 It's a huge honor to be here talking to all of you, both in person and virtually on really on any topic here. But today we're going to be talking about lung transplantation, which includes several of our services together. And I'll point out various aspects of that. It's amazing to be together finally in person a little bit after this terrible COVID pandemic. My disclosures are shown here. The Baylor College of Medicine receives grant support for involvement in several clinical trials as mentioned here. So a lot of what we're going to talk about today is on this concept of risks, of how we take risks, why we take them, when we take them, and then how we take them. But that'll be kind of a theme throughout the case. I'm sure everybody recognizes this individual here, Dr. Denton Cooley, who established the Texas Heart Institute with many additional individuals. So he was actually credited with the first heart lung transplant in 1967. And that was for a young pediatric patient who needed a heart transplant, but her lungs had also failed from pneumonia. So back then you could actually kind of take whatever organ you needed. So he asked to also get the lungs as well, successfully put it in, patients survived for a few days, but then afterwards unfortunately succumbed to infections. Before that, a single lung transplant had been done in the early 1960s, also survived only a couple of days. And it really wasn't until about 1980s that the first reported survivor beyond one year happened. And so I say that only to mention that there is already a pretty baseline high level of risk involved in this procedure to begin with. And then on top of that, now we're stretching the envelope even significantly more on top of that baseline risk. If you fast forward to where we're at today, we're in a program that functions at 98 percent 90-day survival, which if you think about, you know, aortic valves, coronary bypass, they track us out to 30 days. And this is 90-day data. If we look at our data, we're following our data up to one year and even three years. And at one year, we maintain ourselves above 90 and 95 percent. So it's a super high scrutiny and it's important to be able to recognize that as we think about what we're doing for our recipients and to help maximize donor organs. So our transplant program here at Baylor St. Luke's really has taken off substantially over the last two years. You've collectively done nearly 200 transplants and been including this year. And that puts us up at the top five transplant programs in the nation. And it's including Cleveland Clinic, Duke, and several other programs. And our goal is to maintain and to sustain and to continue pushing there. It's no certainly no easy feat and it takes a village. So if we're going to be pushing the envelope beyond there, I think, you know, a couple of things that always resonate with me is just maintaining some humility to understand what the baseline risks are and to try to listen constantly to see how you can safely increase that. And then, of course, you have to have a little bit of courage to move forward. There's just no other way to do that. And we wouldn't have transplantation today. We wouldn't have LVES. We wouldn't have a lot of what we have today without a little bit of courage, which is critical. Yasta Pedersen is probably after Denton Cooley is probably one of the best cardiac surgeons that walked the face of the planet. He had the privilege of training under him when I was in Cleveland. He always would mention that danger is always closer than you think. And the more you respect that, the more you can take on higher and higher risks. So in transplant, obviously we have a lot of options. We can do single lung transplant doubles, heart lung blocks or low bar transplants. I'm just going to walk you briefly through the basics of the procedure. The donor procurement occurs along Sondergaard's groove. We usually protect the heart if we're going to use the heart for transplant, but we remove the heart and we're left with this block here. So we have an open left atrial cuff that we use and we have an open pulmonary artery and then we have an open trachea that we sew. We split this down the middle and we sew each side in individually. So that allows us to use the other organ to be ventilating while we're working on one side in a so-called off-pump fashion. Or we can just go on full cardiopulmonary bypass and put it on as one block. And so all of the surgeons that work with me and our team, myself included, we do a lot of coronary revascularization work. And so we can also actually bring the mammary artery down and anastomose that to the bronchial arteries and actually supply blood flow to the bronchial arteries as well to increase. And there are very few centers doing that right now. We're trying to modify that technique to make it a little bit more broadly user-friendly. Our exposures can be very variable. We can either do small incisions underneath the breastbone on both sides or on a single side if it's a single, or we can go across the sternum if it's a clamshell. We can also go up and down for a sternotomy and it really depends on the patient's anatomy. Much like at least my cardiac practice, and I know many of my partners that do minimally invasive cardiac surgery, it's a lot about the imaging. So we look at the imaging to try to plan where that incision is going to go, whether it's going to be upper-median sternotomy, lateral thoracotomy. And it's no different for lung transplant where we try to plan the incision and tailor it to the patient. And we've published on this and have shown very good results taking this approach. Once we're in there and looking at the high lung, there's the airway which we sew. We run the posterior layer of it, and then the anterior layer, we tend to do it in interrupted sutures. And we found that this leads to the best long-term outcomes for the graft when we do it like this. It's even better if we revascularize the bronchial artery, but there's only special unique situations where that occurs. Here, the pulmonary artery, we see we have a clamp on it and we're sewing the anterior wall of it, and then finally the left atrium. This is a little bit of a dicey part of the procedure in general, especially if we're off-pump, without the cardiopulmonary bypass support, because you're really sewing directly into the heart and really just takes a fraction of a second to lose about a liter and a half of blood before you know it. So thank God things like that never really have happened here, which is amazing in over 500 transplants at least, but it's something that's constantly on our mind. Again, danger is always closer than we think. So who are the patients that we're taking care of? There's a broad category of patients that qualify for lung transplants, huge amount of diagnoses. Many of these patients have concomitant coronary disease, so we're going to talk about that as well. But we have our COPDers, bronchiectatic disease, pulmonary vascular disease, restrictive lung disease, retransplants, obviously our COVID population now and just many, many different diagnoses. This is a study that was done by Elizabeth Godfrey, one of our medical students here who's now a surgical resident at Stanford, and looked at your diagnosis from the time of listing and what your long-term outcomes are, found that for cystic fibrosis patients, they tend to have the greatest long-term outcome. They also tend to be a little bit younger, so it's no surprise. And other diagnoses also have very good outcomes. Our obstructive lung disease and restrictive lung disease have a lot of comorbidities, so they tend to be the ones that sag a little bit behind long-term. But what's fascinating is that if you have a lot of positive factors to the patients, so they're in better shape, they're listed earlier, they tend to actually survive longer, especially conditional on that first year. And for lung transplant, that's very important because it still lags behind heart transplant in terms of long-term outcomes, so it's actually striking to see anything that causes a major improvement in that long-term survival. But improving our long-term outcomes is still a subject of intense research. So it's super rewarding to see the patients that we've transplanted over the years. Many of the people on this slide were turned down by centers for a multitude of reasons. So this gentleman was the first COVID transplant, so unclear whether we should be transplanting patients for COVID, he's now three years out and doing great, celebrates his lung anniversary every year. This gal had severe multi-drug resistant organisms, really didn't have medicines to treat her. We ended up removing her lungs in block, irrigating copiously with antibiotic irrigation, et cetera. Clearing her subsist, transplanting her, now she's skydiving every year as in celebration of her lung anniversary. This gentleman had severe multi-vessel coronary disease, wouldn't transplant him. We did a single lung transplant with PCI as a bridged approach, and he's been doing great. This gal was a redo transplant turned down by the Mayo Clinic and sent to us. She had pectus excavatum, and we were able to do her case and plant it carefully. And the list goes on and on. This gentleman here was to the far corner on the left, the Navy Seal, who was 75 years old, and nobody would give him a transplant. They said, you know, you're 75, so. But we saw him and were like, okay, yeah, he's 75, but he's still climbing like mountains and stuff with oxygen. So he's probably gonna do okay. And he's, thank God, he's done actually quite well. So how did I get into this field? Well, number one, there was no question that I wasn't sure I was gonna be doing lung transplant. Right now, I'm very super passionate about it. But when I went to train at the Cleveland Clinic, which is a really very high volume cardiac center, one of the things that I realized a lot of my mentors, they would pair you up with a mentor, and you would work with them for three months. And so I was paired up with Ken McCurry and with Yosta Pedersen. These guys are doing about 300 hearts a day, 300 hearts a year, but they're doing all the lung transplant. So all of their kind of top tier cardiac services were doing the lung transplant, which was very appealing to me. And you had to choose one of three or four different specialties, aortic or transplant or minimally invasive. And what I, you know, I just felt like this, taking care of this very end stage population of patients really gave you this full spectrum of the worst, and then you can also kind of handle some of the not so worst. So it's made for a really nice, pretty well-rounded practice in my experience ever since then. And there's no question that it is a specialty that there's a lot of questions to be answered related to improving longevity and improving upfront outcomes. So it's been really just an amazing voyage, but it's been that mentorship that really got me started on this path. And I wouldn't be here without that mentorship. So there's several complex scenarios that I wanted to just discuss briefly that build upon the average scenario, which is just somebody with end stage lung disease and you do their transplant and you expect them to do well. But there's a lot of very complicated scenarios that go on top of that. And one is the concomitant cardiac surgical procedures. Up to 20% of our patients have some degree of coronary disease or either valve or disease, coronary disease, PFOs, tricuspid valve, aortic valve, you name it. So concomitant cardiac surgical procedures is a reality that we have to think about as we're doing transplants, whether it's coronary artery disease and doing cabbages or doing AVR, NVR, TVRs, et cetera. I've done aneurism repairs on the setting of double lung transplants, descending aneurysm repair, bypass repairs, ascending aneurysm repairs, aortic valve replacement, maze, left-hatchel appendage, you name it. We've done, and over the course of the time that I've been doing this over 10 years, this has shifted dramatically because of two main things that I'll point out. One is a little more recognition of the impact of the cardiopulmonary bypass and stuff on the lung graft. That's one thing. And the explosion in endovascular cardiac interventions, coronary and TAVR and PFO closures. So both of those have, as you can just imagine, has merged into this plane where we try to limit what we do. And that's how we get a lot of these patients through is we try to limit the stress, limit the stress in the transplant itself and stage a lot of the procedures, whether we do them endovascularly or we do them before or we do them afterwards. And I'll talk a little bit more about what I mean about that in a second. When we have done early in our experience, we did do a lot of concomitant cardiac surgery at the same time as lung transplant. This is one nice series that kind of showed what the landscape of that would look like. Mostly it's PFOs, so ASDs or PFOs that stayed open because it's severe pulmonary hypertension or tricuspid valve disease, which makes sense. A lot of cabbages. And as I mentioned, in our experience, we've also had a fair share of aortic valves and even mitral. When we look at concomitant cardiac surgery, obviously you have longer bypass times, about 193 minutes compared to 148. Overall, survival estimates are pretty similar, though. So that's encouraging. That tells us that we don't have to turn someone down just because they have concomitant cardiac disease. We can do it. But when you look at the morbidity associated with the operation, they definitely have greater re-exploration for bleed. They have almost double the time on the ventilator. They are more likely to be in the hospital for longer lengths of stay. But overall, the 30-day mortality and long-term mortality is actually pretty good. So how about coronary revascularization? This is by far the most common scenario that we see. The options are cabbage or PCI for these patients. All of our patients get cast before they go for transplant. So if you look at this slide here, this is data from the Duke group that was published in 2013, but it's the largest series looking at this. The pre-op PCI is here in the dashed line. Looks like it actually gives a bit of a survival advantage compared to doing cabbage at the same time as the transplant. And this is particularly true if you take into account age. So if the recipient is older than 65, probably more frail, other comorbidities, then doing all of that, three-bessel bypass bilateral lung transplant, all of that at the same time is a lot of swelling for the graft, a lot more end-organ dysfunction. So to me, it's no surprise that the outcomes are a bit worse in that scenario and PCI wins out. When you look at patients who have concomitant cabbage versus pre-op PCI, concomitant cabbage is associated with greater incidence of surgical feeding tubes, greater incidence of tracheostomy compared to patients who were staged with PCI. Post-operative length of stay is longer with concomitant cabbage as well as post-op intensive care units. So the moral of the story with cabbage is that you do it only if you really need to. And then even then, if you really need to, we try to plan off-pump approaches for it or maybe doing it on ECMO, we try to minimize the stress as much as we can. So you're not doing a full-out assault of bilateral lungs, full bypass, three difficult targets or four difficult targets. So we really try to stage it. The challenge becomes patients who are really sick, right? They come in and they can't wait to be listed. But more often than not, we can bridge them. And we bridge them with PCI either a non-drug-alluding stent but even drug-alluding stents, you can actually get away with we've transplanted many people after just 30 days of a drug-alluding stent. They haven't had MIs afterwards. So it's been, obviously this field has been a revolution thanks to our incredible cardiology colleagues. How about PFOs? We see PFOs a lot. As you can imagine, PFO totally changes the operation. If you're gonna repair a PFO in the setting of a lung transplant, you need to go on-pump. You need to probably clamp the heart if you can. If you wanna be safe to prevent any air embolism and you wanna work inside the chamber and repair the PFO, it's a simple procedure but it is gonna increase the amount of support being used at the time of the lung transplant. It's gonna change the dynamics of the transplant. And interestingly, the tricuspid valve repair group actually did quite well. Less time on the ventilator, less graft dysfunction, better long-term lung function. So that tells us that if we're going in there for severe pulmonary hypertension and they have severe tricuspid regerge, we just fix it. And it's okay and it's just quite frankly part of the deal but the outcomes turned out to be very good. People with severe pulmonary hypertension are more than often having the procedure done on-pump anyways. And so it doesn't add a whole lot to that procedure. Reoperations after prior cardiac surgery is becoming increasingly common for us. In 2016, one of my colleagues published a real nice article looking at the UNOS data on this. These are patients who've had grafts before mammaries, maybe lema, maybe reema, maybe multiple vein grafts. And sure enough, cabbage was one of the biggest factors in morbidity and mortality after the lung transplant, worst one-year survival, if the patient had a cabbage prior to the lung transplant. But what was interesting is if you look at the procedure that was chosen by the surgeon, so if they chose to do a bilateral lung transplant, which is what I used to do, what a lot of us used to do early in the experience was we would just go through redo sternotomy, redo bilateral lung, tease out the mammary, protect the mammary, protect all the grafts, go on-pump and do the bilateral lung transplant. Those have the worst outcomes. So that's a lot of work, a lot of pump time and stuff like this have the worst outcomes. If you go in and sneak in from the right side, avoid the lema completely and just do a single lung and maybe even come back later and do a single left if you need to. You have no pump time, you have much less bleeding and by and large, those patients do really well. And that's how our practices has changed because even though we're trying to get the benefit of a bilateral lung, you can't really get that benefit if you have a lot of upfront morbidity. How about reoperative lung transplant? It's becoming more and more common. We're seeing our numbers of reoperative cases going like skyrocketing right now. For centers from all around the country they're sending us their reops. They're second time, third time reops. What you know is that the reop patients do worse than the primary time around. But the greatest risk is in that first year. If we get them through that first year, their outcomes are almost equivalent to when they had their first transplant. So a lot has gone around trying to figure out how to make that first year safer. And a lot of that has to do with the way the surgery is conducted. This is a study by a close collaborator of ours from Hanover Medical School. And they popularized the protocol a long time ago, which we started adopting. A few other programs have started adopting. And again, is completely different than the way I was doing redo transplants like eight years ago. Eight years ago it was, again, full cardiopulmonary bypass support, being very worried about getting into bleeding, things like that, and doing the whole transplant with a full onslaught support. Instead, now we try to do actually minimally invasive incisions. We try to stay working on the quadrant that we're working on. So if we're doing the right side first, we stay on the right side. We get a really good right-sided lung graft. We very carefully tease everything off pump. We may have wires in. We clamp, we do the procedure off pump. We sew the right graft in, and we use that right graft to then support us to do the same thing on the other side. It does take some time. So it's kind of funny that they have this coffee break that they advocate, and we've been doing this as well. So a lot of times after the first one's in, we go and we get a coffee break because it's true. You're starting a whole new surgery, again, on the other side. But if you lose that patience, then you run into trouble and the outcomes are worse. This by far has changed our outcomes when it comes to reoperative transplant. We're barely giving transfusions. We're using a lot more sternal sparing procedures, much less bypass, occasionally ECMO if we need to. Survivals is much better in the first year, first two years, less dialysis rate, less tracheostomy rates, and less 30-day and hospital mortality. Primary graft dysfunction is the real competing risk that we have with these. So we need to limit when we're doing, if we're doing a cabbage in a lung, if we're doing a valve in a lung, or if we're doing a kidney in a lung, whatever we're doing, we can get away with it technically, but we have to realize that the graft, if the graft develops graft dysfunction, that's gonna derail a lot of the post-operative things. So you'll have beautiful bypass grafts, but the lungs aren't working and they won't start working for a while. So it's a real competing threat to us in every lung transplant, but especially in combined procedures. It turns out, as I've alluded to so far, cardiopulmonary bypass is one possible modifiable factor that can contribute to that edema in the lung. And we've been looking at that here with our research groups at the Texas Heart Institute. And it turns out that, in fact, the cardiopulmonary bypass and ECMO groups do have greater inflammatory markers. They have greater B cell activity, so they have a lot more inflammation. You look at the endothelial cells, so in an off-pump approach, they look really nice, but they start to get scattered and disrupted with ECMO and they kind of get pretty sheared up with bypass. So it's really kind of fascinating the way the inflammatory response can affect this. We looked at over 850 patients and found the same thing in a multi-center trial that bypass had the greatest graft dysfunction. ECMO was in the middle and off-pump was the lowest. Now, you can't do every case off-pump, it's impossible. Only 50% of the cases you can do off-pump. So our go-to now has become ECMO. So if we need any additional support, we go with that. It's also important when we're thinking about high-risk scenarios is being careful about the type of donor that you use. So if we get risky on the recipient and get risky on the donor, that can be a bad combination. You start to stack up a lot of risk factors. And if we look here, these are high-risk to high-risk combinations. They have the worst one-year survival compared to perhaps lower risk recipients that had more extended criteria donors. Unfortunately though, there is a critical organ shortage. We can't always be choosy about what we're gonna get. 15 to 30% of patients are dying on the wait lists. And so this is a constant balance that we have to achieve. 80% of donor organs are lost and are not even utilized. And also the decision to accept a donor is a very emotional one. Sometimes it's a risky situation. Two o'clock in the morning, if somebody called you and gave you a stock proposal or an investment opportunity in the middle of the night, two o'clock in the morning, you're gonna be a little bit gun-shy about accepting that. Whereas if it was during the day and you had all the information laid out in front of you, you might look at it differently. So we've taken a lot of interest in that in the emotional aspect of taking higher risk donors. We built a consensus scoring system to try to see what the highest volume transplant surgeons around the world accept. And we actually developed it into an iPhone app. So when it's the middle of the night, we have number one, an independent screening service that objectively gives us a sense of whether this is an organ that is quite good or not. So we don't have to rely on our own biases. And we have a score that is calculated. So we get a lot of information that makes it much easier for me to make a high-risk decision at any time of the day, whether it's at night or in the morning. We've looked at a lot of things. I think that there's a lot of emphasis placed on the donor that sometimes is a little bit not based on science. So the most common question we get is how old is my donor? How old is the donor? How old is the donor? It's the most common question. So of course we had to look at this and we did not find an effect with donor age on survival after bilateral lung transplants. Now we know from the ISHLT data that when you get up in excess of 65 to 70 years, it does affect longevity. But for the most part, you can stay anywhere from 13 to 65 and you can function in a pretty wide spectrum without a lot of difference in your outcomes. We use a lot of innovation to try to increase our donor organ pool. This is a device that allows us to transport the organ from point A to point B and allows us to monitor it to give us a second check of how well it's working. We have our amazing profusionist here in the group that helped lead this program for us around the clock. This shows the portability of the chamber. We've published using this very extended criteria donors with greater than 90% survival which was significantly better than the national average. So that helps us to do more. We also do reoperative donor harvest. So this patient had bilateral mammary arteries in the donor hospital. We had to take the organs from that patient who expired was relatively young with a young coronary vascular disease. The lungs were in good shape. So we did take them but it is in the middle of nowhere. You don't have pump standby. So you have to, it's a much more tricky operation but we're very privileged that we have that all of our surges are able to do this and we're able to offer that much more to our donor pool. So a couple of interesting cases here if we have a little time. So this is a 51-year-old gentleman who had pulmonary hypertension, was on Sildenafil, Bocentens and also CKD3 and he was transferred to us with dyspia and actually ended up having a pericardial effusion as well. He got a pericardial window. It was gonna get a pericardial window but he had RV dysfunction, pulmonary hypertension, AFib. So he was initially admitted for heart failure, tuna, pulmonary hypertension management, started on BiPAP as diarist and then started escalating the pulmonary vasodilators in order to wean the pressers. But unfortunately, seven days into his hospital course he had a PEA rest with Torsade. The chest compressors were done after several rounds. Him being intubated, he did have ROS and returned to spontaneous contraction. You can see his total billy rose up to 3.9 AST and ALT, elevated creatinine went up, lactate went up greater than 13, did not look very promising and this is kind of when we met him for transplant evaluation. So we're like, I mean, you know, there's nothing that we're gonna be able to offer. But you know, I can tell you that working here is one of the things I just love working in this, with this group of these individuals at the Texas Heart and Baylor, nothing's off the table. These guys brought him back to the cath lab, they put in an Avalon, they, our cardiology team did a transeptal puncture, brought a lot of his pressures down, improved his hemodynamics, improved his total billy rubin, his lactate, creatinine started improving, his X-ray cleared up and the ECMO was decanulated and he actually did quite well. He was discharged home 20 days later. Totally floored me when they asked me to come back and look at him again. So he was doing physical therapies, cardiac function improved, heart. He did continue to come in with heart failure admission. So this is one of these guys where if the RV, we expect the RV to be a little down in pulmonary hypertension, this is gonna happen. But if the RV's less than 30% ejection fraction by MRI, we think they probably are gonna do better with a heart lung. Because if not, they're hobbling along with two lungs and they're getting, and you're just flooring them, trying to put them on max dose of epinephrine and dobutamine, it's better to just go to a heart lung in those scenarios. Also adult congenital heart disease, we do a lot of, we do heart lungs for those or patients with severe cardiac disease at the time of lung transplant, we would prefer to do heart lung. So the patient was doing well, came back two months later, had a heart lung transplant. Yeah, a little bit of a complex force but nothing too bad that we would expect. He was here for about 60 days, mostly because of effusions, recurrent effusions. We did trick him out of really precaution and he's still to this day home doing very well after this procedure. So we've been very happy with him. I love heart lung transplant. I think it's, in the allocations a little bit better for it so we're able to get more of the heart organs. Otherwise we used to wait on the wait list too long, it's prohibitive, but now it's a little bit easier to get a heart graft. So it's a very nice operation to do. Now, if we're flying so close to the sun here, you're gonna get burned. You're gonna get burned on cases. There's no question and you're gonna get burnt out as an individual practitioner. Your team is gonna get burned out and your hospital is gonna get burnt out and especially nowadays with COVID. So while it's helpful and important to talk about the technical aspects of what we do and how critical that is, I think that there's also almost like 40 to 50% of what we do is very mental and is very team oriented and trying to develop an elite team around this because none of those cases, it was me alone and half of those cases is my partner doing them or it's just a huge village team up the case so that I can just do the case. But this, you can't push the envelope without having an elite team like we do here. And there are many attributes to an elite team but one of them is comfort zone expansion and that's taking risks, it's a willingness to take a little bit of risk but understanding the value of that within your organization and what that means and how you can handle it and how you can do it. There's something we're constantly thinking about constantly pushing ourselves to do. Trust is also a huge factor. So when you're dealing with super high risk cases, right now I have a patient who's getting dealt with in the cath lab and you have to have 100% trust in your team because you have to trust them to do it because there's just too many factors going on in this enormous training, enormous organization for you to micromanage every aspect of you completely burnout doing it. So we're very mission oriented in what we're doing. We have, there's a huge team involved in these transplants in the high risk or even the standard one. Our surgeons are pulmonologists or cardiologists, administrators, ancillary team members, physician extenders, researchers, our intraoperative teams is enormous they're profusionists, anesthesia surgeons, residents, scrub techs, our donor procurement teams is a whole other aspect of things. They're going all around the country. They're going to Puerto Rico, they're going to Alaska, we're going to Hawaii. So it's an enormous group. Do you need me to get off? Okay, I thought it was like it. No, no problem. So I also think that taking some time for yourself is also super critical when you're doing these kinds of cases and these kinds of scenarios because one thing that I've learned aside from all the stuff with the pump and the inflammatory markers and this that and the other is that if I'm refreshed, you're going to do a really complicated very high risk procedure, a lot smoother than when you're burnt out and just like really it's kind of stressed because of all the stuff that's going on. And as a team, we work a lot on that with our partners and we try to have enough people doing these cases and enough people around us. So this is my family, I've seen probably more as many soccer games as I've seen lung transplants and now this kid, he was playing soccer when I was at the Cleveland Clinic and now he's like playing for NCAA team. My daughter's now graduating. I've been thankful to catch all these major events. Used to play a lot of music. I played in a band before I got into medical school so I really try to focus on playing as much music as I can. My son and I got into martial arts and kick boxing. So we do it. Now, unfortunately, he's gone. So people just beat me up. So now I'll go to another scenario. So this is a 36 year old African American male. I'll leave you with this one and one more. Worse than he's shortness of breath at outside hospital. Was worked up for a lung transplant for severe ILD. It was kind of interesting. I mean, he had a huge BMI which really just kind of takes him off the table in most cases. But he's young and he's just at end stage. He also had secondary pulmonary hypertension. Unfortunately, all the risk factors for primary graft dysfunction after a transplant. He was pretty comfortable when he got to us. His echo showed preserved RV function but he was on high flow nasal cannula. He could barely talk. His RV seemed okay though and his LV function was a little bit depressed. We started his workup up immediately the minute he hit the door. But there was just like a minute or two switching his nitric oxide and he crashed. And he just completely crashed. The hypoxic cardiac arrest, cardiology team rescued him at the bedside, put him on peripheral VA acmeal. I think it was maybe the fellow that got him back. And we then switched him from VA acmeal to VV acmeal so that we could ambulate him, move him around a little bit more. And then, but then on VV acmeals RV started to fail again. So then we knew we needed to get more of a VA arrangement. You know, at this point, we're getting deeper and deeper into a high risk situation. So we don't feel very comfortable here. We're kind of up against the ropes. You got a huge BMI. You got somebody who's totally end stage. They're getting worse, you know, how is this worth it? You know, but, you know, we just kept saying, let's just see where we can get him. You know, let's see how he can do with a little bit of rehabilitation. So my partner actually, so Dr. Shafi does a lot with portable ECMO, very interesting portable ECMO scenarios. So it advised us to do this one where we sewed a graft into the right axillary through the graft. We put a cannula into the ascending aorta so that basically gives a central cannulation without opening the chest. And then we put a multi-stage venous cannula through the right IJ. So this is off-label. This is not, I hope our profusionist aren't listening to, but we're using a 29 multis, 29, 29, 29 cannula just through the neck. And so you're cannulating almost like you're central without opening the chest. So we did that arrangement for him. You can see the cannulas here. And amazingly, he was extubated with that, did not need to tracheostomy. He started weight bearing, started interacting. He was using the bike, his hemodynamics stabilized. And so we said, okay, see, he may be good to go. We reactivated him on the list. We did his, after 28 days of ECMO support. And by the way, at this point, we're transplanting people with nine months of ECMO support. So the time on ECMO support doesn't matter so much anymore. But we did his case on full cardiopulmonary bypass, median sternotomy, bilateral lung transplant. And he did great. And he's actually continuing to do well. It was discharged home. One last case was one of our partners here called me to the room. He had just done a complex root replacement on a patient who had some baseline ILD who came in in shock and was not doing very well. He said, you know, now he's on VVACMO. Can you go and take a look and see if he would be a candidate? So I'm like, okay, he just had a root. You know, it's, no way. You know, it's, but we went over, we saw him. We switched his ECMO arrangement around to more ambulatory. We put him on this Abium Med breed system, which right now is one of the parts is getting recalled. But we're looking forward to getting it back here in September. But this is, this was devised by Barcliffe. So it's, it's from the, from the Maryland group. And, but it's, we're one of, we were the first center in Texas to use it. This is one of few centers in the country. Super ambulatory. It's intended to be a briefcase that the patient can ultimately go home with. So we utilized this form. We were able to get him moving around, ambulating, getting stronger. He got well beyond his initial root replacement about three months afterwards. He got strong enough to get a single lung transplant. He did actually, he surprised everybody was discharged in about two and a half weeks to rehab after his surgery. So he did really well. This is the breed system. This was his X-ray beforehand. And this is his X-ray with a single right lung transplant after that. So in conclusion, combined procedures, high-risk lung transplants are definitely feasible with acceptable or comparable outcomes. Recipient selection certainly is important. Procedural selection, minimizing your support stress if you can. Understanding your extracorporeal life support options is very important. Obviously maintaining elite mission center teams and maintaining balance so you can do these cases is very important. So with that, I want to thank absolutely everybody in this room. Everybody's been involved in this and everybody who's probably watching has also been involved in this. It's an absolute honor to be here. I mean, every day I'm just grateful to be here. So thanks for all your support.