 There you go. Okay, perfect. First of all, I want to thank everyone and especially Deb and Kathy for this incredible opportunity to be here at Joll's 50th anniversary of the Texas Art Institute School of Perfusion. It is certainly an icon of education in our profession. It's where our profession from a modern perspective, I think, began of course with the founder Charlie Reid. I understand that Charlie's son is somewhere in this audience. There's somebody that kind of looks like him, but maybe a little older, not as crazy maybe, not as wild, but certainly here. And it's just a tremendous honor and I appreciate you guys being here, the senior students, the junior students too. You get your chance next year and you guys are welcome to participate if you'd like to. But just being here is incredible. So thank you for very much for the opportunity. So my talk, I'm going to start my little timer and I'm actually going to let it only go for 15 minutes because if I don't, I talk too much and you'll all find that out about me. So my talk is on ECMO overview, why, how and outcomes. Now, in reality, I could probably talk on this subject for 15 days and still not cover a portion of it. It's just such a complex issue. So why do we do it? Well, we use it for circulatory support when we have circulatory collapse, cardiogenic shock, MI, PE, post cardiotomy failure, failure to wean from cardiopulmonary bypass, you know, obviously. And of course, we use it for pulmonary failure, ARDS, status asthmaticus, any cause of pulmonary failure could be pre-transplant support. There's just so many different reasons we do it. But at the end of the day, we either need circulatory support or we need circulatory and pulmonary support or we just need pulmonary support. That's kind of the way this whole thing works. So how do we do it? Well, you have VA, so we can do venoarterial ECMO, right? We can do venovenous ECMO, we can do exotic cannulations where you have VA-V, venoarterial to venous, we can have venous venous to arterial. And for those of you who don't know, friend of Tammy's in mind, Tammy, I think you heard from Tammy next, maybe or second after me, John Ingram pointed this out to me. And I think intuitively we knew it, but he pointed it out. Where the dash is, is where the oxygenator goes. So when you're describing ECMO, it's really good to know what are we doing? Do we have two accesses, two returns? Do we have two different circuits? Do we have one access, two returns? And so where that dash goes tells you a lot. For example, in the VVVV, clearly two different circuits, two oxygenators. That's the one at the very bottom. We can have central cannulation. We can have peripheral cannulation. You can have combinations of those cannulations. So really, at the end of the day, there's all kinds of ways, all kinds of places to put these tubes, where you put them, however, is going to depend on what you're trying to accomplish and whether you accomplish it well or not. So here's just a diagram of all the available options. I won't go through them all, but you can see the ones on the far right of the screen being the butterfly technique. You have dual circuits, and the ones on the left are different iterations of VVA, VAB, and so forth. I know you can review all of these, Chair Leisure, but leave it to say this is only a partial representation of all of the different things that you can do. Now, for the senior students, outcomes. Outcomes is a big deal, and I'm actually spending probably a little more time on that than anything else today. I think if you find six folks believe that when you go and they give a consult, we're going to have to put this patient on ECMO, and we really think it may benefit your patient, that they tell with VA, it's 20%. If you think it's 20% is what is normally consulted as the survivability. So keep in mind, this is survival that the patient will survive. How many of you think it's 20%? 20% raise your hand. Okay, how many think it's 40%? Okay, two hands. How many think it's 60%? Okay, and how many think it's 80%? Okay, good. 10 bucks each. Okay, the VACMO. When you consult for that, the just average, how many people think that they tell the family, we think it's going to be about, and this is for any cause, not specific, so keep that in mind, 20%. 40%, 60%, and 80%. Okay. So very good. So all of you get 20 bucks. Fantastic. 10 bucks, 10 bucks, 10 bucks, 10 bucks, 20, 20. Okay, I may need to borrow some money, Deb, Tammy, anybody, collection jar out there. They're smarter than I thought. This isn't going well. So let's look at survival. Survival is such an important thing. And this is public survival. And it's very, very, I think inconsistent at best, and confusing even to me. And in some ways concerning, because this stuff gets published, people read it and decisions are made about using ECMO in various circumstances that may or may not be a great choice. So we have to look at the data, however, in order to understand. So in this one year outcomes with VV ECMO, this is for COVID-19 published in the STS. We see here that they, and numbers relatively low, it's 30. All VV, BMIs were about 30, and I highlighted a couple of things we can just look through some stuff. Days from intubation to ECMO cannulation were two, which is really short and good because that's important. I think a key indicator, the longer you're on vent support with all the barotrauma, the less likely you're going to recover. And that's something that's very important. Do you have a recoverable disease? Putting people on ECMO, if you aren't going to transplant, you have to recover because you cannot stay on ECMO forever. There are some who have been on ECMO for a very long time and actually survived. So you have to remember there's outliers, but then there's also everyone else. Who's the outlier? No one really knows. You look at their CRP and their PCTs and you can see what those elevations or lack of really gross elevation is. Their PF ratio, surprisingly, were 80, which is low, but I've seen much, much lower before a decision to put a patient on ECMO existed. And you can see their peak pressures and our plateau pressures were 30 and 32. Again, those are high, but not unreasonably high. We've seen much higher numbers than that. Creatinines down in the middle bottom were relatively normal. Not a lot of renal failure in this population of patients. And let's just get right to the thing. They actually used 33%. So out of 10 of the patients, they used cytokine hemo adsorption, which is like the cytosorb filter that you use for removing cytokine. So molecular adsorption recirculation technology. Those that survived ECMO 93%. Those that survived the discharge 90%. Duration of the ECMO was about 19 days. We've seen much, much longer than that on COVID patients. And when you go to the final slide, their one year survival was 86.7%, 26 of the 30. That is absolutely remarkable. I worked here in Houston in a variety of different hospitals, including right here at the Medical Center with patients that were on VV ECMO for COVID. And none of the places that I worked, I saw this kind of survival. But yet this is still published and published in the STS. So small in number, respect that, but how selective were they on their patient population. And that's something that always has to be asked. When you take a look at this other study here monitoring cerebral oxygenation, and this in introspore transport, this basically the study was done to take, and this is published in the SIO 2022 again COVID patients. And this was to determine whether or not the use of cerebral oxygenation would be beneficial for taking a patient from hospital A and transporting them to hospital B. And if you just look at it, the survival of these patients after ECMO support for VV was 50%. So now this was a smaller end number, it was 16, but I still believe that there's a definite difference between a 50% mortality. And in 93, 86% mortality, 86.7, almost 87 at the end of one year. That is a very remarkable difference. And why is that? Well, I mean, we can look at the data and try to understand it. Hours on mechanical ventilation for those that survived were 83 hours, those died were 98 hours, so they were on mechanical ventilation longer than the previous group. Their PF ratios, remember I showed you it was 80, now they're 70, 72, so for average 72 for the survivors and 68 for the non-survivors, though that was not quite statistically significant. Their peak inspiratory pressures were a little bit higher. 34 was the average, 33.5 for the survivors, 35 for those that died. You can see acute injury was higher in this population of patients as well, and obesity seemed to be a little bit higher also. Is this a patient selection issue? Is this a, we waited longer and kept them on the vent and their disease is now irreversible? Is it that the previous study was that we put the patients on ECMO, maybe they really didn't need it? And I think that it's very important to understand that ECMO is in and of itself not good for us. If we take a normal healthy person and put them on ECMO, it will hurt them. And there's a whole host of things that happen without getting into that, but you have to take that into consideration. Deciding to put somebody on ECMO can be the worst thing you can do for somebody if they cannot necessarily go on ECMO and still survive their disease. And how you make those determinations, man, I'll tell you what, I've been doing this for a long time and I can't answer that question. It is just clinical judgment and trying to do the right thing at the right time for the right person. It's very difficult to do, but you will be confronted with this because I could assure all of you guys, especially the senior students and the junior students in the back. ECMO, I believe, will continue to advance as a therapeutic modality. And the harsh reality, and you can feel how you wish, but I'll tell you my perspective, is that there will never be enough profusionists in the market to accommodate what is a seasonal and fluctuating volume of patients for a therapeutic modality. If you have enough profusionists to cover every ECMO that could happen during the pandemic, you will have so many profusionists when there's not that pandemic or there's not that high acuity, you will not know what to do with yourselves and it will be very bad for our market. On the other hand, if you just give it away and have zero control of it, then that can be very deleterious for our industry as well. We have to somehow find a balance between the management of a tool and a modality, while at the same time being able to utilize people who are going to manage the technical component of it at the bedside, hour by hour, and then use us for rounds consulting and so forth. I think that's the only way it's going to survive and not exclude us, but other people may have different views about that, and certainly I respect those, but that's what I think. Moving on from here, we look at this predicted, how about this? No, this is, no, that's not it. I'm sorry, I went to a different, different study. So we look here, then we look at, that was the 16. Then we look at this last study, so there's three studies. This is the next one, also in ASIO 2022, and this was done with a large N number, now almost 2000 patients. And if you look at their mortality in this particular study, it's pretty close to 50-50, and this is their numbers, much larger N, but you can see we went from, and it's about 50-50, it's a little bit better of survival. It's 55, I can't really tell you what that percentage is, somebody could do the math on it, but keep in mind, we're going from a 93%, 87 to 93% survival to a 50% survival to a plus or minus 53% survival. So those are consistent, but there are lots of other studies out there, lots of them that show variation from 80% survival, 50% survival, 30% survival, our data, which we're not quite complete in putting it all together to make sure that we are as accurate as possible. From what, just on a, with a caveat that this is not ready to be necessarily disseminated, TAMI were somewhere around 15% survival with an N of 100, so we have an N of 100, and we had about a 15% survival. And that's dismal. It was very discouraging, and my experience, again, coming to the Med Center and being some of the hospitals, excluding those patients that were able to be transplanted, but I'm talking about patients that recovered from their disease, left the hospital, having survived COVID, ECMO, my experience here, not necessarily Texas Heart, but over at some of the other institutions was that their outcomes were just as abysmal. So it's surprising to me and concerning to me when I see these extraordinarily high survivors, if I have five minutes left. If you're in the REST score, you can see your higher REST score, you have a higher probability of survival, a lower REST score, and you can get the REST score online is very easy. And you can look at your patient, you can put in all the information if you have a very low REST score, you have a much higher probability of mortality. But again, I think it's a very good tool to use. It's been validated several times. There's been also people have validated it and found that it really wasn't as accurate as they believe it to be. So again, you have to take everything with a grand assault, consider all of the resources, look at the patient, make determinations. I remember I was speaking very overweight patients don't do as well, but yet there are patients who had either a patient that was 18 years old had a BMI of 79 and they published it was on ECMO for three months. Yeah, 79 can you believe that that's three people needed three ECMOs at one time, but that patient survived. And those are outliers one never knows when that's going to happen. And so but is that the norm and really no predictably it's, it's not. So, yeah, you just don't know. Okay, test for you guys this is for this is the bonus round and this is for the big money now. Okay, this is for the big money. There's no trick. So if you I can't tonight. Is there a mouse I can use on this. Does it work. Okay, good. So if you look here. Yeah. Okay. Can you take this away. How do I make that go away. Just drag it. Oh, you're doing it. Okay, I let go. Perfect. Okay. So this line right here is in the right femoral artery. This line here is in the right femoral vein. This line here is in the left femoral vein. And this line here is in the left femoral artery. So my question to the students and you could just blur it out first one to blur it out wins that round. What is this and where is it. Okay, it's not too at a time so whoever spoke first whoever spoke first stand up say what you got to say. The SFA Superficial Femoral. Very good. Okay, you won that round. Don't let me forget. Okay. Now, next question just boarded out if you want. What do you notice about these two access lines. This is in the right femoral vein. This is in the left femoral vein. What do you notice about these two accesses anybody see it boarded a stand up raise your hand boarded out color difference very good. Okay. Now, for the final question on this round. Where is this cannula. Where's the where what is this draining. It's in the femoral vein and it's red. This is in the femoral vein and it's blue. Why is it red. What's it draining. You moved. Come on, you left. Anybody say it. Junior students anybody got an idea is where near the RA. Okay, you're staying a junior student sorry. Wrong answer. Anybody else. Okay, so any of the any of the experience profusion is where is it. I'm sorry. That's a good thought but no, that's a good thought though you can join those guys back there. So, it basically so let's think about it. I'm going to give you guys a chance. It's red right. It's draining arterialized blood. It is in a vein. It's in the right femoral vein it's kind of hard to get to the pulmonary vein from there you can do it. But how would you get weight you're you're getting there. Where is it. How did it get there. Transseptimal approach is that what you're going to say. It's got to be a tandem you are correct. Good job kids. That's a catheter that's punctured through this atrial septum into the left atrium to decompress the left side. Very good. That concludes my talk. Thank you all very much.