 Before I get started real quick, I have a little cleanup to do and that's expressing my thanks and appreciation to all the directors and boy the many faces I see in this room that were precious to me, they're seated up here on the front row. I think then, and like Craig said, Dr. Cooley and Dr. Frazier, it warms my heart to see Dr. Frazier participating at our meetings. Dr. Cooley commonly presented at our meetings with the Academy and he would just show up because he wanted to. And so I think that was a wonderful, wonderful attribute in him and every time I look at that picture of Diane Clark and Charlie with the reading Clark textbook I always think the expression on Diane's face is did we really write that or something I can't figure out what they're talking about. But anyway, and there were three of them. There's three of my classmates here, including myself. Let's see. I'm right there. Doug Thompson. Penny getting she's here. And then, unfortunately, two of my classmates are deceased now, George Bigley and Corey Singer. So we were voted the most outstanding class in the history of the program. Not. Chris has contest that. But anyway, all right, my presentation is taught a past and future of profusion technology. And I think everyone in this room will agree with me. It is inextricably interwoven with cardiac surgery. I have no declarations or no conflicts of interest. So, having gotten that detail out of the way. I'll start by looking at that very topic, medical ethics bio ethics, and for 500 years, you know, through the classic great period Hellenistic age the Roman age the emergence of Christianity. I'm an unknown disputatious pre-hippocratic writer who wrote I am utterly at a loss to know how those who prefer these hypothetical arguments ever pure anyone. I don't think they are ever discovered anything that is purely hotter code dryer wet, rather they impute heat to one substance and code to another. It is my opinion that all that has been written by so this on nature has more to do with painting than medicine. I'm ready to adopt the hippocratic oath and the hippocratic corpus wasn't that anyway, we have greatly improved on that as you know, in the last several years, modernly. So, if I don't accomplish anything with this presentation. This is the greatest goal from in compiling this and this is not a technology perfusion lecture. It's a hopefully a motivational lecture, and mainly for the students, the younger people 10 to 20 years into your career and encourage you and unravel a modern day myth that technology is dead. And if you think I've been drinking or smoking something. That's not true. I'm going to hopefully convince you of this very thing that I wish to impose. I'll begin with the stagnation of science and the fact that many writers in history have wrongly characterized the myth of the dark ages from 500 AD to 1500 AD as a period when academia scholar scholastics and so on and so forth were sort of not happening in a sleet you know, if you look at the fact that Columbus confirmed the earth was anything but flat that was pretty monumental discovery. And the most wonderful discovery occurred in anatomy in that period, beginning with Leonardo da Vinci whose anatomical drawings were discovered 300 years after his death, and he just he was the first to describe coronary artery disease as a cause of death. He described the heart valves and the great vessels prior to William Harvey, his his work as I previously stated went on for 300 years and not notice so his heart drawings and his anatomic drawings were just magnificent. And as Craig said, Marcello Mulpeage, he discovered in 1661 as she transitioned to the Renaissance era, Mulpeage discovered the capillaries, the missing link in Harvey's discovery of the circuitry system, Harvey didn't have the benefit of a microscope. And so he never connected the two and Mulpeage made the monumental discovery sitting in the courtyard at Padawa, the University of Padawa, and I actually have been to that school and enjoyed touring it. And when it's sunset the sun was just right and it wouldn't blind his eye with the mirror. He was able to see the capillaries in frog belongs. And here's a topic we don't tend to like to talk about in our profession but yet we do, when we have to, and it continues to haunt us. So Reedy in 1667 was the first to publish on the fatal potential for vascular air embolism. Others contributed in this regard in that period, you recognize a few of the names at least. Now, Salva, we hear that every day, but yet in 2000 Muth and associates described air related injury mechanisms and I thought they did a great job if you get a chance read their article, it's listed up here at the top of my slide but they proved that it wasn't solely just occlusion, causing ischemia in the brain and the subsequent neurologic injury. It was a variety of factors, including temporary occlusion along with secondary thrombo inflammatory responses at the sites of the air injured endothelium and then ultra structural and functional structural complex interactions among bubbles, blood and the formed elements and endothelium with fibrin deposition and you see the two pictures of Venus reservoir there. The damage done by failure to ameliorate Venus line and train air and I discovered this and took a picture with my cell phone and I couldn't wait to go to the hospital the next morning and confirm the lady had not had a stroke or something of this nature. She was doing better than I was she was sitting up in a bed accident. I mean sitting up in a chair ex the bed, which thrilled my soul. Okay. Now, it is true if you read the history of our profession 17 of the first 18 patients in published medical literature. There were others that weren't published, but about a 94% death rate or mortality in the first 18 patients that were placed on cardiopulmonary bypass and air embolism was the most common cause of mortality and always attribute this to the fact that it was the profession. The surgeons that were in training others, maybe anesthesia residents or something that were operating the heart lung machine. They were more interested in other things but one day. It happened in perfusionist and their career was born. And if you think that our work is done this, this cardiac surgery and the world is done and complete and over and things like that and dip down into the doldrums. Look no further than 310 million people undergo a surgical procedure annually around the world. And it's in a very good study 474 hospitals in a seven day period involving 44,814 patients. Medical error was one of the most alarming things that they realized from this study, one in six patients developed in hospital complications, one in 35 of those died. And if you extrapolate the numbers out 50 million patients annually in the world experience some form of complication in hospital and one and a half million die from these complications so what are your goals in perfusion, what are your goals in managing the heart lung machine and applied physiology. I think, look real hard at that. I have a series of calculations that I do on every single patient. I'm not going to bore you by belaboring that the symbol of star of hope and guidance is something I use to motivate myself you have things that motivate you. And I go through calculations, identifying the patients body composition, because body composition is a major factor when you start considering how you're going to conduct the act of perfusion. I look at their renal function, I look at their colloid osmotic pressure estimations, and we learn all this from the pediatric perfusion is I take notes when I go to hear them talk. And so, think about how you can improve your conduct of perfusion by looking more deeply at yourself. I do this for not publication purposes. I've studied 100 patients, and what can I glean from looking at that it's a self analysis, but yet it can be institutionally evaluated as well, 68% of the patients I do are anemic. And it's hospital acquired anemia. I don't even worry about looking at the thematic until the final, or the initial ACT after I run on systemic heparinization and a concurrent blood gas. What's the crit five minutes for I'm going on pop and I guarantee you 68% of them are in the range of 26 to 32. And what do you think the predicted dilution rates going to be versus the actual dilution rate. So we need to clean that up. I don't you may do a better job of that than some of the places that I have worked. It's something that we need to apply in go directed therapy, and it's beginning with the patient's admission to the hospital. So excuse for Matt, not paying attention to detail and infusing in the pre op holding area area of leader of crystalline fluid and oh my God, the direct rate what manage profit, you know, so I think there's work to be done there. Now, the 20th century. If you look at 1900, the leading the heart disease was the fourth leading cause of death. I commonly use the eighth leading calls because you have to back out all the various infectious diseases to Berkeley losses dip theory and so on and so forth. And it actually moves closer to a, but it's the first century in which cardiovascular disease was the most common cause of death in the United States and it may well be the last century between now and the end of the current period. Like he stated previously what's it going to be like in 2053 I won't be here but maybe y'all can shout at me up above if I'm there. Hopefully, but anyway, it may well be with all the progress that's going on in medicine that I'll elaborate in a minute. So cardiac surgery is dead. Really, right about the time I reached the age where I should be making life choices and health decisions you know I'm not willing to admit that and I don't think you will be either if you look at these numbers and I'm not going to read them all to you the 5 million people suffer congestive heart failure 550,000 patients annually are new newly diagnosed with congestive heart failure every 40 seconds there's a mild cardio infarction. And if you look at all the other figures. Deb will have this presentation you can go back and look at the numbers. I'm not convinced cardiac surgery is dead. I'm going to elaborate on the modification process we're going through but there's no question about that and I'm not in denial. Today's statistics the younger people. There's 7.5 billion people in the world today and 6.65. And 85% of Americans on a smartphone that's up from 35% in 2011 when it was introduced. Relentless innovation is what got us here today by cardiac surgeons perfusion is manufacturers and all the people involved in how we care for our patients and by the year 2030, you at least have eight more years. 2030 cardiovascular disease will be among the three leading contributions to disability adjusted life year 65% of death around the world will be due to cardiovascular disease so I think as I stayed here relentless innovation or the lack there of will dictate your future and you guys getting ready to graduate and so on and so forth need to really be involved don't sit back and wait on others to do it. Jump in and get your feet wet. We're better today than we were previously our systems are dramatically improved there's no question about that. We need new manufacturing ideas and credit clinical research, and then the question I have for people like me and others, what are you and I going to give back to the schools to promote research. Oh, something. And I need to be doing that. What is your idea as you approach retirement or enter retirement to make a bright future for these people in this room that are going to take on the challenge of treating us in our adulthood in the advanced years. Well, fun. Okay, who are the faces of innovation here at Texas Heart I think we all know the answer that I think that's our, it's Dr. Cooley Grady homin senior, and I think Domingo Leota, when they did the total artificial heart 69 and then bud Frazier of course as Craig said, I'm not going to read the numbers to you my God, they're staggering. I think Terry said they've done about 125,000 open parts now. Sequencing the human genome took nine months and $100 million to complete in the year 2001. Today, it can be done in 24 hours for $1,000. This is the area I start delving into for the future. You're going to see genomics practiced in medicine where massive data coalesce and you're going to see nano technology, you're going to see artificial intelligence smart technology, and our manufacturers need to keep our heart lung machines and us plugged into this. I'm not smart enough to do that, but I know every one of you are the STS database when you look at the year 1960 there were 10,000 open hearts performed in the world. Now look, since 1989, there's 7.5 million cardiac procedures registered in the STS database with 3800 facisions participating. So, man, just look at the explosion. And if you think that's dying, you know, I don't know how to comprehend that. In the way we were, we have made dramatic improvement in 1952 46% of deaths were due to cardiovascular disease 30% of heart attack victims did not survive. And if you look at Dwight Eisenhower while he was president of the United States, he had a stemming heart attack. He was very consistent of the amyl nitrate morphing. And that's it, bad rest for about a month. And there was no cardiac cath available to him there was no EKG and all the various hospitals he was in Denver on a golf outing when this took place. He didn't have an EKG machine. And so pacemakers and everything else were yet to be discovered on the horizon. And if you look at john Kennedy's quote victory has 100 fathers defeat is an orphan. He was referring to the Bay of Pigs debacle. But I apply that quote to cardiac surgery and who gets the credit you know they're monumental people that made discoveries from 1897 to 1988. And I'm not going to read the slides for you you can do that for yourself but I don't think that this profession is dying. Are you convinced more so now than before I started talking. Good. We're redefining our profession. We're in that process right now. And it's a very young profession. Heck it's only been 58 years since daughter performed the first peripheral angioplasty. It's been just a short period of time if you look at all these events that took place. It's just amazing what we have done in a short period of time due to relentless innovation. If we let innovation die. I can promise you you're not going to be happy with your future. But the next 25 years will be challenging cardiac surgery I think experience complacency in the coronary bypass era what we refer to as the golden era of cardiac surgery. People kind of got complacent. They didn't think it was going to go away and then all of a sudden. The term PTC a drug eluding stance and so on and so forth started emerging in the late in the early 80s. And I don't have to tell you the rest of the story because you're leaving it today but that that stent for drug eluding stent doesn't cure coronary artery disease. The coronary artery disease still exists distal to or proximal to the stent and the gold standard is coronary bypass and the syntax trial of angioplasty versus coronary bypass surgery. We won that argument. But it's just a deal where in the future. This very topic here may sensitize you tab or even pathology is eventually going to define how people are treated in cardiovascular illness. There's going to be corroboration and collaboration you're not going to just admit a patient go straight to the cath lab and. Do what you please. They're going to have to be pathology guided treatment where maybe the patient has a disease condition that makes surgery the more preferred treatment versus angioplasty or drug eluding stance. None of us want to have our chest split open. We should applaud the fact that in the future 75% of the aortic valves will be done by cover most likely, but they accept less standards for results than they do by the open aortic valve method. But yet we still will be doing 25% of those vows so we cannot fail to look at that and maintain preparation. New horizons as I have alluded to and then I'm almost done with you. Artificial intelligence are on the new horizon, merging in the genomics and the period for introducing the smart applications that all of you guys comprehend where you'd have to sit for hours with me and try to explain how to do some of the things you do. With this technology right now, so you wait until it's applied to genomics disease and so on and so forth it's going to be staggering. And working in concert we're doing that right now in the cath lab or hybrid operating room in the one statement I'm going to make here and move on. You'd be the best standby perfusion is that you can be for these procedures. I know of a case today in our institution, the catheters were too large for the Iliac artery. And guess what they had to open the patient. You got to be prepared read the patient's chart know their history. They're more advanced in their disease phase than what we used to do when we did 5000 open parts they didn't take the memory back then that things have changed in our patient profiles. So be the best you can be at everything you do, and you probably won't have to worry about your career. And so the modern myth, give us a chance came to my mind and associating just a short period of time when all these accomplishments took place. And I think this is my last slide. I'll carry you into the future. You've heard that from Craig. And now you hear it from me in person of manufacturing demand innovation, and more and more of yourself demand most sacrifice of clinical responsibilities. So once you give something away you don't get it back. And then this is not a career of convenience never even consider that as Craig alluded to with all the events in his personal life he missed of yourself be willing to accept new roles and improve old ones, and then be active in your part of your profession. And I mean, that is something very important. Don't go for the next 510 years and just accumulate your CEO credits and not be involved. I'm going to help your career, get involved and be active. And then if you sit oddly by the one thing I can tell you with certainty is, I guarantee you your vocation will die. If that's what you choose to do as a professional so be the best heart team member that you can be. And I'm done. Thank you.