This week’s faculty spotlight shines on Andrew Landstrom, MD, PhD, assistant professor of pediatrics in the Division of Cardiology. Landstrom talks to us about how he became interested in becoming a physician-scientist in pediatric cardiology, and his interests in the genetic and molecular mechanisms of sudden cardiac arrest in children and young adults. He also shares his reflections on his most significant mentors, and offers some valuable advice for trainees.
How long have you been at Duke? How did you decide to come here?
I started with Duke over the summer of 2018 and have been here for about 6 months. Duke offers a truly unique environment for young physician-scientists. I was drawn to the trajectory of the Department of Pediatrics and the Division of Cardiology and the ability to grow a research team in a supportive environment. My clinical interests are in heritable arrhythmias of the heart and diseases which can cause sudden cardiac arrest. The ability to have access to knowledgeable clinical colleagues in a collaborative team and the opportunity to build a practice that serves North Carolina was a huge draw. In addition, as a physician-scientist, the research and scientific support at Duke is really second to none. The ability to build a research program in an environment of research support, shared facilities, scientific collaboration, with internationally known mentors was also a huge draw. The strong academic side to Duke and the University allows me to easily cross disciplinary lines with my research and to re-think how we ask increasingly complex questions in novel ways.
What are your responsibilities within the Division of Cardiology? What does a typical day for you look like?
I am a physician-scientist with both clinical and research responsibilities. I see patients in clinic with arrhythmias that can be passed in the family and evaluate children at risk for cardiac diseases that can cause sudden death. I lead a laboratory-based research team that explores these diseases, and we collaborate with a host of other scientists and physician-scientists around the world to ask what puts children at risk of sudden cardiac death, and how can we prevent or treat these diseases?
How did you first get interested in medicine? What made you decide to pursue pediatric cardiology in particular?
I have always loved the biological sciences and had a curiosity about the natural world. This love found home for me in how changes in DNA can cause disease and threaten the lives of otherwise healthy children. During my graduate training, I learned how understanding genetics could be a powerful tool to identify children “at risk” of disease before they showed any symptoms or clinical signs of disease. I learned that understanding how these genetic mutations can change the molecules and cells of the heart to cause disease is a critical prerequisite for treating, or perhaps, curing these diseases. I believe that pediatric cardiology, and the emerging field of cardiovascular genetics and molecular cardiology, offer the opportunity to identify those who are at risk of potentially fatal heart disease before our traditional tests show any abnormalities. As genetic testing becomes more mainstream, and families are able to order a genetic test from the internet to test their children, it is going to become increasingly important that we know how to deal with this flood of genetic information. The vast majority of children who get genetic testing will not have a sudden death-predisposing cardiac disease, but a small number of children may. Being able to tell the difference is critically important.
What’s one thing you wished more of your patients knew about pediatric cardiology or medicine in general?
Pediatric cardiology, and medicine in general, is always a work in progress. Our understanding of how heritable arrhythmias and sudden cardiac death-predisposing diseases, like all of medicine, is growing and evolving. For example, our ability to detect changes in the DNA has far exceeded our ability to know what all of the changes mean or whether some will lead to disease. Because of the uncertainty that is always present in the work that we do, working as a team with the families, have clear communication about what our testing shows and does not show, and what our plan is for the future, is tremendously important.
What are your specific interests in the field of pediatric cardiology?
My clinical interests are in arrhythmias that can be passed in the family and cardiac diseases that can cause sudden death in children and young adults. Some of the latter can also be passed in families. I am referred patients with concerns for these diseases, which include syndromes such as long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and short QT syndrome. I also see families that have lost children to unexplained causes of sudden death. These can be the families of infants of have died sudden without explanation (such SIDS) or children who may have died without explanation. Often, I am asked to see the siblings of these children to try to determine if they have a risk of sudden death. It is a challenging field, particularly in pediatrics, but I feel passionate about providing care for these families.
Is there any research or other special projects you are doing or plan on doing?
Our research interests center around diseases which can cause sudden cardiac death in children and young adults with a goal of 1) identifying children who are at risk and 2) understanding how these diseases develop so that we can fix, or otherwise mitigate, the genetic and molecular abnormalities of the heart. We utilize a host of research tools to be able to address the goals. For example, we are very interested in why a young child who I cared for had recurrent bouts of life-threatening arrhythmias. We suspected she had a genetic mutation, but all of our typical genetic tests were negative. Using more expansive genetic testing we were able to find a mutation in a gene that has not been implicated in arrhythmias of the heart. We set out to prove (or disprove) that this mutation was the cause of her disease and, working closely with her parents, were able to take some of her blood. From this sample we isolated and grew a specific population of her blood cells then converted them to her own stem cells. We can then take these stem cells and guide them to differentiate into heart cells. In effect, we have the ability to directly study her heart in the lab--from a blood draw. This provides a valuable model to test the electrical changes of her heart and to try therapeutic interventions without testing her directly.
Tell us about your NIH K08 grant.
My NIH K08 is a training grant administered through the National Heart Lung and Blood Institute at the NIH which supports me during the early years of my faculty position so that I can work on building a research program. I am fortunate to have received this research support, and I have a window of time to grow and pursuing our lab’s research questions so that we can sustain ourselves long term with additional funding. This K08 has provided a vehicle from which we can beginning to investigate the causes of life-threatening arrhythmias in children and to purse novel therapies based on these discoveries.
Who was your most significant mentor and what knowledge did you gain through this collaboration?
I have had the benefit of a number of mentors--many of whom I still turn to for advice and perspective. Among these are Mike Ackerman at the Mayo Clinic, who was my graduate school mentor, and who taught me that being a scientist can make one a better physician. He also set me on the path of pediatric cardiology and cardiovascular genetics. I have also had the benefit of incredible clinical role models who I try my best to emulate. Among these are Jeff Kim at Texas Children’s Hospital, who has a gift for making complex things very simple, and when one can do that, one can take better care of patients. While this may not seem all that challenging, this requires complete mastery of one’s clinical specialty, a humility to recognize boundaries of knowledge, and a true humanistic approach to conveying all of this to a family.
Do you have any advice for trainees?
When one is in training, it is very easy to get stuck in the weeds of what has to be done on any given day--these patients need to be seen, these notes need to be written, these call nights need to be covered. If one can occasionally lift their head up and see the bigger picture, that this is a valuable time the forms the foundation of one’s career, then training becomes more meaningful. Often, we can all get stuck looking over the horizon at what lies just beyond, only to move on to the next horizon, and the next, and we do not see that the path we are walking is what is important. I have certainly struggled with this at times, and I have had the benefit of incredible mentors who are quick to point this out, and I have always found it centering.
What passions or hobbies do you have outside of work?
I try to spend as much time as I can with my two boys re-discovering North Carolina. We have family in the area with other young children, and we enjoy being part of their lives. Both my wife and I are graduates of a university just down the road, and while it might get us in trouble during basketball season, we enjoy staying involved with our alma mater.