 Well, good morning. Welcome to the second day of this fantastic perfusion conference. I'd like to thank Kathy Kibler, my dear friend and longtime colleague and others in the Texas Heart Institute Profusion Program for inviting me to speak again at your conference. It's an honor and privilege to continue to be associated with the Heart Institute Profusion Service. I would like to share with you again today a really a philosophy, a philosophy that I was introduced to almost three decades ago, a philosophy that I think is more relevant today than it was even then, yet a philosophy that is not broadly embraced or I think consistently practiced. And that is the notion that physiologic perfusion is predictable and consistently achieved. And that proposition, we believe, is built on an optimally coordinated relationship in the operating theater and probably beyond, which we call the triangle of trust. So physiologic extracorporeal circulation, is it a myth or should we view it as an imperative? I can't tell you how many times I hear to this day, oh, the patient was on pump and therefore the heart function is depressed. Oh, the patient was on pump and this bad thing happened or that bad thing happened. It's almost like in certain quarters, it's assumed and accepted that any time a patient is exposed to cardiopulmonary bypass, there is a net physiologic detriment. My opinion is that our historical viewpoint on this is quite varied. People say the length of time on cardiopulmonary bypass correlates to outcomes. I would like to challenge that. They believe to this day that speed in the operation is of the essence. I also would like to challenge that. In fact, I believe that accuracy is of the essence and that speed can be dangerous. Have we reached the limits of cardiopulmonary bypass? Well, clearly not. Look at the advances that are being made almost daily and other durable forms of support, mechanical circulatory support. So overall, I believe that some of our beliefs are holdovers from another era, but this sets up a problematic paradox and that is what do we believe? And I argue that what the surgeon believes really matters a lot. And what the anesthesiologist believes matters probably even more. But what the profusionist knows in terms of achieving accurate, predictable physiologic profusion, that's paramount. So what can the surgeon do? Well, we can do a lot. We can be accurate and appropriate in our cannulation. I won't delve into things like vacuum assisted bypass and other more modes of assisted drainage, but I don't know how many times we have a debate maybe every day in the operating room about is the erotic cannula too big or the venous cannula is too large? Is drainage going to be sufficient? It's up to the surgeon to get that just right, so that the body is well drained, the profusionist is not having to add volume to the circuit, the liver is not congested, the bowels aren't congested. And this happens, I think, more frequently across the world than we would like to accept. We can minimize blood trauma. Of course, a lot of work's gone into coated tubing and more physiologic cannula designs, et cetera, but we add a lot to that. We surgeons add a lot to that. Riding the pump suckers hard, again, poor cannula positioning and other features. Our job is to perform an accurate operation and be gentle with the heart. And if we do that, and if we keep the heart decompressed and we're careful with myocardial preservation, and of course, a lot of research has gone into that, I think there are a lot of different ways that we can preserve the heart, but the key is keeping the heart decompressed. And to plan these operations well in advance, to discuss the strategic goals, the approach to the operation, and that only happens through effective communication. So what should the surgeon's perspective on the perfusionist be? I very much emphasize that our perfusionists are colleagues, are not our subordinates. Having visited a lot of different operating rooms, not only in the Texas Medical Center, not only in the state of Texas, but around the world, I can tell you that's not always the case. This relationship is optimized by precise communication. A quiet operating room, no background, unnecessary chatter. I personally don't favor music and precise audible, unambiguous communication with a readback, much as a pilot and an air traffic controller expect. And if we reach high, we can achieve more than we think. So high expectations for the interoperative experience translate into high performance. And then how are the patients doing? Rapid cycle feedback analysis. I would ask all of you as perfusionists in the audience, how often do you go to the intensive care unit and see your patients post-op? I don't mean just walk by the bedside, I mean actually see how the patients are doing. It's critical that the perfusionists know how vital the perfusion experience in the operating room is to the overall well-being of the patients. And so if you're not seeing the patients, how can you measure what you're doing? How can you refine what you're doing? How can you be consistent? And the goal, the goal should always be a warm, euvolemic, biochemically normalized, replete, well-supported patient at the end of cardiopulmonary bypass and thereby as the transition to the intensive care unit occurs. Again, communication is paramount. The Hart Institute of course was the brilliant idea of Dr. Cooley and the principles of modify, simplify, and apply still are relevant today. However, the perfusion philosophy of the Hart Institute and across the street at the Methodist Hospital still is permeated by the historical holdovers of an era where frankly you did have to be a really fast surgeon. You really did have to get the patient on and off bypass as fast as possible. And certainly we wouldn't enjoy the field of cardiac surgery that we know today had it not been for intrepid pioneers like Drs. DeBakey and Cooley and many others who boldly forged a new frontier. But the holdover of negative philosophy about bypass I think doesn't really translate into the current world. Moreover, how many times did we hear, certainly I hear in the course of my education early on, perfusionists is sort of training someone to do something of a lesser stature, which unfortunately that pejorative implication really undermines the overall triangle of trust in the operating room. The early days I can't imagine what perfusion was like in the early days. I certainly don't know that I would have had the courage to do things like controlled cross circulation and this photograph that's probably been shown a million times around the world, if not more, of Dr. Lilihine colleagues. It's kind of another all star operation. That was an amazing time and then no doubt in that period a perfusion was an iffy proposition, whether it be with this method biologic pump oxygenator or down the road at the University of Minnesota with Dr. Kirkland and colleagues with a giant mechanical device that again nobody really knew how it was going to work. I got introduced, I think got some glimpses into what we could do better with circulatory support as a resident specifically as a lab resident at Johns Hopkins in the mid 1980s. We were required to work in the research lab and one of the areas of interest we had and there's yours truly on the right of the screen with my colleague and friend Dr. Adachi from Japan. We were interested in heart lung transplantation and heart lung graft preservation and a lot of people were working on a lot of different ways to preserve the heart lung block but we would put the animals on bypass and that was an invaluable experience for me because I learned how the pump actually works and that served me really well in my career. Moreover, I probably made about every mistake that a perfusionist could make because we didn't have perfusionists, we were just doing it all ourselves. Anyway, we would harvest the heart lung block and then we would put these organs in an auto-perfused working heart lung circuit and this is a biologic graft supported in an extra corporeal closed-loop circuit. So the heart kept beating, the lungs provided the oxygenation, there was a reservoir, there was tubing and we figured out how to make this all work. Moreover, we figured out that we could do this and we could preserve the lungs for hours and hours and hours maybe even for more than a day without seeing significant edema organ system dysfunction and it was quite elucidating. So that initial work in the auto-perfused heart lung block then translated into this idea, well what if we just cooled the whole donor down, the entire donor down on cardiopulmonary bypass? So that's what we did. We did a series of animals and then we took it to the clinic and we actually published on this subject donor core cooling on cardiopulmonary bypass provides superior vital organ preservation for transplantation and we published this way back in about 1986. In fact, it was a highlighted paper at the International Society of Heart and Lung Transplantation and our lab was awarded the Philip Caves Award for innovation that year for that work. So it's dichotomous isn't it? It's dichotomous that we could prove in the laboratory that we could put a donor on bypass, cool the entire donor down and then in an unhurried fashion retrieve the vital organs and have them perform better than other static measures of preservation. And of course now today it's widely accepted that donor organs can be resuscitated in these various commercial devices that have been developed to support these organs extracorporeally. That all goes back to the 80s the work that we were doing and the Bartley Griffith and his Griffith and his team at University of Pittsburgh were doing. Interesting how these ideas come full circle. So we then and again this was the culmination of that work this auto perfused proposition really told us that we could be very accurate in the preservation of the patient's organs. Now we'll also say at that time in clinical practice at Johns Hopkins not so accurate. We were very formulaic to the way we approached patients and particularly children and I can remember vividly there was this philosophy many of you probably remember this that the flow rate the flow rate should be linearly related to the patient's temperature. So we would go on whatever ambient temperature the patient might be. Usually we found the patients were very vasoconstricted when we initially went on bypass that I learned I had there were many reasons for that but mostly because the prime wasn't appropriate. Then the patients would be cooled and of course the colder we got the patients the more vasoconstrictive they came. So by the time we had reached hypothermia and we were typically cooling the patients at least at 25 degrees nasopharyngeal temperature we'd be on 60% calculated flow 50% calculated flow and unfortunately often would see that the lactate was rising that perhaps the perfusion was having to add some volume to the circuit because we were losing volume and really not idealized perfusion. So fast forward to 1990 I got to travel to this hospital the Royal Children's Hospital the old Royal Children's Hospital in Melbourne Australia pretty austere looking place at that time but really doing sophisticated work. So I journeyed down to the Royal Children's Hospital and that was epiphanous for me in profound ways. I will say that to this day I point to the miracle that I was instructed by one of my mentors Tim Gardner at Hopkins that if I was serious about doing cardiac pediatric surgeon surgery I needed to go to Australia and I can remember sharing that with my wife and her saying my goodness after this long residency now we have to travel to Australia but Dr Gardner was so right and the work they were doing there was really field leading and the babies the children were just better supported and I would see patients come out of the operating room that were warm not edematous again physiologically so much better off and it was a real eye-opener. I also saw and so this is a photograph from then this is I think about 1990 in the operating room at Royal Children's Hospital and that's my friend and colleague Dr Stephen Horton now Dr Stephen Horton he has a PhD and extracorporeal support educated me about their methodology for physiologic profusion in Melbourne and it was really really different. First of all the way things were set up so that the pump was always on the patient's left side of the table it's amazing to me still how variable that is in cardiac surgery some people like the pump behind them some people like the pump in front of them I require that the pump be in front of me because we have to see each other and we'll expand on more of that in just a second but in any event you see the setup there in Melbourne and that that was a game changer for me. This really all got started because of the man there shown with a much thinner yours truly that's Dr Roger Me I think probably the singular most influential person in pediatric cardiac surgery around the world over the last 40 or 50 years and he unfortunately has received a lot less credit than he should have. This methodology this approach was sound rational predictable and remarkable so these these are stolen slides from Melbourne plagiarized borrowed from way back when what are the premises of small body profusion don't think of children and scale down adults accurate gear in other words if the pump says it's delivering to a two kilo baby 150 ccs per kilo per minute it's actually delivering that it's not delivering plus or minus 15 percent appropriate cannulas and I could spend a whole hour talking about that and customizing the profusion to the individual not cookbook profusion some of the other principles which were prescient and I think have proven the test of time avoid rapid temperature changes high flow low pressure meaning profound systemic vasodilation lower mean arterial pressures at the time we were using phenoxybenzamine which is a wonderful drug unfortunately it's yet another orphan drug in the United States that doesn't have a big commercial application and so you can no longer get it and we now use fentolamine um ultrafiltration continuous ultrafiltration on bypass and then again paramount cannula positioning high flow low pressure avoiding circulatory arrest and interestingly way back when the notion that ph stat management was superior so that was a protocol that we brought to Texas Children's when I was recruited there in 1995 and that was the hospital then in 95 and we were fortunate to attract three and then ultimately four believers or people that came to be believers um and it's gratifying to say that one of them the sole male figure in this picture Richard Owens is still working with us today and he's running all of our profusion services at Dell Children's Hospital now so we got to work these are pictures from those early days typically having two perfusions on a case working together this is our pump setup won't go into that too much other than to say that it's expensive it's expensive for a hospital to have a gem premiere or some other um mini chemistry lab to have you know state-of-the-art yostra or subsequent iteration pumps to have a vaporizer on the circuit that was enormously controversial when we started doing that um to have a video monitor so that the profusion can see the field to have the perfusions on physiologic monitor it's remarkable to me how people practice without having all this stuff but nonetheless it requires a lot of investment on the part of the hospital and one of those things is this simple idea of having a headlight not for the benefit of making pretty videos but for the benefit of everyone in the team to see what's going on and this was one of our earlier headlights way back when and then as I said checking up on the patients all the time seeing the patients with the perfusionist patient looks a bit more edematous maybe the patient's been too dehydrated when we and we have seen that through the years so we focused a lot since then on refining things of course the brain is our biggest fear on all forms of mechanical circulatory support we've developed I think our own methodology to this or modification of this methodology which was first described by Dr. Frank Pagula sewing a graft on the anominated artery and perfusing the brain rather than having periods of hypothermic circulatory arrest or aortic archery construction and now we do that as we wrote about some years ago and have refined since then using all available cerebral physiologic monitors and the game changer in my estimation was by cortical near infrared spectroscopy so that we could do things like this and this is a patient that in another era we would have never known that the brain was not being optimally perfused and this my colleague and partner Dr. Gottlieb wrote this up this was my patient and I had the tip of the cannulin too far you might say well how'd you do that well I did it and we would have had no way of knowing the blood pressure was fine but clearly both cerebral hemispheres were inappropriately perfused so we moved the cannulin got it fixed and we can do things like this we can adjudicate the flow rates and the time of circulatory arrest so here's a patient I think this was a patient with total anomalous pulmonary venous return that we do have to do circulatory arrest and so rather than just assuming that a certain length of time of circulatory arrest is appropriate we can use our near infrared spectroscopy data they're highlighted in purple to help us adjudicate durations of circulatory arrest go back on pump or subsite the brain go back on circulatory arrest and so we developed a set of core cardioporny bypass strategies that Texas Children's way back when and we've carried those on with us to Austin and these are some of the basic principles high flow low pressure minimize or eliminate circulatory arrest through the use of integrate cerebral perfusion adjudicate that with near infrared spectroscopy and transcranial Doppler pH stat acid base management high hematocrit slow profound cooling former colleague Dr. Androplas and others did some really outstanding work looking to see if this actually made a difference in patient neurologic outcomes and I think this quite nicely demonstrated that that's probably the case we could expand a lot of time talking about that subject this is our current setup in Austin it's the latest iteration I think of state-of-the-art technology you see there the profusionist viewpoint with our physiologic monitor video monitor cardioporny bypass machine readout blood gas and chemistry analyzer our livenova pumps and other gear but this is really what we think is paramount this is this is that triangle of trust you see in the purple the anesthesiologist that's dr. Gottlieb you see immediately in front of her dr. Beckerman you see to everyone's left the profusionist in this instance it's Blake Denison and Kellan Rosson and everybody working together everybody can see each other everybody can communicate with each other that's the triangle of trust when the triangle of trust breaks down and any one of the any one of the players can break down the triangle of trust when the triangle of trust breaks down or when it's not there when people don't perceive that it's important you got a problem I can promise you it's a suboptimal operating room environment just as a symphony orchestra is set up the operating room should be set up for optimal choreography of course this is where the rubber meets the road appropriate cannulation I won't expand on this too much other than to say that we're all about outcomes we're all about granular assessment of outcomes this is a program data sheet that represents our program activity since inception I'm happy to say that we're after a good start overall mortality so far of 1.3 percent that is just part of the story and we could go on lengthily about all the different things that we're measuring in terms of outcome performance this is the current device that we're trialing this is the Edwards bichortical near infrared spectroscopy device it's meant to be a little bit more forgiving in terms of patient pigmentation instead of using two wavelengths of near infrared light it uses five and so far we're happy with it I'm just learning how to use it this is our team I think it's a stellar team of individuals that we've recruited from far and wide really superb professional colleagues they round with us they conference with us they work with us in an integrated fashion in the operating room and we socialize as well they are integral to our heart center family and we're pleased to be participating in the educational programs the Texas Heart Institute which have been so important for so very long this is the first Texas Heart Institute profusion student who came and rotated with us we'll look forward to having more but we're proud to be part of that heritage so I'll leave you with this we're very proud of the main building here on the University of Texas campus inside the main building is a storied library with a lot of really important people quoted on the beams and these beams have been there for a long time and as an undergraduate and subsequently later doing some studying and whatnot I usually look up and ponder some of these valuable opinions about things and this one seems quite appropriate for the subject of profusion all that is human must retrograde if it does not advance we have to keep moving the field forward we have to keep having higher and higher expectations the goal of physiologic profusion is achievable and the triangle of trust that really sacred relationship is the key to that door so I thank you again for this honor and privilege of being part of the conference and I know that you are going to have a very vibrant and exciting day thank you very much