that I could be. When I was training in cardiac surgery at Columbia, it became evident to me that otherwise excellent cardiac surgeons who were calm under fire and technically superb, would freeze in almost a panicked state when they confronted every surgeon’s worst nightmare – a patient whose heart was too weak to separate from the heart-lung machine. Furthermore, when they were asked to see patients who had hearts that were too damaged from prior heart attacks or long standing valve disease, they would turn those patients down for “prohibitive risk.”
One surgeon, however, the director of transplantation at Columbia, my mentor and close friend, Dr. Yoshi Naka – took those patients on without hesitation. He was the one called in when patients hearts were too weak to come off the heart lung machine, and he was the one who operated on patients deemed “prohibitive risk,” by his partners. I put myself under his tutelage and Dr. Eric Rose’s tutelage for three years and came to gain appreciation for the fact that really, there was no one that was a “prohibitive risk.” These guys were skillful, talented, technically brilliant, but also fearless. They knew tricks and strategies that even their peers did not. They never had to call for help, as they were the “last men standing.” I decided therefore, that that was to be my career path. I wanted to be the last option for a patient, I wanted to be the person who could offer patients thought to have no options an option. And that is why I elected to specialize in high risk cardiac surgery and heart and lung transplantation.
Q. How much has technology in heart and lung transplantation changed over the fourteen years that you have practiced in this field? Please give a specific example.
A. Things have changed tremendously over the last fourteen years. Our understanding of immunosuppression has improved dramatically, newer and less toxic agents are available to selectively control the impulse of the recipient’s immune system to reject the transplanted organs. The mechanical devices (artificial hearts, artificial lungs) that have been developed are far more sophisticated and physiologically tolerated by patients. One specific example is the heartmate-2 left ventricular assist device, which is basically a blood pump that we implant surgically into the left side of the heart. It is one-seventh the size of the older generation pumps, and is far better tolerated by patients. Surgical and anesthetic techniques have improved. We can work far more effectively and efficiently through smaller incisions. Cardiopulmonary bypass machines are easier on the human body than they used to be.
Q. What do you see in the future for heart and lung transplantation?
A. I think the future will bring about continued evolution in this discipline. We will see far more sophisticated means for supporting critically ill patients as they await transplantation. We will see rapid advances in biological therapies such as stem cells or small molecule medicines that stimulate the proliferation of stem cells within the body, and other drugs that enable homing of stem cells in large numbers to damaged areas of the heart. We will see further miniaturization of mechanical devices, and ultimately, I suspect will see hybridization of bio-mechanical devices to support the heart and lungs.
Q. What is the greatest accomplishment you feel you have had since you became a surgeon?
A. I’ve been fortunate to participate in a number of “landmark” operations. We have supported several young patients who have come into the hospital in shock with extreme and acute heart failure either from congenital birth defects or from massive heart attacks. We have been able to use novel devices in novel configurations to support these patients until the heart recovered and spare them a transplant. In other instances, our centers have been amongst the first in the world to support patients at risk of dying within 6 to 8 hours from progressive lung failure with artificial lungs in order to get them to survive until transplant.
We are now enrolling patients in studies to investigate whether administration of novel medications can help reverse some of the bleeding dysfunction that is seen in patients undergoing implantation of artificial hearts, and are investigating whether implantation of stem cells at the time of artificial heart implantation can help the heart recover to the point where the device can be removed, thereby avoiding the need for transplantation.
Q. What is your take on the “battles” doctors have to face with insurance companies? Do you feel that America is having a health care crisis? How does this impact your work?
A. I’ve had to get on the phone a number of times to advocate for my patients in front of a panel of insurance experts. I don’t see it as a “battle” per se, but as part of a re-education process oftentimes because the medical nuances of what we are trying to do are beyond the areas of expertise of boards at insurance companies, which have, of course, their own areas of expertise.
America’s health care “crisis” is in some ways real, and in some ways, over-hyped by opportunistic agencies. I think what America suffers is a crisis of availability of broadly available, uniformly applied, evidence-based preventive medicine; health maintenance programs, and primary care. From a financial perspective, tremendous bureaucratic redundancies in billing and collecting, the absurd practices generated by fear of litigious patients are part of what have contributed to runaway costs in our systems.
However, because of its unique culture that espouses individualism and the inherent opportunities of the self, America will always be a beacon for those seeking “high-end,” highly specialized services such as those that we provide.
Clearly what has happened over the past few years is a shift away from health maintenance towards high end therapies for specialized care. That pendulum needs to shift again, but the dilemma of course remains – where does the money come from?
Q. Have you had any interaction with heart and/or lung surgeons in Pakistan? Please describe. Have you ever practiced medicine there or do you plan to in the future?
A. I have never practiced medicine in Pakistan. I have interacted with cardiac surgeons and cardiologists in Pakistan informally and have always enjoyed those discussions. Its amazing how much technical expertise there is in our Pakistani surgeons and how under-appreciated it is. One of the things I have always wanted to do is to establish a permanent program, in collaboration between our institutions, whereby I could spend some time every year in Pakistan and not only operate on critically ill people, but also spend time teaching (in real time) young Pakistani cardiac surgeons some of what I have learned over the years. Similarly, it would be great to have some of them come over here and learn about how our systems of tertiary and quarternary level services work.
I am not sure if Pakistan is ready (from a structural standpoint) for heart and lung transplantation per se, as priorities need to be on grass-roots level of health care, but clearly there is an abundance of patients with advanced pathology who need high end therapies. I think a collaborative model is the best way in which to get these patients the care they need, whether in Pakistan or whether by transfer here to the States, for further care.
Q. What advice do you have for other Pakistanis who are trying to get into the same field of medicine as you?
A. The things that I will say may seem redundant, and most surgeons know this already. I’m also not sure that it is my place to dispense advice. However, I believe that it’s important to work hard, it’s important to dedicate oneself wholly to the discipline one wants to practice. It’s important to be able to learn as much as you can, because you never know some night standing there alone at an operating room table, in the midst of a bad situation when something that someone did or said will come to you as a vision and bail you out of a desperate situation.
It’s important to be humble, because truly the scale of what we know is vanishingly small compared to what there is to be known. It’s important to be relentless, to continue to push systems to change. It’s important to invest oneself in one’s patient. If a little bit of you doesn’t die every time a patient dies, there’s something wrong with the way you’re approaching the patient. It’s important to believe in yourself, in your decisions. It’s important to stand up for what you believe in. It’s important not to be intimidated – being a stranger in a strange land that is increasingly hostile to certain groups of people is no excuse.
Q. Is there anything else you want to say about yourself or your work? I
A. Its been a real privilege for me to spend some time speaking with you, thank you for giving me this opportunity. I feel passionately about the work I do, and am very grateful to have been given the opportunity to do it. Every person who we can thrown a life line to and work tirelessly to salvage them from desperate situations is a mother or sister or daughter, or father or son or brother to someone. And just the fact that we are able to help them return to their families as robust vibrant members of their families; and return them to their communities as contributing members shows us how powerful we can be as physicians when God allows himself to be expressed through our hands and hearts.
Alden: Thank you, Abeel for your time.