 I can say definitively that Dr. Cooley, Dr. Willerson, many of the luminaries that I had the privilege of knowing over the course of my life would be thrilled to see this. Absolutely thrilled. So to be a small part of this is really an honor. This will not be the most scientific presentation you've heard, but it may be one of the most passionate. Maybe it's going to feel like a sermon a little bit. I kind of actually hopes up. Expectation setting in pediatric heart surgery, pediatric perfusion is profoundly difficult. All you have to do is look at the published outcomes disparities and you know everyone here. We can take a moment at the Texas Heart Institute and pause and think about what's going on in our country and in our world in terms of health care disparities. It's an absolute abomination. You all know that over the last three years in the United States life expectancy has gone down. That's in our country. Despite the fact that we spend 20% of our GDP on health care. We have serious problems and is for serious people like you to take them on but you can't take them on by diluting yourselves. You can't take on complex pediatric perfusion. By diluting yourself. So, anyway, enough of that, let's just give you a rundown of what I think are some important some important elements of this, especially first of all, great colleagues. Tiffany, Kellen, our tremendous colleagues we've recently added Doug and Madeline to our team in Austin so we're five perfusionists. And we're really proud of our association with the profusion school, Texas Heart profusion school where we have welcome. You all, and we'll continue to do so as long as you give us that privilege. First, we're here in the house of Dr. Cooley built and the symbol of excellence is everywhere. It's all about excellence, but defining excellence is not so easy. And achieving it how do you know that you've achieved excellent how do you really know that she's excellent. And then once you think you're there how do you maintain it. And excellence is not a destination. It is a continuous journey, and it can be painful, and it can be unpopular. But this is not a popularity contest. We're here to work together for the benefit of our patients and their families. I also can't come to this institution and not think about our late departed friend Dr. David sugar Baker, who was a transformational thoracic surgeon as you all probably know some of you know. Dr. sugar Baker was president of American Association for thoracic surgery, which is pretty much the highest honor in chest surgery. And in his presidential address, he had a slide that I plagiarized clarity of purpose focused attention. The essence of excellence. So I made a copy of that it's been on my bulletin board ever since which is a lot of years, you see how prominent it is right next to picture in my family, I look at it every single morning. Because I believe that we have to touch base with who we are and what we are doing every single day. And this is what we propose to do. We propose to take care of people's children. And when we come become callous or wrote or protocolized about that too much. We lose sight of what we're about. How do we set expectations so in a medicine and medicine now personally talk about observed to expected outcomes. So what are observed expected outcomes and profusion. How do we pick the cannulas do we use vacuum assistance. What's the prime look like what device are going to use and what vendor are we going to go with who's going to be on the team what are we going to use for pH management. Are we going to use any grade cerebral profusion. What are adequate flow rates how do we assess that. What cardioplegia do we use what mode do we deliver it do we use nears we not blood pressure targets. How important is serum lactate base a dilator coordination modified ultra filtration zero balance ultra filtration continuous ultra filtration. How do we transition from ECMO what vads are available. And how do we make patients accessible transplant candidates. That's what we do right. Do we have answers to all of these. No we do not. I'm lucky enough to have been in a lot of great places over the course of time they all indelibly influenced me University of Texas Medical Brands Johns Hopkins Cleveland Clinic, Texas Children's and in the upper left quadrant of the screen. World Children's and Melbourne. So be very careful about what you don't know. Be very careful about what you don't know. I highlighted that in red, because as I was at a great place. This is the story Johns Hopkins hospital. Kathy and I were colleagues. It's the story Johns Hopkins hospital. And I was there for almost 10 years, and I participated in a lot of heart surgery in fact that's where I learned to be a heart surgeon. And parenthetically I put this is in as a side, having a an extra corporeal profusion device to resuscitate heart lung blocks is not a new concept. And this is what we were doing in the laboratory in the early 80s of Johns Hopkins and it's wonderful that this is now coming to clinical fruition to the benefit of our patients. In that experience we got to spend a lot of time in the research lab and this is yours truly, and one of our profusionists and so I learned a lot about the pump. In fact I broke a lot of pumps. I broke a lot of messes, but that was a bit that was actually a very vital experience and this is me in the operating room of Johns Hopkins. This is probably about 1992. I thought I knew everything. I promise you seldom wrong, never in doubt. That was our mantra. What I believed about profusion around that time was that every baby came out of the operating room cold and edematous and usually acidotic. The longer the operation for the outcome. Leading is an expectation and pediatric cardiac surgery speed is paramount accurate accuracy is desirable, but compromise for speed is acceptable. You can be a pediatric heart surgeon in the morning and an adult heart surgeon in the night you can be a pediatric. Refusion is on the weekend, but an adult perfusions during the week. And that perfusions are pretty much technicians. You know, out of sight out of mind, turn it on, pull a listen, pull that and don't bother me during the operation. That's what I believed. What I know about pediatric profusion in 2022 is that every baby should come out of the operating room you've only make warm well profused and with a closed chest. The lengthy operation has absolutely no bearing on outcomes. Everything should be extremely rare. Speed is irrelevant and often dangerous, gentleness, accuracy, attention to detail of paramount and should never be compromised. Patients are individuals. Therefore, focus for fine circuitry support is mandatory. And the perfusion is our integral professional colleagues on our team. So what happened. What happened to me. I just slapped up by the side of the head. So I drug my poor family and many of you have heard the story before but you can't hear it enough. I drug my family to Australia to a very meager hospital will children's hospital and thank goodness I was introduced to a tyrant, a brilliant tyrant, the sort of person that I would want operating on my grand, grand children Roger me. He is the most under recognized surgeon of my lifetime. He should be lauded everywhere for what he has done in pediatric cardiac disease, but he's not. But fortunately the country of Australia saw fit to honor him recently and he received the order of Australia which is essentially the same as being knighted. This is something under the official auspices of the Queen of England and so a very appropriate acknowledgement for Dr me's contributions. But he was a tough cast master. And this is where I learned that all those things that I thought were true at Johns Hopkins, I needed to pitch them out and start over. I needed to meet people like Stephen Horton, who were intensely focused on precise physiologic profusion of the server, and the results were shockingly different, not just a little different shockingly different. And I can tell you exactly where I was, and with whom, when I said I'm either going to do it this way or I'm not going to do it at all, and that continues to be my commitment. And I stole these slides, these are Melbourne slides, small body profusion, not scaled down adults, accurate machinery appropriate cannulus customized profusion, not new avoid rapid temperature changes high flow low pressure system evades a dilation ultra filtration cannula position, not new. And by the way they were pression in their understanding of pH debt management at that time. So I'd hopefully someone in this meeting has talked about this but this article just came out last week and journal American College of Cardiology it's very worth, well, well worth reading, written by a senior author Jim Kirkland the origins and evolution of extra territorial circulation. It's a tremendous article of course it's a, it's a viewpoint on the heritage, the Texas heart team might view it a little different. And you know I might suggest that some of you all think about writing an editorial comment about this because it's very interesting article about the development of the subject. Now I came to Houston in 1995 was invited to build a new program. And we had a lot of things to take on that needed house key housekeeping. And if this is making people a little uncomfortable good. We should talk about that, because this is the reality of expectation setting and the pursuit of excellence there was a problem here. There was a problem with pediatric cardiac surgery, and there was a problem with pediatric cardiac profusion, undeniably. So what did we have to do we had to build a team committed to the children and that required challenging Titans, challenging Titans of the industry to say we need to go back to the basics of commitment. And that included continuous rapid cycle following improvement we got the right people we embrace them. We clearly articulated the expectations, and we were and continue to be relentless about this. And that including taking to task people like Dr debate. You think that wasn't difficult to talk to Dr debate about a different way of doing things in the Texas Medical Center I can promise you it was. You think that wasn't difficult, I can promise you it was, Dr Keats difficult to tell them that we needed committed profusionist committed anesthesiologists, surgeons committed or. But we got it done this is Texas Children's at that time. Again, there were very low expectations, the perjury of term was the pump. I heard it once I heard it 1000 times from our cardiologist. Well, he's going for a re operation you know he's been on the pump before. So he must have had an incremental problem developed with the myocardium because of being on cardiometry bypass. Imagine that pervasive opinion that every time you're on bypass you got worse and worse and worse. In adult cases, throw a few children in here and there. I tenor it everything. You did a child in the morning you did a cornering bypass in the afternoon, etc, etc, etc, except cardiology. And there were very low expectations, my patient, you thankfully is still alive. Nicholas Burke was the first surviving hyperplastic at Texas Children's in August 1995. This is what happened. The expectations were low. It's uncomfortable and comfortable information. So to change the legacy got to get the right people. It's always about the right people. You can have all the tools all the bells and whistles if you don't have the right people, you're not going to get the job done. And we got the right people. We got a dream team. Hopefully y'all know some of these folks one of them is sitting right there Richard Owens and we've been colleagues now for longer than either of us want to admit Richard leads our program in Austin now, but that Mary Ann Mary Claire. Thousands of hours together and a lot of direct critique quality improvement. One thing that really made them unhappy is for probably the first 500 cases we did what take the profusion record, the anesthetic record. I will fax it to my colleagues in Melbourne and say look at it. What do you think, how do you think we're doing. What can we do to do better. We're not friends and that I promise you, but that's what we had to do. And we started having two profusals at the at the at the field. That wasn't a popular reality. But it worked. And then, of course, we had to invest a lot with the credit of Texas Children's. They didn't resist the significant investment we need to make a machinery. And with all due respect to Dr. Cooley modify simplify and apply doesn't work on complex detailed small body profusion. We needed the right tools, accurate tools, and a lot of gear. And we needed to be watching things really really closely so I pretty much live in the, the ICU. So all about committed profusion, optimize outcomes require serious committed people. Optimize outcomes require continuous improvement, optimize outcomes are not easy. And they can be undermined by perverse incentives. So what does that mean, if there is an in a disincentive to doing the best thing for the patient, there's going to be a problem. That includes itinerant personnel, who do something and do something else, and may have a conflict of interest with regard to patient commitment. And we can have administrative intrusion, we can have an administrator somewhere that said, you know, we'll need that. Why would you need that why would you need nears. What are the data that support the use of nears. And we have to resist that and then sometimes we're just out of resources. So how do we get accurate. It's all about the details. And of course I could be having the same lecture with aspiring pediatric cardiac surgeons, cannulation, no big deal right. No big deal can you let all the time. We don't get it right all the time. Ladies and gentlemen, we don't get it and the smaller the baby. And by the way, for those of you here who are connected to industry. In psychology, cannulas have gotten worse and worse and worse. What I use today is infinitely worse. And what I use when I started at Texas Children's in 1995. It's all about industry interest. A traumatic, thoughtful, accurate. There are so many ways to mess it up. The smaller the baby, the more likely continuous troubleshooting. Stay with it. Don't tolerate or drainage. Don't tolerate or drainage. You can't overcome it. Don't tolerate or drainage. Don't interact. Don't smash on the heart. Sneak up on it is what I say, whisper to the heart whisper that you're coming in you don't know that I'm here. I'm not going to beat you up. I'm going to barely touch you. I'm going to get the cannula in you're not going to know I'm here. You're not going to know I went on bypass, and I'm not going to tell you when we're coming up, we're coming off with a whisper. In our core practices, you know, we could have an entire electron each one of these subjects, high hematocrit, short circuit left side of the pump on the left side of the patient. I'll show you why in a minute ph stat. Yes, integrate cerebral profusion, rarely deep hypothermic circulatory arrest, pretty much only for total anomalous pulmonary abuse return, customized prime, no vacuum assist. We have crystalloid cardioplegia to this day, which we haven't changed in over 25 years. Did it yesterday. Did it the day before intermittent crystalline cardioplegia high flow low pressure, planned early exhibition and continued self interpretation. So can a surgeon mess up cannulation. Well, I did. I do. My colleague Dr Gottlieb who will speak to you on a little bit. Publishes quite a number of years ago, I got the candle to deepen the arch, and we had cerebral malprofusion. Now if we've not had nears been never known that right now is this clinically relevant. Not sure. But definitely we had a detriment in the near because I stuck the candle in too far. So we can all mess it up. So what can the surgeon do to optimize bypass, again, accurate cannulation, minimal minimize blood trauma, and that means not writing the suckers all the time, keeping the heart well decompressed diligent preservation plan in advance, that's things in advance. If your surgeon colleague is not discussing the strategy of the operation extensively with you before an operation, your expectations are low. You will not achieve excellence. I don't know how many 10s of 1000s operations on in my career now I need to figure that out. I need to review this with our team every single day. What is our plan and what are our expectations. And that is communication. So my, my view on my profusion colleagues is just that the professional colleagues not subordinates. I'm very much, very much a difficult person when it comes to communication in the operating room. You know, look, we all want to have a pleasant professional environment. We all want to be able to do our very best work. But the operating room is sacred territory. It's not where we go to have fun. My own son is about halfway through his cardiac thoracic residency at Hospital for University of Pennsylvania. And a year ago, more or less, he said he had done a case and it was fun. And I said, well, well, well, well, well, well, well, well, you're my friend fun for whom for whom, please go talk to the patient and the family and ask how much fun coming to a cardiac operating room is as a patient. It ain't no fun. That doesn't mean we can't have a good decorum in the operating room, but I am very much a critic of having music in the operating room and communication in the operating theater should be just like an air traffic controller. Pump on, pump on. Hepburn, clamping the IVC, clamping the IVC. Unambiguous, clear, always with a readback. And what kinds of things do we need to know? I'm losing volume. We've got a marginal line pressure. You're riding those pump suckers, Dr. Fraser. We're having homolysis. The lactate is rising. The nears is not doing what we predicted. Where are we with hematocrit electrolytes, calcium, warming, cooling? Did I remind you to warm? And again, sneaking on, sneaking off the bypass. We know as surgeons, any experienced surgeon knows when we go on bypass and we'll baby if the prime is right. We know. We can see it in the heart. The color of the heart changes. The heart rate slows. So you're starting off. You do that. You know that you're starting the operation in a bad place. Maybe you climb out of it. Maybe you won't. Personally, I believe that we have, because ECMO is so easily available that we tolerate poor and poor and poor surgery. ECMO is a failure. Post cardiotomy ECMO is a failure. Now, do I use it? I do. Do I like it? Not one bit. If I execute an operation and I have to come off on ECMO, I've probably not done something right. Either the assessment of the patient, the execution of the operation, something was not right. Just a little bit about the brain. Again, we could spend a whole week talking about cerebral protection or our perceptions of cerebral protection in children, but it mystifies me that we've gone from what was clearly the case when I started a black box and certainly Richard will remember that in the days when I was first getting started, I was looking over the ether screen a lot to just see what the color of the head looked in the children. Biggest worry. Huge worry. And now we have technology. We don't use this particular device anymore, the somenetics device. We now use the Edwards device, but the point is the debate about using near-infrared spectroscopy to me is over, but apparently it persists in some institutions. Now, for sure, those of us who have quickly adopted anti-grade cerebral profusion have used nears extensively to adjudicate cerebral blood flow. And again, we could spend a lot of time on that, but it's very helpful in cases like this. So this was a baby, very small preterm baby, arch interruption, VSD, a lot to do, a lot to do. A lot of steer kentrons, hard to see. Could we do this under-circulatory arrest? Sure. But if we were so bypass flow rates, nears, how would we know if we were in a period of circulatory arrest, how would we know how long the brain could tolerate it? How would we know in a given individual? How would we know? Well, in fact, we don't know. We don't know. You probably know that the number of 40 minutes, more or less, a continuous circulatory arrest in children has been accepted. How do we know in a given individual what can be tolerated? What we don't, if we don't have some form of physiologic monochrome. So how do we assess how we're doing? Well, that's what we do. We go to the bedside. So how many profusions? Don't raise your hands, but think, answer this for yourself. How many of you all are going by the intensive care unit and seeing your patients? How many of you are doing that every single day? How many go over there the day after surgery and look at the eyes, look at the liver, see how the urine output is? Oh, by the way, does the patient have seizures? How many of you are doing it? If you're not doing that, do it on Monday or tomorrow or tonight. Go see your patients. You can't know how you're doing. You're part of the management team. And so unless you're integrated into the care of the children, you won't know. You won't know how they're doing. Moreover, if you're not discussing it with your colleagues. So this is an older photograph, but it could have been yesterday. So just like my entire tenure at Texas Children's, and for as long as they give me the good grace of working in Austin, we will meet every Friday morning at 6.15 and we will review every case that we found in the preceding week. And this is anesthesiology, critical care, perfusion, cardiology. We review every single case. And sometimes we're pretty brutal. We can be pretty brutal about it, but it's the way we improve continuously. And we're granular about our performance. So this is something we're very proud of in Austin. This is our program datasheet. I won't bore you with all the details, but we have an ongoing, basically report card, which goes through the entirety of the program and to anybody that wants it, quite frankly. And sometimes it's painful to look at how you're doing. So far, we seem to be doing okay. We have to look at it all the time. We seem to compare favorably to the current benchmarks, but if we don't, we have to look at it. Now, what else are we looking at in the realm of hopefully refinement? You all know that most patients with congenital heart disease have chronic illness. So there are very few things that we cure. So it occurred to me some time ago that transposition, we've gotten really good with the arterial switch operation. In fact, in my personal career, I'm well over 400 arterial switch operations. I've not had a mortality in this millennium. Hundreds of arterial switch operations. Think about that. When I was a baby, everyone with trans-transition died. Everyone with trans-transition died. Dr. Cooley, others implemented the atrial switch, the arterial switch. The mortality for the arterial switch at Texas Children's when I arrived here in 1995 was 25%. So we've come a long way, but we've not cured the disease. And so we got a whiteboard and said, what's life like for a patient with transposition? Well, we know a lot. And so we've started a journey mapping project for categories of disease, including single ventricle, AB canal, transposition of great arteries. So this is continuous assessment of how we've done. Now, obviously, mortality is mortality. It's extremely sobering. And we have to focus on that. But we know that if we're not looking beyond mortality, we're not refining our expectations. And so this is what we're doing with trans-transition. Now, what about physiologic support? It's imperative. What the surgeon believes matters. What the anesthesiologist believes probably matters more. But what the profusionist knows is paramount. Now, this is that field setup that I talked about. We, Dr. Gottlieb coined the term, the triangle of trust. We believe that there should be line of sight communication between the anesthesiologist, the surgeon and the profusionist. And the surgeon should be able to see exactly what's going on. That should be profusionist. And so we set the field up. I mean, many of you all have the same setup, where the surgeons, where a headlight camera, the profusionist can see what's going on. Critically, critically important. Beyond the OR, of course, we're all involved in extracorporeal membrane oxygenation, which by the way was derived from cardiopulmonary bypass. I always bristle at the notion that someone says, well, we're on the pump too long. And so we have to come off on ECMO to recover. Well, that's antithetical, isn't it? It's plastic tubing in a membrane oxygenator in a power source. Maybe less flow, maybe more flow, but doesn't make quite sense to me. We have a VAD dilemma in pediatrics. Don't see great hope on the near-term horizon, but we have to make really challenging decisions. Recovery, my cardiorecovery, an important topic. I'll share just with you in just a sec. And then we have this new transplant paradox, and it's trouble. Trouble. We're seeing challenges with donor availability for our patients. Our patients seem to be waiting on the list. Extreme, extreme lengths of time. So we've had some pretty cruel cases of late. This was a big two days at Dell Children's Hospital, and I thought it would be fun for you all to hear about this. We didn't have a transplant program when we started on September 1st of 2018. We didn't have a VAD program when we started on September 1st of 2018. So we have to quickly implement that because the patients and families needed it. And this is one such. This is a single ventricle patient shunted. So systemic to pulmonary shunt, whose heart fell apart and ended up on a Berlin heart for months. And unfortunately, she developed a significant infection, but fortunately, her heart recovered. So we explained it. So she's still a shunted single ventricle having been explained for a Berlin heart. That doesn't happen very often. That doesn't happen often at all. In fact, she's about ready to go home. And this one was really, really gratifying. So Koyana came to us. She was in persistent re-entrant junctional tachycardia. She had an injection fraction of about 8% when she presented to us. And we supported her with a percutaneous trans thoracic open chest LVAD left atrium to ace in the aorta centrifugal pump. She did not recover eight days. Heart not recovering. We put a Berlin heart in her and listed as a transplant. And she waited and she waited and she waited five months in. She had a TIA. Despite being on bival and very effectively cared for by our team, she had a TIA and we got scared. So the notion was raised. She's, and I have she recovered sufficiently to be expanded. And you know, that's a big decision at the big decision, isn't it? Ex-planning and then re-implanting in a child, not so easy. In fact, doesn't usually work out. So this is at the time of the Berlin implantation. So we'll complete our full scan. Now we'll complete our full scan at 30 minutes. And whenever our sonographer is done, we'll do our pump stop and another repeat echo 10 minutes after that. Yeah. So looking at the tricuspid valve and the pulmonary valve, we're going to be doctoring. The wall motion is still a little dyskinetic, but it's the stable compared to before. So she's home and more importantly, that's what her heart's doing now. And we're enormously pleased and it is encouraging to think that this is now part of the armamentarium that we can offer our patients more consistently. At Dell Children's, we have a bubble parade for long-term children that finally get to go home. And so that was a great day for our family. Well, this is who we are. I mean, it's always great to come into the Texas Medical Center, which is incomparable anywhere, nothing like it in the world. And humbling to come back in a certain way. But things are coming along in Austin quite well. Austin is a very, very rapidly growing part of the world, very attractive place to be. This is our Dell Children's Hospital, just out in another bed tower. We have a busy cardiac program there which didn't exist before. And other than the patients and the families, the most gratifying part of that has been all the colleagues we've attracted there and get to work with who are working hard. So I love this. Good things come to those who wait now. Good things come to those who work their asses off and never give up. So don't give up. So this is UT and you know what's on the inscribed on the main building. If you don't, there it is. You shall know the truth and the truth shall make you free. So the truth is aspiration of excellence is not easy, but it's achievable. And I wish you all well in your own pursuit of excellence. And Kathy, thank you and Deb, thank you for this invitation. I really appreciate it.