SHAPING THE FUTURE OF ANESTHESIOLOGY: Faculty Spotlight

He has always been driven by a deep desire to heal. Disturbed by his father’s diagnosis of diabetes, described at that time as “incurable” in his native Romania, an inquisitive five-year-old began to think deeply about solving conundrums that perplexed his young mind. Today, as chief of the Cardiothoracic Anesthesiology Division at Duke, Mihai V. Podgoreanu, MD, continues to search for solutions as he seeks to transform perioperative medicine and critical care into a system that is not just reactive, but predictive, preventive, and personalized.

His vision is bold and clear: to prevent organ injury and predict clinical deterioration with timely and tailored responses to help patients recover faster and heal better. “I like tackling complex issues and big ideas that disrupt the way we deliver acute care, and central to this theme is the ability to make care more precise,” informs Podgoreanu.

Using cardiac surgery as a unique lens, Podgoreanu examines why surgical stress affects patients in diverse ways. He explores the mysteries surrounding why some individuals withstand surgical injury with resilience while others face complications that seem inevitable. As a clinician-scientist, Podgoreanu studies what differentiates these groups using genomic science, systems biology, and data science to bridge the gap between research and clinical practice.

Podgoreanu was raised by economist parents in Bucharest, Romania, where he first studied mathematics and physics for a strong analytical foundation, and followed that with medical school, which was fueled by his passion and commitment to science. A journey that was ignited by a personal challenge brought him to the US for residency in anesthesiology at Yale University.

His early days in the US were marked by a deep sense of determination mixed with profound uncertainty. “Deciding to come to the US was a super hard decision, and arriving here with exactly $120 in my pocket, sleeping on the floor with my coat as a pillow, and being a completely unknown entity in need of ‘proving myself’ in a new world are all early memories,” recalls Podgoreanu. The stress of emigration and the strain of cultural adjustment took their toll on his marriage. The heartache was compounded when his two children moved across the Atlantic back to Romania.

Podgoreanu was faced with a heart-wrenching choice – to return to his children or create a better future for them in the US. Guided by faith, he stuck to his resolve and fell in love with his adoptive country that had “its system of governance with checks and balances, democratic rule of law, a value system set right based on competence, performance, and hard work.” Life did give him a second chance at happiness; he remarried, and together with his wife remains close to his five children, two daughters as bookends with three boys in the middle. “They are my biggest life accomplishment by a long shot,” says Podgoreanu proudly, reflecting on the family he cherishes and the new life he has built.

While Podgoreanu did not specialize in diabetes, his academic pursuits focused on altered metabolism in disease. His research trajectory began during residency at Yale under the mentorship of anesthesiologist David Silverman, MD. His exploration into how small blood vessels adapt in response to non-pulsatile flow during cardiac surgery has implications for patients supported with long-term centrifugal heart pumps and was recognized at the New York Post Graduate Assembly in 2001.

Attracted to Duke Anesthesiology for its academic might and innovation, Podgoreanu was inspired by visionaries in the department. Then chair Jerry Reves, MD, introduced him to the role of genetic variation in postoperative outcomes – a concept advanced further by Mark Newman, MD, Debra Schwinn, MD, and Joseph Mathew, MD. Supported by an American Heart Association grant, Podgoreanu joined Duke in 2000 and completed three years of training that included fellowships in cardiothoracic anesthesiology and critical care medicine, and post-doctoral research with Schwinn, a pioneer in molecular pharmacology. The lab experience ignited his interest in the nascent field of genomic technologies applied to surgical patients, now recognized as perioperative genomics.

Podgoreanu began his Duke faculty career in 2004 already armed with a National Institutes of Health (NIH) R01 grant. In 2008, another R01 grant enabled Podgoreanu to explore adaptive mechanisms preserved through evolution that confer protection against organ injury. He studied the responses to simulated cardiac surgery in three species using comparative biology approaches and was subsequently awarded the prestigious American Society of Anesthesiologists Presidential Award for his efforts.

The heart of the matter for this driven clinician-scientist is to develop novel therapeutic approaches. He is proud of the genetic research on the impact of intense inflammatory responses in some patients – colloquially termed ‘inflamers’ – in cardiac surgery. His seminal work on metabolomic pathways published in the journal Circulation in 2009 provided insights into how the heart uses fuels during cardiac surgery. This new knowledge contributed to a significant shift in clinical practice — removing glucose from the cardioplegia solution used during heart operations, which significantly improved blood sugar control during and after surgery.

As a clinical and translational researcher, Podgoreanu leads the Duke PEGASUS (Perioperative Genomics and Safety Outcomes Study) group that investigates how genetic variability predicts acute organ injury after cardiothoracic surgery, particularly in elderly patients. Involving more than 5,000 cases at Duke, his work discovered key genetic variants associated with post-surgical complications, using the first wave of genome-wide association studies in the perioperative field.

Podgoreanu expanded the scope of the PEGASUS program from human observational studies to animal models of cardiac surgery. In collaboration with the Institute for Arctic Biology at the University of Alaska in Fairbanks, he investigated the adaptive responses to surgical stress in Arctic ground squirrels. He found that the adaptations to extreme metabolic stress in hibernating mammals may offer insights into potential resilience mechanisms in humans that can be targeted to improve surgical outcomes.

A co-inventor of six patents, Podgoreanu has authored several review articles and book chapters to introduce perioperative genomics and precision medicine to the broader academic community. He is also credited with writing the first genomics chapter in a premier anesthesiology textbook to increase genomic literacy among perioperative clinicians. He says, “Nearly 19 years ago, we introduced and coined the concept of ‘perioperative genomics.’ We have since become among the first to have robustly characterized and published how genetic variation is associated with different types of adverse outcomes, with a resurgence through OneDukeGen – a new Duke-wide precision health initiative.”

"We have become the largest thoracic organ failure program in the country. The fundamental challenge unique to this division is sustaining our growth while equitably balancing clinical and academic efforts and controlling the call burden. This extraordinary patient complexity demands a unique level of clinical expertise, a deep leadership bench, and continued focus on innovating in education and research to deliver the highest standard of care to severely ill patients.”
- DR. MIHAI PODGOREANU

A dynamic sequence of events took place in 2013 when Podgoreanu took on a pivotal leadership role as the cardiothoracic division chief. This period was marked by other significant changes, including the opening of the new Duke Medicine Pavilion that led to the multifold expansion of operating rooms (ORs) and cardiothoracic intensive care unit (CTICU) beds, and the introduction of a culture-changing, new electronic health record. Amidst these professional developments were personal milestones as Podgoreanu welcomed his fifth child into the family, all while remaining focused on a division in transition that provided care for the most complex surgical patients.

Embracing a collaborative leadership style, Podgoreanu crafted a vision to build on the strong foundations laid by his predecessors and take the division to greater heights. Podgoreanu knew he had big shoes to fill to further the legacies of his mentors who had expanded the role of anesthesiology in the Duke Heart Center and built an infrastructure to foster academic growth and education, while continuing the tradition of clinical excellence.

With the expansion came the growth in the number of patients, which was also accompanied by an increase in complexity and severity of illness. “The Duke University Hospital CTICU has indeed been maintaining a very high patient acuity level for many years,” he explains. This has required a substantial increase in the number of faculty – from 13 in 2013 to 31 in 2024 – that included an exclusive anesthesiologist CTICU team that ensures 24/7 continuity of care.

Under his leadership, the CT division has seen robust growth in the delivery of multidisciplinary care for complex surgeries. An expanded team of anesthesiologists that includes many dual trained in cardiothoracic anesthesiology and critical care medicine provide seamless transitions of care between the OR and the CTICU, a source of great pride for him. Cutting-edge tools like echocardiography help these well-trained experts make critical, real-time decisions and ensure high-quality care, informs Podgoreanu. He says, “The key is that we’ve developed, as a corollary of this integrated care model, what we call an ‘academic school for comprehensive training in cardiothoracic anesthesia and cardiothoracic critical care,’ which has become a national model. There is an extreme ownership displayed by our team with 24/7 coverage of both the CTORs and CTICU; it’s challenging, but certainly necessary.”

“Medicine is a series of decision making, akin to navigating with a GPS – this precision health approach empowers us to choose our path based on the unique information of each patient. Just as a GPS allows for rerouting based on real-time data, this approach integrates precision data from various sources like omics and physiology, leading to more informed and dynamic decision-making processes.”
- DR. MIHAI PODGOREANU

Determined to break down barriers between different specialties, Podgoreanu’s approach envisions teaching the next generation of doctors, including residents and 24 anesthesiology fellows, the impact of integrated care beyond the traditional siloed textbooks. Today, division faculty are experts in managing heart failure, shock, emergencies, and high-tech mechanical circulatory support systems like extracorporeal membrane oxygenation (ECMO).

The care of complex, high-acuity patients requires sophisticated decision-support tools. Podgoreanu has spearheaded an innovative data-driven strategy called Symphony to guide decision-making and enhance patient safety. Part of a concept he proudly calls “A CT Anesthesiology Learning Health Unit,” Symphony integrates patient monitoring and medical device data into clinical surveillance and decision support tools. These efforts have positioned the CT division as a leader in adopting innovative practices that not only improve patient outcomes but also streamline care delivery. The division has taken significant strides in enhancing educational and operational practices, according to Podgoreanu. A forum known as the CT Scholarship meeting sparks collaboration among faculty, while a focused mentorship initiative guides fellows through their education and research using advanced digital training tools. Smart, data-driven dashboards boost operational efficiency, track and enhance performance, and provide critical feedback to this learning unit.

Podgoreanu is optimistic about laying the foundation for precision perioperative care. He shares his enthusiasm about expanding partnerships through the institution-wide OneDukeGen initiative, which aims to merge whole exome sequencing with physiological data to pinpoint genomic indicators that might predict complications after major surgeries with plans to study 150,000 patients over the next 10 years.

Podgoreanu is co-leading the Surgery Perioperative and Critical Care Working Group of OneDukeGen and has been appointed to the leadership team of the newly-created Center for Precision Health within the Duke Clinical and Translational Science Institute.

The CT division has also embarked on an NIH-funded Bridge2AI project alongside CHoRUS, a coalition of 14 academic medical centers, to create a comprehensive, and possibly the largest, AI-ready dataset of critically ill patients to transform recovery from acute illnesses. The team is involved in refining, standardizing, and labeling multimodal data ranging from electronic health records to imaging and high-resolution physiologic signals. Other key areas include developing innovative tools to securely manage AI data, tackling ethical challenges to protect patient privacy and reduce bias, and nurturing the next wave of AI experts in perioperative and critical care through dynamic educational initiatives, informs Podgoreanu.

As the division boosts its role within the Heart and Vascular Service Line, it envisions solidifying its expertise in the management of shock, participating in advanced cardiogenic shock teams, and taking an increasing role in ECMO procedures, including exploring mobile ECMO setups. Podgoreanu is proud of the division’s growing national and international reputation in precision health tailored for cardiothoracic surgery and critical care with a special focus on thoracic organ transplantation.

Advancing, albeit through vertical leaps, is still what gets him excited each day. He strongly believes “the key roles and responsibilities of any leadership position are to create and cultivate.” Over the past 10 years, Podgoreanu has seen the multifaceted evolution of the division into a vibrant and diverse multicultural team. A substantial increase in women faculty assuming leadership roles locally, nationally, and internationally has highlighted this growth. Podgoreanu is proud to work with a team that cares and supports each other “in times of loss and in times of glory.”

While bridging the gap between discovery and actionable knowledge remains a work in progress for this clinician-scientist, Podgoreanu is happiest when taking care of patients in the operating rooms, the CTICU or electrophysiology labs. This is what he feels he was meant to do as his main purpose and calling in life.

“A key recipe for happiness in a human being is a very, very distinct and strong sense of purpose. Generating new knowledge, delivering knowledge, and leading amazing teams are all very important to me. I have the best job in the world; it’s amazing that I also get paid to do it,” says Podgoreanu with a smile. BP

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