 Good morning, everyone. This is Chuck Fraser in Austin, and I'm really excited to be able to participate in this Texas Heart Institute perfusion course. Of course, the Heart Institute has been a preeminent center in the education of literally thousands of perfusionists over the last half century, and this is just a continuation of that thread of leadership, and I appreciate Kathy Kibler and all the folks who are including our team here in Austin. And to have the opportunity to provide a few opening comments about what I've learned about pediatric perfusion over the course of my career now, which is amazingly coming up on about 30 years. So these are some of the lessons I've learned about pediatric perfusion, the goal being physiologic perfusion, not cookbook perfusion. So is physiologic extracorporeal support a myth? Or should we think of it as imperative? I would very strongly urge we think of the latter as our responsibility. Now, historically, opinions are widely varied on this subject. Many people have believed and still believe that the length of time on cardiopulmonary bypass correlates with outcomes, that speed in the operating room is paramount and is the of the essence in safe cardiac surgery. And that maybe we've reached the limits of cardiopulmonary bypass. I personally think these are holdover beliefs from other eras. And this is problematic. It is very true that what the surgeon believes, what the surgeon believes about what is possible matters a lot. But what the anesthesiologist believes matters more. But most importantly, what the perfusionist knows is paramount. And we certainly value that partnership very, very strongly. What can the surgeon do to optimize cardiopulmonary bypass? Well, quite a lot. Accurate appropriate cannulation. Now, this seems so simple, but it's actually not. Particularly in pediatric cardiac surgery where size constraints are an issue. Sometimes we are tempted to compromise on cannula positioning, cannula design. And this can result in suboptimal perfusion. The surgeon should do everything he or she can do to minimize blood trauma. And of course, the cardiotomy section is a primary source of blood injury. Accurate surgery, gentle cardiac manipulation, keeping the heart decompressed, diligent my cardiopreservation by whatever method you use. And I would argue that there are a lot of good ways to preserve the heart. All of those are part of the cardiopulmonary bypass strategy. And we need to plan these operations in advance. We need to discuss our strategic goals and our approach. And most importantly, the surgeon needs to communicate, not just show up in the operating room and expect everything to work out. My perspective on the role of the perfusionist, this has been something that has been central to my philosophy ever since I started pediatric cardiac surgery back in the early 90s. My perfusion counterparts are my colleagues. They're certainly not subordinate to me. I like our communications to be precise, audible, unambiguous. And I do favor the notion of a readback, much as you would if you were a pilot communicating with an air traffic controller. High expectations on the part of the perfusionist translate into high performance. Said differently, cookbook strategies, itinerant care, sloppy approach, you get the results that one might expect. And the perfusionist should be continually improving by rapid cycle feedback analysis. What does this mean? Look at the patients. How are they doing? Are the edematous, cold, acidotic? Are they well perfused and well supported? Measure, refine, repeat. Practice does make perfect. And believe in the goal. The goal is a warm, uvelemic, biochemically normal, well supported patient at the end of the cardiopulmonary bypass. Communication, again, is paramount. We can't talk about the Texas Heart Institute, about talking about Dr. Cooley. And we're so grateful for the many things that he brought to the world of cardiac surgery. And likewise, his counterpart and at some levels arch rival preeminent scholars in the development of cardiac surgery. But I would argue at certain levels, they held that relationship back between the perfusionist and the surgeon. And if I heard Dr. Cooley say it once, I heard him say it 100 times, don't pay attention to the pump, just get off the pump. And unfortunately, this is sometimes how the perfusionist is thought of in the operating room, which of course is ridiculous. So let's think a little bit about the history. Think about where we've come. Probably most of y'all seen this diagram of controlled cross circulation, where a parent is used as the pump oxygenator for a child undergoing cardiac surgery. This is kind of how we got it all started. Ultimate physiologic perfusion. And of course, this allowed Dr. Lily High and colleagues in Minneapolis to get started way back in the early 50s. Fast forward to my residency at Johns Hopkins in the mid to late 80s, where I saw children come out of the operating room cold, swollen, essentially in shock after being in the operating room. And I thought, well, I guess this is the way it is. I guess children just don't do well on bypass. How wrong I was. But I got some glimpses of things while I was there. This is yours truly on the right of the screen with my colleague Dr. Adachi from Japan. And we're doing an animal model in the in the cardiac surgery research labs at Johns Hopkins. And one of the benefits of this is we were the profusionists. So I learned how to run the heart lung bypass machine and learned a lot about what could go wrong, quite frankly. And of course, we were pretty simple in terms of how we thought about the setup in the in the lab there at Hopkins. But we were able to achieve some pretty amazing things through a lot of practice. And one of them is this. We developed an auto profused working heart lung bottle that was essentially a extracorporeal circuit hooked up to the heart lung block. And we could keep the heart lung block vital and viable for 24 hours in an extracorporeal circulation and then implant these into animals and have them work very well. So that was a little window of understanding for me that prolonged physiologic profusion was not only possible, it could work really well. Of course, we take that for granted with ECMO, which has always seemed to be kind of an oxymoron to me, that people would put a patient on ECMO for two weeks, but think that three hours on bypass was bad, strange paradox. This was our team in the lab there at Hopkins and really learned a lot about profusion. And we could show this auto profused working heart lung model that we could keep these organs in good condition for prolonged periods. But this was really the transformational experience for me when I was a fellow at the Royal Children's Hospital in Melbourne, Australia, and got exposed to really, I think the field leading pediatric profusions in the world at that time. This was my friend Stephen Horton, now Dr. Stephen Horton. He achieved his PhD from the University of Melbourne on all the work that he's done with physiologic profusion. And basically, I learned about the setup relationship between physiologic profusion and outcomes in small children. And this is a picture from our operating room in Melbourne way back when. This was all really the brainchild of Dr. Roger Me and the unit that he developed there was, without doubt in that era, the best unit in the world. Dr. Me's mantra was that children are not scaled down adults and that we needed accurate machinery, appropriate cannulas, customized profusion, and otherwise individualized profusion for the patient. Some of the premises that were developed to avoid rapid temperature changes, high flow, low pressure, thusly profound vasodilation. At that time, we were using phenoxybenzamine. More recently, we used fantolamine. And that was when I was first exposed to continuous ultrafiltration and the benefits of that. And of course, we spoke earlier about cannula position which is paramount. Okay, so the bypass strategies again involved high flow, low pressure, profound vasodilation, long-acting alpha antagonists, avoiding where possible, which was most of the time circulatory arrest, and using pH stat acid base and CO2 management, which I think was, you know, they were very forward-thinking in Melbourne to realize that this was going to be probably the best management strategy for the brain of these children. Fast forward to Texas Children's. When I came there in 1995, we developed a new perfusion service. There's the Four Musketeers, Mary Claire McGarry, Mary Ann Mueller, Deb Surprise, and Richard Owens. And we have Richard Owens here with us in Austin after all those many years carrying the flag forward. This is one of the early photographs of Richard and Deb. We have favored having two perfusionists on all cases. This is a real benefit when things get tough and there's a lot going on. Of course, this is the bypass setup that you're all familiar with, but the most important thing beyond the technology is the ability of the perfusions to be able to see the patient, have a monitor that is for the perfusion machine, and this was the first headlight camera that we use at Texas Children's. We've refined that since then, but the perfusionist needs to be able to see the heart in these cases. And then we were off to the races with small baby heart surgery, which became very safe and very predictable. Of course, one of the things that we worry the most about in pediatric cardiac surgery is the brain, and the perfusionist has enormous responsibility when it comes to brain protection. Antigrate cerebral perfusion is really revolutionized arch reconstruction in small babies, essentially of weight circulatory arrest in all patients. And we developed a brain protection strategy, which includes intraoperative neuro monitoring, the use of bicoarticle near infrared spectroscopy to help adjudicate bypass flows. This is a paper that my colleague, Dr. Gottlieb, and I wrote about cannula malpositioning. If you weren't using the nears, how would you know that the cannula wasn't positioned appropriately in the aortic arch? And then we can use the data for novel perfusion strategies, like the repair of an interrupted aortic arch patient like this, where you see on the slide varying the bypass flow rates during various times of the arch reconstruction, brief periods of circulatory arrest, reperfuse the brain, circulatory arrest again, and hopefully a physiologic protection of the brain. The core principles we've reviewed before, high flow cardiopulmonary bypass, minimize low flow bypass and hypothermic circulatory arrest, and cool the patients slowly with hematocrit of at least 30 to 35 percent. My colleague, Dr. Andropoulos, worked really hard on this at Texas Children's and demonstrated that physiologic brain perfusion translates into better no develop outcomes for children. Well, we're here in Austin, and this is a photograph from our setup, which of course would look very familiar to those of you that work with me at Texas Children's with the pump setup, the physiologic monitor, and the video screen. And there's the relationship we like to have in the operating room. You see myself, Dr. Gottlieb, the anesthesiologist and the perfusionist, we can see each other, we communicate readily, and refine the bypass to the benefit of the patients. And that of course is what we're here to do. We were off to the races here in Austin. This is our program data sheet since we started on September 1st of 2018. I'm happy to report that so far we've only had two deaths and over 500 patients. And we really believe that that the perfusion support is key to that accomplishment. I will say as a surgeon, I don't worry about the length of time on bypass one bit. My job is to focus on an accurate repair. So if it takes a long time, I'm confident that the patient is being well supported, well protected. And just like the Norwood operation that I just did, the baby comes out warm, not edematous, not acidotic, 200 minutes of bypass, chest close an hour after coming off bypass. That's the kind of perfusion support that's possible. And we're very grateful for the support of our profusion colleagues. Now, we have to keep moving this field forward. That's of course one of the premises of this conference. And this quote, which is on the main building here at the University of Texas from Edward Gibbon is perfect in this sphere. All the human must retrograde if it doesn't advance. So keep up the good work, keep moving the field forward. Physiologic perfusion is possible and it should be reproducible in just about every setting. Thank you very much for this opportunity.