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Transplant Greats: An Interview With Lori West

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Martin Schweiger, MD
Pediatric Cardiac Surgeon
Children's Hospital Zurich
Zurich, Switzerland

There was much to think about as we flew home from the ISHLT meeting in San Diego. We were able to meet new colleagues, reunite with old friends and take home many new ideas. For me, the trip was inspiring. I got the opportunity to meet Lori West and continue our interview series on the legends in the field of heart and lung transplant. Everyone, especially those involved in the field of pediatric cardiac transplantation, knows Lori. She was the scientific program chair of the ISHLT in 2008, became president in 2011/2012, and is currently serving as development committee chair and involved with symposium planning and abstract sessions. We met at the terrace of the Manchester Grand Hyatt Hotel overlooking the San Diego Bay while enjoying the evening sun.

Lori, can you enjoy this meeting while heading from session to session, study meeting to study meeting and talk to talk? You must hardly find time to enjoy this wonderful location?
Well, yes, I do. I cannot go to as many sessions as I want to and listen to all the new ideas out there. Things have changed since my early days with the ISHLT. I am now more involved in the planning, development of other projects of the ISHLT; but it gives me another perspective and it is great to see your ideas brought in and how they work out. Take, for example, the History Project (one can find great interviews there, including one where Lori is interviewed by James Kirklin) or the I2C2 Committee. If you go now to the committee meeting, you will get the impression that it has been held for long time, but the truth is that it was started just two years ago. It was a focus to get started during my presidency together with Drs. Andreas Zuckermann, Steve Clark and Josef Stehlik.

What is the idea behind I2C2?
The idea was that our society would not just be dedicated to the 'western world' like Western Europe, North America, and Australia. As an international society, we have to integrate other countries around the globe and help address their problems, if possible. If you go to transplant meetings in Latin America, the Middle East, Turkey or Asia, you will find that they have also great programs. links imageColleagues there face different challenges concerning transplantation than we do in the 'western world'. We have to integrate them into the Society, give them a home to present their perspectives, and grow as an international community. Recently, Argentina started providing their data to the ISHLT registry, which is a wonderful initiative.

You will give the introduction to the session about cardiac transplantation in Latin America on Friday the 11th from 4pm to 5:30pm. Is it also part of the story?
Yes, this is one of the achievements of this program. The session reviews the present state, achievements, challenges and opportunities of heart transplantation and MCS programs across Latin America. Sometimes, due to language barriers, young physicians from other countries are hesitant to submit abstracts or give presentations at the ISHLT meetings. If you invite these countries to special ISHLT symposia like we have here in San Diego, people are grateful. That's why the ISHLT is pushing for this. We have to encourage them in order for us to understand their problems in their countries. In the coming years, we plan to have similar symposia and bring in Middle East, Asia and some other places.

Thinking back to your first ISHLT meetings and your career, what comes to mind? What do you feel are the strengths of this Society?
I joined the ISHLT in 1992/93. I guess my first meeting was the one that took place in Venice in 1994. Since then, a lot has changed. We all have noticed that the Society has grown a lot. Starting with about 20 or so surgeons gathered in a room, the Society has grown constantly and new scientific sections have been developed like MCS, PHT and basic science, among others. I think the key role is to interact with as many other professional societies as possible and grow with that experience. Transplantation is a core competency of the ISHLT, but it paved the way for many new specialties. There are so many different professionals involved now; it is not just the surgeons and cardiologists, it is pulmonologists, nurses, basic science experts, pediatricians and many more. It has become interdisciplinary and it is great to bring together this heterogeneous field of different specialties.

One other thing I really love about this Society is that we are working right on the edge. Just imagine ex-vivo lung perfusion!

You have such an amazing career at the ISHLT. What would be your advice to those of us who want to start our careers?
Well, I would say just go ahead and get involved. There are so many opportunities. The main reason for success is that you must love what you do. I do at least, and can see that you have real enthusiasm for what you are doing (laughing). 'Youngsters' should join the Councils of their interests and go to the Committee meetings; get things started by bringing in new ideas about what they want to read about. At present, someone is discussing new ideas and, in the end, there will be published guidelines on that topic. You have to work hard to achieve things but you still have to love what you do. Speaking for myself and my career, I never had a master plan; the opportunities just came along, and I made good use of them. For the young ones I think that opportunities emerge, but don't think that the chance will come to you. You have to be the active one, you have to go forward. Try to be on as many Committees as possible, get involved, pick a little piece out of the big field, and maybe follow guidelines. If you think that there is something to do, just get it done. Let us take, as an example, the wonderful Basic Science Academy (Core Competencies in Basic Science and Translational Research). This was, in part, organized, planned and put together by a post-doc from my lab, Esmé Dijke together with Tereza Martinu. Esmé and Tereza got this started and the response was enormous. The course was noticed by the whole audience and today (Thursday) the entire ISHLT is speaking about this great Academy.

One bit of advice I received at the start of my career was that one should get the best training possible, no matter where it requires you to go.

Speaking about your training, you have worked at a lot of different places. You started your training in New Orleans then at UCLA and Toronto's Hospital for Sick Children. You made a research stay in the UK (Oxford) and returned to Toronto. Now you are in Edmonton, Alberta. What has been the most enjoyable time for you?
Hard to tell but I certainly had a great time at Oxford. At first it was supposed to be a one-year stay, but you realize pretty quickly that a year is too little time to obtain good research training. It turned out to be four years. I think what I liked most was that I did not have to stretch between clinic and research. links imageI was able to solely concentrate on basic research. One major support was my husband Jeffrey; at that time he was already a well-established academic pediatric cardiologist. He understood that it was important for me and said, "Lori, you have found your niche and if you think that is the best place to go, I will support you." He stayed in Canada while I was in England, where I had my first child, Patrick. When Patrick was sleeping at night in a cot in the lab, I was doing my cardiac transplants in mice. I can remember that I was tired, but happy.

I would not say that it was always easy but we got through pretty well I think (laughing). Today, Patrick is 23 years old and my other son is 16. They're both heading for careers in science!

I returned to Toronto in 1994 when Patrick was 3 years old. After about a decade building the transplant program at Sick Kids, I was offered a new job at the University of Alberta with great research opportunities and organization. So we moved to Edmonton in 2005.

Looking at your time schedule and career, I wonder what your thoughts are on work time regulations, especially for the younger colleagues?
That is a good question. Well I think it is important that one has her/his balance and gets time to recover from a heavy clinical shift or overnight call. The question I ask is if you must go home what will happen to academics? You will do your clinic work, but when will you have time for academics? Academic work must also have a place of priority or the field will not advance. I remember taking my family with me while flying to conferences all over the country; I still can remember that after giving a talk at the ISHLT meeting I was breast-feeding my child. And the other question is how long your training will last. If 'shifts' are more and more limited, it may take 10 years until one is fully trained instead of six years, for example. There is no question that you have to be trained well, and that needs its time.

One other point I wonder is why trainees are sent home and sheltered from excessive clinical time, with the understanding that this is safer for patient care, but the older employees are not. My husband is now 64 and I think you need more time to recover when you are older.

From your perspective, what kind of research will we do in the following years and what will we learn about in the following ISHLT meetings?
I personally would like to focus on ABO incompatibility in adults. I think that HLA incompatibility is likely more dangerous than ABO incompatibility. links imageAnd, remember, the method for testing the ABO system is very old. It goes back to the days of Karl Landsteiner. Better methods are needed today. With techniques like ex-vivo lung perfusion, we might be able to use novel technologies to alter ABO antigens in donor organs.

Another very interesting field which, I think, may have a renaissance, is xenotransplantation, especially transplantation of pancreatic islets, due to the very high number of patients suffering from diabetes. I can also imagine that solid organ xenotransplantation might return. I think the porcine endogenous retrovirus discussion destroyed much of the work that had been done before industry pulled out. It was demonstrated that this fear was not founded but the hysteria was a major factor back then.

Concerning tolerance, I think it is a matter of how we define it. Have we asked the right questions? If we limit our definition of tolerance to 'zero immunosuppression', I think we are wrong. Co-stimulation blockade, for example, is leading us in the direction of tolerance and will impact further research. Stem cells will continue to remain a huge field. So far, we just don't understand enough. Think about induced pluripotent stem cells. It is a complete new field.

What do you think about ethical boundaries? 20 years ago, ABO-incompatible transplantation was termed unethical in some places. We have seen a change in that.
I think we asked the right questions. If somebody says something is unethical, it is important that they understand the science behind the proposed pathway forward. For example, if a baby has a 70-80% chance of dying without heart transplantation, is it ethical to let the baby die or it is it preferable to try a new untried pathway based on solid scientific rationale? If you then think about it, talk it out, understand the science, and if you then still think it is unethical, then maybe it is.

After the interview, Lori had to leave quickly for the next meeting. Due to her obligations at the ISHLT, it was not easy to arrange a meeting at San Diego. I want to thank Lori's secretary, Carrie Andrewes, who did an amazing job to bring us both together. I was told by Susie Newton that I would absolutely enjoy talking to Lori and, I must confess, she was right. One can tell by listening to her, especially when she talks about research and transplantation, that there is so much energy involved. It was just great talking with her and a wonderful experience. I was excited to share some time with one of the transplant greats. I am very grateful that Lori had some minutes of her valuable time for this interview.

Disclosure Statement: the author has no conflicts of interest to disclose.

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