4/27/22 – Angela Lorts, MD, MBA – Current Review: Advanced Cardiac Therapies for Children in Heart Failure

April 27, 2022

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00:00Still we are have.
00:02We are having this symposium
00:05for cardiology on June 3rd.
00:07The evolution of congenital
00:08cardiac care will be inviting.
00:10Some of our former fellows back
00:12and some friends and colleagues
00:14should be a great event.
00:15So if anyone's interested we're going to put
00:18the information in the chat box for you.
00:20If you're interested in signing
00:21up for that next slide, please.
00:25So today we have our 6th annual
00:28Dinsmore Lecture in Cardiology,
00:31and I just wanted to take.
00:32One minute to briefly recognize this,
00:35so we were approached back in around
00:392016 by Louise and Jeff Dinsmore,
00:42who were the parents to a young
00:45girl named Gabrielle who was born
00:47with complex form of hypertrophic
00:49cardiomyopathy and over her short
00:51life had a couple of cardiac surgeries
00:53and unfortunately succumbed to her
00:56disease around the age of three.
00:58Although she was not cared for here,
01:01the family wanted to recognize her and her.
01:05All all the beautiful things
01:06that she loved in life,
01:07including the ladybug,
01:08which is a symbol here and they
01:10had a lot of ties to this area and
01:11so they approached us and said,
01:13well, how can we help?
01:14We want to support her and her memory
01:16and support the cardiology group.
01:18And so we decided that one of
01:19the ways we could do that is to
01:21establish a lectureship in her honor.
01:23So this is the 6th annual
01:25Lectureship in her honor,
01:26and if you would just hit the next drew,
01:28we've had the opportunity to really
01:31have some outstanding speakers over
01:33the years who have brought excellent.
01:34Teaching about cardiology and cardiac
01:36care to us and I know we're going to be
01:40thrilled to welcome our current speaker.
01:42I just also want to mention one last thing,
01:44which is that we are going to be reviewing
01:46some cases tomorrow with our speaker.
01:47So if anyone's interested in
01:49diving deeper into cases of
01:50heart failure and transplant,
01:52please reach out to me or doctor Hall
01:54and we can certainly plug you into
01:56that tomorrow morning at 9:00 AM.
01:57So without further ado,
01:58I'm going to turn over to my colleague.
02:00Doctor Kevin Hall is going to
02:02formally introduce our speaker.
02:03Kevin
02:05thank you Rob. I also want to extend
02:07our welcome to everyone joining
02:08today and I'm delighted to have the
02:11privilege to introduce our speaker,
02:12doctor Angela Lorts.
02:15Doctor Lawrence is the associate
02:16chief Quality officer and professor
02:18of Pediatrics at the Cincinnati
02:20Children's Hospital Medical Center,
02:21where she practices as a pediatric
02:23cardiologist and where she directs
02:25the ventricular assist device and
02:27total total artificial heart programs.
02:29She's an internationally recognized
02:31leader in the field of cardiology
02:33with broad expertise and outcomes,
02:34measures and quality improvements,
02:35and currently serves on the board of
02:38directors and Executive Governance
02:39Committee with the International
02:41Society for Heart and Lung Transplant.
02:43And while her list of accomplishments
02:45in this field is long.
02:47I want to introduce what I believe will
02:48be one of her more broad and lasting
02:51achievements with a brief historical note.
02:53Only a few years ago,
02:54it seemed that the that pediatric cardiology
02:57programs kept mostly to themselves.
02:59As much as I would imagine
03:01most pediatric fields.
03:02Information was of course
03:03shared behind highly refined,
03:05but far too rarely published reports,
03:07but there was too little, if any,
03:09formalized and open discourse
03:11between programs.
03:12It wasn't that programs trying
03:13to hide knowledge,
03:14but they they didn't actively
03:15seek to share it either.
03:17And so data and experience were
03:18inactively protected secrets,
03:20so to speak.
03:21In a sentiment,
03:22I'm certain you'll recognize the
03:24French poet and novelist Victor
03:26Hugo has been credited with the
03:28phrase that nothing is more powerful
03:29than an idea whose time has come.
03:31And coupled with all the newly emerging
03:34communication technologies we all recognize,
03:36and perhaps the sense that this is
03:38not enough for the children we treat.
03:40Doctor Lawrence co-founded the
03:42International Action Learning Network.
03:44This is an organization dedicated
03:45to improving heart failure and care
03:47for children by broad collaboration
03:49and through her leadership,
03:50the network has grown to not
03:52more than 1000 members and 57
03:54institutions across eight countries.
03:56It's hosted more than 40 quality
03:58improvement projects and has
03:59achieved significant improvements
04:01in clinical outcomes,
04:02including the decreasing of stroke rates
04:04in these patients by more than 50%.
04:06The standardization of clinical practice
04:09across more than 50 institutions.
04:11It's developed collaborations
04:12with six pharmacologic and device
04:14companies and developed a content
04:16learning management system for
04:17members and other stakeholders.
04:19So broad collaboration among
04:21institutions is clearly an idea whose
04:24time has come and doctor Lawrence
04:25deserves much credit for both.
04:27Recognizing this and acting upon it to
04:29build one of the foremost collaborative
04:31networks in pediatric medicine.
04:33So it's my true pleasure to
04:35introduce Doctor Angela Lawrence.
04:36Doctor Lawrence.
04:37Thank you everybody.
04:38I'm going to share my screen.
04:57So thank you for having me.
04:58That was a great introduction Kevin,
05:00to something that I'm very passionate about.
05:02Which is the Action Learning network.
05:03Interestingly, I am not.
05:05I'm going to interject some of
05:07the work we've done with action,
05:08but I'm going to talk more about
05:11advanced cardiac therapies in 2022.
05:12For heart failure,
05:13and I know that it's a big program
05:16for Yale to continue to mature your
05:18heart failure transplant program.
05:21So I thought it would be good to talk
05:22a little bit about device therapy.
05:27So heart disease remains one of the
05:30top ten causes of childhood mortality.
05:32Some of the things that Kevin said are
05:35so important that we, despite this,
05:37we really don't work well together.
05:39We don't collaborate well.
05:40We don't share ideas all the time.
05:43Sometimes we do,
05:44but we are also using manuscript process,
05:47anecdotal reporting,
05:47and how do we make the outcomes of
05:50kids with heart disease even better,
05:52since it is one of the top
05:56reasons for mortality.
05:57There's diverse ideologies of
05:58heart failure in children,
06:00and this is a really important point
06:02because in adult heart failure a
06:05lot of the care and the devices
06:07and the drugs are made or studied.
06:10For one ideology of heart failure.
06:13But for Pediatrics we have to
06:14deal with congenital heart disease
06:16that could be Fontaine failure.
06:18It could be failed palliation
06:20and those patients develop.
06:21Heart failure may need to go to transplant,
06:24may need a device,
06:25may need medications,
06:26there's cardiomyopathies.
06:27Which is more similar to the schematic,
06:30heart disease that the majority
06:32of the heart failure patients in
06:34the adult world world look like?
06:36Then there's myocarditis which we all know.
06:39There's kind of a new new interest in
06:42myocarditis not just from the vaccine,
06:44but the viruses that are around us.
06:46But there's many ideologies of these
06:49heart failure patients which make
06:51treating them and using devices
06:53a little bit more complicated.
06:55Not only are the ideologies pretty diverse,
06:57but also the size of the patients.
07:00So we go from infants where you
07:02see this little baby over here
07:04with this temporary device.
07:06So stuck in bed not able to do
07:08much while waiting for transplant
07:09to a younger child to school age
07:12children who were trying to get
07:14home on their device to children
07:16who are more adolescents or young
07:18adults and in some institutions
07:20such as Cincinnati Children's,
07:21we're taking care of all of the
07:23adult congenital heart disease.
07:24Patients that need devices and
07:26transplant so you can imagine the
07:29diverse number of patients that
07:30you're seeing that one day you're
07:32seeing an infant or the same day,
07:34and then you're seeing a 45
07:36year old Fontan failure patient,
07:38and so this makes it really hard to learn.
07:41There's small numbers of each of
07:42these patients at each institution.
07:44Just to reiterate what Kevin said is,
07:47you know,
07:47everyone has a small number to learn from,
07:49and so how do we all learn together?
07:52The other thing that's important
07:53about advanced heart failure?
07:54And Pediatrics is,
07:55we really don't use many things
07:58that are studied in kids.
07:59Most of it is studied in adults and
08:02then we extrapolate the data from the
08:04adult studies to use the medications.
08:06The rehabilitation or monitoring.
08:08In this case,
08:09I would say it would be Cardiomems
08:12is approved for.
08:13Approved for adults,
08:14not for children and we use that most
08:16of the ventricular assist devices
08:18historically have been approved for adults.
08:20Although we're seeing a change with the
08:22network really driving a change in how we
08:26label those devices and then transplant,
08:29so transplant has been around
08:31a long time historically has
08:33been studied more in the adults,
08:36but there are new studies in Pediatrics
08:38that are looking at immunosuppression drugs,
08:40which will be really exciting
08:42for a field to see if.
08:44New immuno everolimus will be the
08:46drug or the teammate trial will give
08:49some results that will help kids.
08:52The scope of the problem is not only
08:55the diverse ideology and diverse
08:56size of the patients and all the
08:59different types and small numbers,
09:01but also 25% of children with
09:03heart failure die during their
09:05first hospitalization.
09:07This is remarkable if you think
09:09about the adult world that a lot
09:12of patients with heart failure
09:13come in and out of the hospital.
09:15In children,
09:16that's not always the case or
09:18fourth of the time it's not the
09:20case that they come in and they
09:22become very sick very quickly.
09:23With that only less than 2% of
09:27the heart failure funding from the
09:29NIH actually goes to Pediatrics,
09:31so obviously this all sounds very negative,
09:33but we let's put it into a positive
09:35spin that what Kevin talked about
09:36is that if we work together,
09:38we can fix the problem so we can
09:40bring devices to children, we,
09:41and that's what I'm going to
09:43really talk about.
09:43But can we also bring medications
09:46and other technologies to children?
09:49So I kind of mentioned
09:50that there's medicines,
09:51devices and transplant to
09:52treat heart failure.
09:53Always think of this in my head.
09:54Like Oh my,
09:55there's so many things,
09:57but let's just talk about devices
09:59because we have only 45 minutes left and
10:02medicines for heart failure and transplant.
10:04Although interesting,
10:05we could be for another day.
10:08So first, just to make sure
10:09everyone's on the same page about it,
10:11what a ventricular assist device is.
10:13I'm going to show you a little video.
10:16My sister.
10:18Help.
10:23Please make the party.
10:27Right, yeah? Why you asking?
10:32It's getting a little bit too big
10:34and the blood just wasn't pumping
10:37out the way it should
10:39have, so it was hard for her to bleed
10:42and they had to put in the pipe where
10:45to help her height to pump a little
10:48better than what it did. She has been
10:51feeling so much better
10:52and really glad that she
10:54got to get this.
10:56So I think she explains it much better
10:58than I could do and quicker probably,
11:00but I've ventricular assist device
11:02can bypass the heart or augment
11:05the blood flow to the organs.
11:07The one that you just saw that that little
11:09girl had what was called a Heartware.
11:11We're going to talk a little bit
11:13more about that device in a second,
11:15but avad is used to support patients
11:17that don't respond to medical management.
11:19I think this is a really important point
11:21is we always try medical management first.
11:24It's a big operation.
11:25It's not something that we.
11:27Take off the shelf if we think we
11:30can use strips or other medications
11:33to help the heart failure.
11:35It's really used to prevent death,
11:36and this could be prevent death to go
11:39home and live their life on a bad or
11:42prevent deaths to get to a heart transplant.
11:45It's implemented to bypass or augment
11:48the function to all vital organs.
11:51And it's becoming increasingly
11:52more common to use a ventricular
11:54assist device to keep these children
11:56with heart failure alive.
11:58The percentage of patients that need a
11:59VAD to as a bridge to transplant while
12:01they wait for an organ really varies,
12:04but a third of those patients are
12:05on a bad prior to transplant.
12:08I think this is an important point,
12:09because this is actually a little bit.
12:11The state is a little bit old.
12:12There's actually not a new graph yet,
12:16but it will come out soon and I
12:17think it's even going to be greater
12:19than 30% of patients.
12:20Need support to wait for an organ and
12:22why that's becoming more and more
12:24important is the organs are becoming
12:26more and more scarce and so are we're
12:28our wait times are extending more
12:31every day so our babies are waiting 5-6
12:35months so they're not going to make
12:37it without ventricular assist devices,
12:39so it's becoming more and more
12:41important to figure this out.
12:43And many of the patients that need
12:44a heart transplant have congenital
12:46heart disease,
12:47so that makes it even a little bit
12:49more complicated for them to wait if
12:50they can't get a surgery so it can
12:52evad improve the outcome of these
12:54patients waiting for transplant.
12:55So these complex congenital heart
12:57disease patients.
13:00The challenges with pediatric bad therapy.
13:03I touched on a little bit,
13:04but really this varied age and size.
13:07I can't say enough because you have to
13:09have a bad that will take care of the
13:11smallest 2K baby and a VAD that will take
13:13care of your adolescence or young adults.
13:15You'll have to have a you know Vads that
13:17will help the right side and bags that
13:20will help the left side and good plans
13:22for right sided and left sided support
13:24the complex anatomic structures of the
13:26congenital heart disease portion is
13:28also very interesting to think about.
13:30And those are the Fontan patients
13:32which I'll touch on in a minute,
13:34are really on the form,
13:36are really important to us right now in
13:38the pediatric bad community because they're
13:40coming to our clinics needing support,
13:42and we don't have great options.
13:43But we think that we're making we're
13:46making some differences that will help
13:48those Fontan patients while they wait.
13:50Implantation indications so.
13:52Decompensated heart failure as I said,
13:56should be unresponsive to medical management,
13:59and I think it's a really important
14:01point for the.
14:02For the cardiologist,
14:02especially in the room who can think
14:04about this a lot is that the decision to
14:06put a VAT in should not be intertwined
14:08with trying to get higher on the list.
14:11It should be to support the patient
14:13because you think that they're not
14:15going to make it to transplantation,
14:16not necessarily to to change the system.
14:20If they're escalating in their
14:22inotropic support,
14:23or they have any indoor organ
14:25dysfunction that you're seeing,
14:26and I think one really important
14:28thing about indoor organ dysfunction
14:29in kids is it's not just creatinine
14:31or bilirubin or something obvious,
14:33sometimes it's just that they're
14:35really fussy or they're vomiting,
14:36and that vomiting can sometimes be as
14:39far as side is a sign of heart failure
14:42and impending a really a decompensation.
14:47There really aren't a lot
14:48of contraindications to
14:49bad therapy and trying it.
14:50You know, these are the historic
14:52complication or contraindications.
14:54Bleeding or having a problem with
14:56clotting because these patients are
14:58have to be anticoagulated if they
15:00already have a neurologic deficit or
15:02irreversible indoor organ dysfunction.
15:04I actually it's very rare that we
15:07find a contraindication because
15:09irreversible end organ dysfunction
15:10is really hard to define.
15:12A lot of times we think that
15:13we can make the indoor organs
15:15better with better blood flow.
15:17I think hypertrophic cardiomyopathy
15:19and restrictive cardiomyopathy,
15:20which I think will probably
15:22talk more about tomorrow,
15:23are difficult to support,
15:24but there are some different
15:26cannulation strategies you can
15:28use to support those patients,
15:30so not necessarily as a contraindication,
15:32but does put it on your list of worries.
15:36Findings that motivate me
15:37to support with the VAD.
15:39I do find that and I'm sure the
15:41cardiologists in the room know this too.
15:44But doesn't it seem like a heart failure,
15:46patient, always decompensated?
15:47The two in the morning?
15:48So for some reason they always wait and
15:50then all of a sudden they're really sick
15:52really fast and they're looking fine all day.
15:55Maybe they're a little like vomiting,
15:56a little bit more and
15:58then they get really sick.
15:59So trying to find some clues to that so
16:01low mixed venous but feeding intolerance.
16:04I can't say enough.
16:05That I really think feeding
16:07intolerances are clue.
16:08So more vomiting,
16:10not tolerating feeds,
16:11no heart rate variability,
16:13how they look on exams.
16:15Sometimes it's not their indoor and sometimes
16:17you can predict just by the touching the toe.
16:20You know how they look and how they
16:23their color and what their mom or
16:26father says about what how they look.
16:28Increasing BNP's despite diuretics.
16:30So using some of the
16:33neurohormonal biomarkers.
16:34Escalating your diuretics but no change
16:38in your urine output is also a bad
16:41sign that they will soon decompensate.
16:44For patient selection.
16:47You know for the non cardiologists in the
16:49room this is is maybe not as interesting,
16:51but it kind of sets up the next
16:53slide is that we have taken our bad
16:55patients and put them into different
16:57profiles of how sick they are.
16:59The reason why we did this and
17:00this was done in the adults and
17:02we have just adopted it,
17:03and Pediatrics is because the sticker,
17:05they are the worst.
17:06The outcome on the back end,
17:08so the worse the outcome after the VAD you
17:11can see here that the sticker patients,
17:13the profiles one and two are the
17:15patients that were really putting bads.
17:17And if we really want to try to be
17:19proactive and prevent bad outcomes
17:21on a bad or prevent decompensation,
17:24we need to,
17:25you know,
17:25push this to two and three and
17:27not let them be in cardiogenic
17:28shock when we take these patients
17:30to the operating room.
17:31So you'll see these outcomes here.
17:35This is the PD Max data from the 3rd annual
17:38report. Just looking at the
17:41overall patient population,
17:42but we know that the sicker the
17:45patient is going into implant,
17:47the less likely they are to do well.
17:49So just to give you some perspective
17:52for those who haven't looked
17:53at these this PD Max report,
17:55this is the Kaplan Meier of the
17:58All pediatric bad patients.
17:59So at this time there was
18:02400 and 2386 deaths.
18:04Or the yeah the at six months you
18:07see you have like a 70 to 80%.
18:09Survival, which in most of these cases
18:12was much better than the survival
18:14they would have without a VAD.
18:17The important part here is that
18:18if you get to a point where you're
18:21in critical cardiogenic shock,
18:22this blue line you can see how
18:25poorly the outcomes become,
18:27so these are the other stages
18:28that I showed you.
18:29We're trying to,
18:30you know,
18:30get more implantation in this range,
18:33knowing that those patients are
18:35sick enough to need a VAD and
18:37not let them get to be in shock.
18:41Historically, there's four main reasons
18:44for Evad Bridge to transplant transplant,
18:47so those are the patients
18:48waiting waiting for an organ,
18:49and that's about 49 percent.
18:5150% of our patients in Pediatrics.
18:54There's a bridge to recovery,
18:55which is not as common,
18:58although we spent three hours of our
19:00action meeting yesterday talking
19:02about how to recover patients,
19:04and so that's something that you'll see
19:06on the horizon is can we put Vads in,
19:08turn them down, put them on medications?
19:11And get the data out so they
19:12don't have to be transplanted.
19:14So there are some patients populations
19:15that we do think that will work in,
19:17but you see here in this older data,
19:19it wasn't very common.
19:20We hope that next time I talk to you,
19:23well, we'll have this number up to 20%
19:25because we think there's probably one
19:27in five patient could be recovered.
19:30Bridge to eligibility or decision.
19:31These are the patients that have
19:33some reason why you can't go straight
19:36to transplant and those patients
19:37need time to get good support.
19:39They may need to recover their
19:41indoor gun function.
19:42You may need to figure out if the
19:43patient the family is going to
19:44be able to care for the patient.
19:46Lots of reasons for that and then
19:48destination therapy is this is.
19:50These are the patients that aren't
19:52going to be transplanted candidates.
19:54In Pediatrics.
19:54This is more likely that Duchene
19:56muscular dystrophy patients,
19:58which we do put Vads.
19:59And and they do do well.
20:02We have one that has been out three
20:04years and one that has been out five
20:07years on their ventricular assist
20:09device as a destination device.
20:11And so they go home with their
20:12device and they've lived with it,
20:14knowing they're not going to transplant.
20:19But the bridge concept you know?
20:22We kind of need to get away from
20:24because really a VAT is just
20:25a tool to treat heart failure.
20:27So my new thing I would say is let's just
20:29burn that bridge because we don't need to
20:32think about what we're going to do next.
20:34What we need to think about at this
20:36time is treating the patients heart
20:38failure and making sure that they are
20:40alive and well to make that next decision.
20:43You don't necessarily have
20:44to know where you're going,
20:45and you can change paths.
20:47So you could think the patient
20:48wasn't going to recover.
20:49But you should always be thinking
20:51about can I take that bad out?
20:53Can I recover that patient or the patient
20:56that wasn't a transplant candidate?
20:57Can I make them a transplant candidate?
21:02And patient selection.
21:05This is a little detailed more for the
21:07cardiologist in the room, but you know,
21:09thinking about all the device possibilities
21:11that you could possibly need.
21:13When you think about a patient,
21:15what if it doesn't fit?
21:16What if you take them to the operating
21:18room and that VAD does not fit well, what?
21:20What is your backup plan thinking about?
21:23What if the right ventricle
21:24doesn't do well most of the time,
21:26we're supporters supporting
21:27the left ventricle.
21:28But do you need some kind of
21:29plan in case the right?
21:30Intrical isn't doing well.
21:33We can calculate how much
21:35cardiac output they need,
21:36which goes into which device they get.
21:38And then also,
21:39I think this is a really important point,
21:41not just for Vads,
21:42but anything we do is that you really
21:45need to determine is it a high risk
21:47case and that will help you determine
21:50what your goals are afterwards.
21:52So if we have a low risk case and
21:54we send them to the operating room,
21:55we will say OK,
21:56we want to excavate within 24 hours.
21:58We want the patient to be on
22:00the floor within seven days.
22:01If I've talked to the team and
22:03we've had a good conversation about
22:04this is a really high risk case.
22:06This is going to be really hard
22:08and modify our expectations.
22:09Really helps the entire process go better.
22:14So thinking more about patient selection,
22:16the kids that are high risk when
22:18I'm talking about, you know,
22:19changing your postoperative timeline
22:21or expectations so that everyone feels
22:24good about how the progression is going.
22:27You're not making false
22:29expectations that are too lofty.
22:31These are the kids that are in
22:34cardiogenic shock when they go to
22:36VAD or their little teeny kids.
22:38Single ventricle kids that need
22:41a VAD complex congenital.
22:43Kids, kids with hypertrophic
22:45or restrictive cardiomyopathy.
22:47These are kind of the higher risk VAD
22:49patients that you still can support,
22:51and we have great data to show that
22:54we can support these populations,
22:56but the populations just need to.
22:58You just need to kind of modify
23:00how you're thinking about the what
23:01they're going to look like coming out.
23:06So we talked a little bit about
23:08patient selection, really.
23:08You know, trying to prevent the
23:10patient from having being in shock,
23:12trying to prevent the indoor
23:14organs from getting sick?
23:16Who are the right patients?
23:18Those that can't be managed
23:20with medical management.
23:21But then once you decide
23:22the patient needs one,
23:23what kind of device are you going
23:26to use and what's available?
23:28This is just and you many of you
23:31at Yale have seen some of these
23:34devices come through your ICU.
23:37That centrimag PD Mag wrote a flow
23:39type device which sits outside
23:41the body and the cannulas come
23:43in to the chest is really meant
23:46for more of a short term option.
23:49For urgent cases the these
23:52devices in the middle here.
23:54The Berlin heart comes in a ton of sizes.
23:56I'm going to show you that the
23:58hardware used to be our go to for
24:00little kids and has been taken off
24:02the market and I will touch on that
24:04and then the Heartmate 3 is really
24:06the device we're focused on right now,
24:08which is a great device in the adult
24:10world and it's been great for kids too.
24:12It's just a little bit big
24:14for some of our smaller kids.
24:16And then, in some institutions,
24:18this syncardia or total artificial
24:19heart is available to kids.
24:21There is a smaller.
24:22There's a 50CC which is the smaller
24:24device and then the adult device,
24:27which is a 70.
24:28So if you have biventricular failure just
24:30thinking about that could be available.
24:35Also, thinking about what kind of support,
24:38what kind of ventricle you are supporting,
24:40and I talked a little bit
24:41about this, but are you?
24:43Are you supporting those left side?
24:46A single ventricle?
24:47Which would be an S bad?
24:49Are you supporting the right side
24:51or you supporting both sides?
24:52And what do you predict going
24:54into the operating room that
24:55you're going to need to support?
24:57Are you going to need to support
24:59both or are you going to need
25:00to just support the left?
25:01And having that kind of plan up front?
25:07The Berlin heart.
25:07This is really our go to this is
25:10the pediatric device that has been
25:12around for a decade. It or more.
25:15It has many different cannula sizes,
25:19many different sized blood pumps.
25:21It's a little archaic,
25:23though it's archaic because the
25:25patients are stuck in the hospital.
25:27Right now they're stuck on Ivy
25:29Anticoagulation which is very
25:31different than the adult devices
25:33and they are outside the body.
25:35So the patient has Dr.
25:37Canulas and they have a device.
25:38I'll show you a picture where
25:40the device is outside the body so
25:42those kids are not able to have
25:44a really great quality of life.
25:46But this has all the sizes
25:48so you can support any size.
25:50I would say most most institutions at
25:53this point will support up to 20 kilos.
25:56With the Berlin heart and
25:57then around 20 to 25.
25:59You're starting to think about
26:00what adult device could you use.
26:04Canula placement we kind of touched on this,
26:06but just thinking like.
26:08Is it the left side that you're
26:11supporting the right side?
26:13The svad this is a single ventricle
26:15here and what a buy bad would look
26:18like if you had two Vads in a patient
26:21that needed both sides supported.
26:25The Berliner heart outcomes.
26:26This slide is a little busy.
26:28I don't want you to focus on all the words,
26:30I just want you to focus on really the
26:33Berlin heart outcomes are are good.
26:3686% of the patients in the most recent
26:39cohort had a positive outcome at 180 days,
26:42meaning they were either transplanted
26:44or still alive on device,
26:46which is much different than historic
26:48information about the Berlin heart.
26:50We are getting to a better place with
26:52the Berlin heart and I think a lot of
26:54it is because we're working together.
26:56So all the institutions are really
26:59working hard to make this better and we
27:02have seen improvements only 11% of the
27:04patients in this cohort had had a stroke,
27:07which is down from 30% prior to the
27:11older historic data before the network.
27:14So we are seeing some really
27:16great differences in outcomes for
27:19our Berlin patients.
27:20So definitely if needed if
27:22you need to use a Berlin it,
27:24there's lots of different opinions,
27:28experiences to learn from.
27:32One of those. Experiences that helped
27:36us decrease stroke rates in the Berlin
27:39heart happened with the network,
27:40so when the network started in 2017,
27:43our number one priority was
27:45to decrease the stroke rate.
27:47In Berlin heart patients we changed
27:50the anticoagulation strategy,
27:52we changed the blood pressure how
27:54we monitored blood pressure and how
27:56we treated it and we changed how we
27:58communicated at the bedside amongst
28:00staff and teams to really see if we
28:03could decrease the stroke rate quickly.
28:07One of the biggest things was the
28:09anticoagulation and I used this example
28:11to just show you the power of this
28:14network that we have developed is that
28:17at the time there were 25 centers in 2018.
28:20Now there's 60 but at the time we all
28:23decided we were going to change how
28:25we thin the blood for these patients
28:28how we anticoagulate these patients?
28:31We'll just all change at the same
28:33time so one day everyone changed.
28:35We had the day set.
28:36And at that point on we changed
28:39from heparin to buy Valley Routin.
28:41I'll never forget the CEO of Berlin Heart
28:43calling and saying what just happened.
28:45Like we've been trying to do
28:46this for a decade.
28:47We've been trying to change how
28:49we anticoagulate for a long time.
28:50It was the power of that network and we
28:52really learned from some of the centers
28:54who had used by Valley Ruden and said,
28:56you know their outcomes are better.
28:57They will us decrease the variation
28:59and let's just change what we're
29:01doing right now is not working.
29:03So with that,
29:04we wrote a harmonization document which
29:06is a little bit like a standard practice.
29:08Although people do a little bit
29:10different things of each institution.
29:12Which is fine.
29:13It's really what has built the network
29:15to move forward with standardizing
29:18care and you can see here the stroke
29:20rates coming down in these Berlin
29:22heart patients where we had 25 to 30%
29:24depending on which data source you
29:27looked at and down to 13% in the network.
29:30And now we're at 11.6% stroke
29:33rate for these patients and so you
29:35can see with an intervention.
29:37We've really worked together to improve
29:39the outcomes of these patients.
29:44I'm going to, but despite better
29:47results with Berlin heart,
29:49we still want to use these adult devices,
29:52and one of the reasons that I kind of
29:55alluded to earlier is that these patients
29:57are still hooked to this huge driver.
30:00You can see the device here hanging on this
30:03patient little girl with a big wrap here,
30:05so not very conducive to play.
30:09Quality of life is not great and the
30:11patients are stuck in the hospital.
30:13Wouldn't be much more want this for
30:16our patients where this little girl is
30:18out in the community coming back for
30:20rehab and so we're really trying to get
30:23these adult devices and kids so that
30:25we can get them out of the hospital.
30:27Going to school, getting better,
30:29waiting for their heart transplant.
30:36Sorry. So these three size kids,
30:39we're just going to talk a teeny bit about.
30:41So this is the Berlin heart.
30:42Here. This is the size baby that
30:45we usually gets a Berlin heart.
30:47This happens to be a heart mate,
30:49three which we're going
30:49to touch on in a minute,
30:50which is the device we now are
30:52you using for big bigger kids?
30:54And then this is the hardware which
30:56we were were sad to have seen go go.
30:59It was taken off the market in June,
31:01but it was really a great device
31:03for kids because it was a little bit
31:05smaller than the device we have now.
31:08So Medtronic stopped the
31:10distribution of the HVAD in 2021.
31:14And so we were back to having
31:16only the heart made three,
31:18which is a great device and I'm going to tell
31:20you why it's a great device in a minute,
31:21but you can see it's a little bit bigger.
31:23So where we thought the HVAD were
31:26squeezing into these little kids,
31:29we're now squeezing in something even bigger.
31:31So we went backwards a little bit there.
31:34And you can see the difference
31:35here in the size of these pumps.
31:37And so you know, this is the base of the
31:39pump and this is the base of the H fad.
31:42This is the pump we're using now.
31:44A little bit bigger,
31:45a little bit harder to get
31:46into some of the smaller kids.
31:51So the tweeners.
31:52This is what we have, you know,
31:54talk about these school age kids
31:56that we talked about at Berlin heart
31:58and the babies and then the bigger
32:00pump in the in the adolescence.
32:02Or the young adults we really are
32:05trying to figure out the best
32:08device for those kids in the middle.
32:11So and Kevin knows that there's lots
32:13of talk in the bad community about HVAD
32:17leaving the market and what we do instead.
32:20We think we can place a heart.
32:2123 and a kid.
32:22That's 2025 kilos.
32:23And we're trying and we're
32:25following that data really closely
32:27to see if it's the right thing.
32:29But we're also having to go back to
32:31using more Berlin hearts than we did
32:33in the past without when we had the aged fad.
32:36We're using a lot of fit studies
32:38to figure out what will fit.
32:39This is happens to be a hardware,
32:41but this is a CT reconstruction
32:43of a child's chest.
32:44With CT,
32:45we reconstruct the device
32:46in the CT scanner as well,
32:48and then we can place it and
32:50reposition it in all different ways.
32:51To figure out the right device
32:53for that child.
32:56And when you're thinking about
32:57these small patients and trying
32:59to use this bigger device,
33:00you know the the Heartmate 3
33:02is very is a very good device.
33:05It is a great device for adults.
33:07It's more forgiving.
33:08There's less bleeding,
33:09there's less clotting,
33:10the drive line is a little heavier.
33:13The low flow alarms are a little different,
33:15so just things to be thoughtful about,
33:17especially for the cardiologists
33:18in the room that are thinking
33:21about you know what device do I
33:22use for a child that is school age?
33:25And above.
33:28There are some trials going on for
33:29these tweeners these kids in the middle
33:31that don't have the perfect device.
33:33There's the pumpkin trial which is the
33:35Jarvik device which is going on now.
33:37It's been going on for a long time and
33:39it's very hard to recruit patients
33:41into a pediatric device trial.
33:43There's also the new driver
33:45for the Berlin heart,
33:47so this Berlin heart will be the same,
33:49but the driver will be able
33:51to be put on a stroller.
33:53The child will be able to stand
33:55and walk with it, it might improve.
33:57Quality of life.
33:58So we are really focused in trying
34:00to get this patient population cared
34:03for as the HVAD has left our use.
34:10So I'm going to just switch kind of thoughts
34:13a little bit about removing barriers,
34:16and I think this is a really
34:18important concept, and Kevin alluded
34:20to this concept of collaboration,
34:22but it's not just collaboration with
34:25all the centers that we've really
34:28been pushing and successful with,
34:30but also collaboration with
34:33industry and the FDA.
34:35And the story that I'm going to tell you
34:37right now is just about labeling devices.
34:40And why is it important to advocate for
34:42children to get devices and drugs for them?
34:44And why do we want to change
34:46that historical way?
34:47We've done things where we use
34:50adult devices and adult drugs,
34:52and then just extrapolate them to kids.
34:56Well, there's many reasons I'm going to
34:59tell you that for devices in particular.
35:02This is a backpack that this little girl
35:05made so she we used an adult device.
35:08The mom made this.
35:09You can see the Rick Rack here with the
35:12little vent and the reason is because
35:14the accessories aren't the right for
35:16children and so if they're not labeled,
35:18if the device is not labeled for children,
35:20or the FDA hasn't approved it for
35:22children or we're using it off label,
35:24no one will make the right
35:27accessories for the kids.
35:29So that's one reason.
35:31They don't.
35:32Industry doesn't necessarily
35:33do human factors on these kids,
35:35so this happens to be the syncardia.
35:37Human factors wouldn't have had to be done
35:40on a non pediatric device and you see,
35:42you're trying to hold this huge backpack.
35:45The drive of the vacuum tubing
35:47is too long for that child,
35:49so just thinking about you know how
35:51do we test that these children are
35:52going to be safe and then the education
35:56materials really not pediatric friendly
35:58unless we get these devices labeled for kids.
36:02So we action went to the FDA and
36:05worked with the industry and said,
36:09let's try this.
36:10Let's try to expand a label for kids and
36:12see if it changes how we treat these kids.
36:15So we worked with industry and
36:17the FDA and it was collaboration.
36:20It was the greatest partnership that
36:22we have had in action and we said This
36:24is why we told all the reasons why we
36:27needed these devices labeled for kids.
36:29We said we'll collect the data.
36:31The action.
36:32Industry collected all the data
36:34for the Heartmate 3 patients.
36:36We adjudicated all the data and
36:38we worked with Abbott to submit
36:40the application to the FDA.
36:42And on December 17th 2020.
36:44We had the first device in
36:46a decade approved for kids,
36:47which is the hard made 3
36:49and we're continuing to do.
36:50The post surveillance in action.
36:52So it was 18 months from an idea of
36:54getting a device approved for kids
36:56to getting it actually approved.
36:58And I think the really important
37:00point of this is that it was all
37:02just working together advocating for
37:04the kids and why we had to do things
37:07differently and why we couldn't
37:08do a clinical trial when there's
37:10so few children that need a device.
37:12And really, why it was important,
37:13I think that that was the most enlightening.
37:17Part is that everyone thought, oh,
37:19Pediatrics, they can get the device.
37:21So what's the what? What, Matt?
37:23Why does it matter?
37:24Why do they care?
37:25Well, insurance now pays for
37:28it easily all the device.
37:30Education is the appropriate for kids
37:32and now we can all learn together openly
37:35instead of saying oh it's off label.
37:37We can't talk about it.
37:40This was the press released
37:42from the Abbott Heartmate 3
37:45expanded pediatric approval.
37:49We're going to talk a little better
37:51about patient outcomes in these kids.
37:53The one thing to know is that these
37:56adult devices that we're using in kids,
37:58the outcomes are the same as adults.
38:00They're really good.
38:02These kids do really well and
38:04we have multiple papers kind
38:07of outlining these results.
38:09And then we've been looking close
38:10at our own results in action to
38:12make sure that pushing this forward,
38:14expanding the label was the
38:16right thing to do,
38:17and we're seeing that our results are
38:20actually better than some of the adult.
38:22Adult data that has been published.
38:24We have a 94% positive outcome
38:26in these patients even though
38:28there are kids with a big device,
38:30very low stroke rate.
38:3452% of these patients are
38:36discharged before transplant,
38:37so they're getting back into the Community,
38:39so this is a really exciting way
38:41to follow these outcomes and make
38:43sure that this expanded label
38:45was the right thing to do,
38:47that getting them to kids is the
38:48right thing for these children.
38:53And I'm just going to touch on
38:54just in the last 10 minutes or so
38:57of the five current bad trends.
38:59Some of them I've alluded to,
39:00but I think to take away from this lecture,
39:03if you're thinking about what is
39:05avad and what can it do for me,
39:06or what am I gonna see it
39:09doing at your institution?
39:12I think we've talked about this,
39:14but bad use is increasing and it's
39:17decreasing weightless mortality.
39:18More centers are using the Vads to
39:21rehabilitate their patients and make
39:23them better transplant candidates,
39:24and so I think you will start to see
39:27more and more bads if you're developing
39:30or maturing your transplant program.
39:33We know from this data this
39:34is now a little bit old,
39:35but this was 2015 that patients
39:37supported with a VAD were four times
39:40more likely to survive transplant.
39:42So this is just really impressive that
39:46even in 2015 without all the knowledge
39:49that we've now gained with bad support,
39:51we really were getting
39:53more kids to transplant.
39:56And the allocation system has changed
39:58things dramatically because now
40:00in 2016 there was a view vision
40:02of the pediatric allocation and
40:04that's really pushed,
40:06not going to get into all
40:07the details about it,
40:09but it's really pushed people to use
40:11bads more or need to use Vads more
40:13because the there are many kids that
40:16aren't getting transplanted because
40:17of how they're listing status is.
40:19So that's especially true for kids with
40:22cardiomyopathy that they can't be the
40:24highest status unless they have a VAD.
40:26It's a whole nother hour talk
40:28about why that is,
40:29and if that's the right thing to do,
40:30but the reality is,
40:31it's really pushing the bad
40:33use in the community.
40:37This is just touching on that that the
40:39second most you know trend that we're
40:41seeing is that you can't really have the
40:44dilated cardiomyopathy and be A1A, and
40:46milrinone just doesn't change your status,
40:48which for the cardiologist in the room
40:50you know that we used to be able to put
40:51a child on milrinone and they could sit
40:53in the hospital and wait for transplant,
40:55and now they're not in the highest
40:57status and they're waiting a long time.
41:00I have one patient that's on
41:01milrinone that's waited 18 months.
41:05Some of the listing status issues
41:08as I said, You know really.
41:10I'm really passionate about this.
41:11But I think that it is another talk,
41:14but it's just you know how we list.
41:16A 17 year old versus an 18 year old
41:18is different and that's driving
41:19some of the need for more bads
41:22because we are going to need to
41:24support these patients longer.
41:25Some of the listing status
41:27changes have made a dilated.
41:30Cardiomyopathy have a lower status than
41:32a congenital heart disease patient.
41:35Maybe that's the right thing to do.
41:36I think we'll have to see as we
41:38look at that data.
41:42We're using these devices in
41:43really creative ways and I
41:45think this is really important.
41:46Point is that we used to not
41:48use Vads and single ventricles.
41:51Very rarely did we think it would work,
41:53and the data is supported
41:54that it wasn't a good idea.
41:56I mean, there's a patient from
41:58or a paper from six years ago or
42:01so that showed really awful bad
42:03outcomes with all three stages.
42:06It's not really true anymore.
42:07We're actually having really good
42:09outcomes in our single ventricle stage ones.
42:12Shunted patients,
42:13there are some centers who have done
42:16multiples and we've learned a lot
42:18from them sharing that knowledge,
42:20so some really good success
42:21stories of supporting these single
42:23ventricles in different ways.
42:25So not only the shunted patients are
42:27we seeing supported more frequently,
42:29but also the Glen patients
42:31were always or the stage.
42:33Two patients were really hard to support.
42:36We are supporting more and
42:37then the Fontan patients,
42:39which I'll talk about in a second.
42:43So Fontan patients also a
42:46preview to another hour talk,
42:48but really an exciting thing is that
42:52Fontan patients are coming to your center.
42:55They're coming into your
42:56center with heart failure,
42:58and they're going to need transplants.
43:00We don't have enough transplants,
43:02so we need some kind of life
43:04saving device or something that
43:06can get them to the transplant.
43:07Or they can live on and I think we're
43:10really starting to understand who the
43:12best Fontaine candidates are for a device,
43:14and so that's exciting.
43:15Like that's a new thing for the field
43:17is that we can support Fontan patients,
43:19not all of them,
43:20but a group of them.
43:22And they could do really well.
43:24We also have been showing that Fontan
43:26Vads can be a bridge to a heart
43:28transplant or a bridge to a heart and liver.
43:30Transplant so once again it's
43:33a very big topic,
43:34but I just wanted to give a touch of
43:37that coming up in the next couple years.
43:40And the Fontan data outcomes looking good.
43:43This is a little bit old now.
43:45It was published in 2021,
43:47but you know how long it takes
43:48to get a manuscript published.
43:50But this was 45 pontians,
43:5369% transplanted, 21% mortality.
43:55But thinking about how many patients
43:58would have died waiting for a transplant,
44:01which would probably be all of them.
44:04That is great news for our Fontan
44:07patients that are are failing
44:09and waiting for transplant.
44:14We often get a lot of
44:16questions about fontains.
44:17I think that action is working really
44:19hard to answer these questions.
44:21I touch on these here because I'm
44:23sure that when you if you have
44:25done your first Fontan bad or you
44:27plan to or you have a patient,
44:28all of these questions will be
44:30on your question list and I think
44:32we have some answers from the
44:34experience across the network,
44:35but we are always welcome to work
44:38with anybody who has the Fontan bad.
44:40I think there are some nuances
44:42to trying to support. And while.
44:47The fifth thing last trend is always being
44:49open to recovery and I touched on this
44:51and I think this is really an important
44:53concept is that once you put a VAD in,
44:55that doesn't mean that you can't
44:57keep trying to get the VAT out so we
44:59always can try to recover the patient
45:01and this is a big concept in the
45:03adult field is like is it can we get
45:06them on heart failure medications?
45:08Can we support them and unload that
45:09heart and then get the device out?
45:11Does it always have to be a
45:13bridge to transplant?
45:14So also a very exciting thing to think about.
45:19Collaboration Kevin touched on it.
45:21I've touched on it multiple times.
45:24There's nothing more exciting to talk
45:26about than the collaboration that's
45:28happened in the heart failure community.
45:30Really, what Kevin said is exactly
45:32right is that everyone got together.
45:34There's 60 leaders and 1100
45:37members of action, and now 6.
45:42Sorry I can't see my screen.
45:43I think we're at 6058.
45:45Sixty centers that are all working together
45:49to improve the outcomes of these patients.
45:52Our mission has been the same
45:53since 2017 that we're really
45:56focused on collaborative learning,
45:57uniting all stakeholders.
45:58I showed a few examples of what we've
46:01done in action, being the change in
46:03the anticoagulation all in one day.
46:06I also showed the example of working with
46:08the FDA and industry to say, you know what?
46:11This isn't good enough like we
46:12have to do better for these kids.
46:13And we have to change the outcomes
46:16of these kids and that worked.
46:17And we did.
46:18We did make a difference,
46:20so I really think that this is just an
46:23important concept that I have a lot of
46:25passion about and love to talk about more.
46:27If anyone has a disease process
46:29that they think are learning
46:31network or a collaborative.
46:33Would would be something
46:35they would be interested in.
46:36We we are always welcome to
46:37talk about how we did it.
46:42Action also has really focused on
46:44education and there's a learning
46:46management system that really looks
46:48at heart failure education for the
46:50provider and the patient and family.
46:52And I'm bringing this up if there's
46:54questions that came out of this talk.
46:56Kevin has access to the provider
46:58site and can give access to your
47:00center if you don't have it,
47:02and then patients and caregivers you
47:03can always refer to the site too.
47:05If you're starting to think about
47:07treatment for heart failure or Vads
47:09or understanding the diagnosis.
47:13Standardizing protocols,
47:14these are our harmonization protocols.
47:16I mentioned these with the BYVAL,
47:18but an important concept when you're trying
47:20to work together and share experiences.
47:23There are 35 now harmonization
47:25protocols and so really anything
47:27that you think you might come across
47:30that you've never seen before.
47:32There should be some kind of
47:34protocol from some site that's been
47:36harmonized into one document that you
47:38can use as a as a like jumping off
47:40point for caring for that patient.
47:44Just stay. Summarize collaboration.
47:51Giant drinks, unfortunately our
47:53numbers are smaller, right?
47:54There's just not as many
47:56children as there are adults.
47:58It's also important to realize
48:00that more children die of heart
48:02disease than any other disease.
48:04With that being said,
48:06it's very hard to do traditional research,
48:08so it's hard to do randomized
48:09controlled trials.
48:10A lot of our experiences, anecdotal,
48:13and so there's no great way to
48:16learn except for collaboration.
48:19Like many. I think that just
48:21summarizes kind of the whole talk.
48:23This is a really evolving field of
48:26really complicated field for Pediatrics.
48:28For all the reasons that I I discussed
48:30and this collaborative effort and this
48:32action Learning Network has really
48:34brought everyone together and so
48:35anyone who is interested in working
48:37in action working on a project.
48:41We would be open to.
48:44Any involvement so excited to
48:46talk more about it?
48:47I think there's a few questions in the chat.
48:51Thank you very much.
48:53Doctor Lawrence. What I wonderful
48:55overview of both the problem.
48:57I loved hearing your that sort of
48:59discussion in between the lines
49:01and the great highlight of all the
49:03great work that action is doing.
49:05We do have a few questions I'd like to jump
49:09in and start with one and then that is.
49:13While there have been clear
49:15improvements in in post transplant
49:16management and and obviously
49:18survivability in the recent decades,
49:20and we're still suffering
49:21from organ shortages,
49:22and so one when one pays attention,
49:24I think can almost sense an alternate
49:26convergence of two different approaches.
49:28There's the first,
49:28which is the improvements and
49:30mechanical devices as you mentioned,
49:31where the devices are becoming smaller and
49:33more indwelling and less failure prone,
49:35both from a mechanical and biological aspect.
49:38Less redundant, right?
49:40The ICAS drivers getting smaller than
49:42everything, but at the same time.
49:44The recent news.
49:45There's a second wave of sort
49:46of xenotransplant and tissue
49:48engineering coming in,
49:49such as the report of the first pig
49:51heart transplant down in Maryland,
49:52and so these were sort of approaching
49:55this problem of a kind of a complete
49:57solution from two different angles,
49:58and I was wondering,
49:59sort of where you thought,
50:01maybe the next leaps would come,
50:02whether it's indwelling batteries,
50:04and conductive charging so that they
50:05don't have to have external devices?
50:07Or is that close or far or or how
50:09do you see this specific thing out?
50:11These are great questions,
50:12I think that we're going to add it.
50:14In this field, from every angle,
50:16because we know it's a problem
50:17and we know that there's less.
50:19There's less organs and
50:20more patients needing them.
50:21So you're exactly right.
50:23I think that there's going to be an
50:26indwelling no drive line device that will be
50:29for kids before we are using xenotransplant.
50:32That's just my prediction there.
50:35I think there's some really great devices
50:37that are available not to patients yet,
50:41but are actually built.
50:42So I would love to see those coming through.
50:45For kids,
50:46definitely something smaller on the back end.
50:50And with no drive line,
50:51it's going to be perfect for kids.
50:53And if we were able to support children for
50:56three 5-6 years before we have to transplant,
50:59that's another 365 whatever years
51:01before they they're transplant fails,
51:04so any amount of time we can
51:06push that transplant off,
51:08I think,
51:08is where we really need to think and get to.
51:10Whether that's medications,
51:12whether that's whatever it is like not
51:15jumping to transplant if we don't have to.
51:18I think it's going to be a really important.
51:20Concept,
51:20but I do think we're going to
51:21have really good devices before
51:23we have snow transplant,
51:24but I might be wrong.
51:27Thanks so much for the the talk.
51:29There's a couple of quick questions
51:30I want to see if we get a couple
51:32of them in the in the chat.
51:33This is an interesting question
51:34from one of our ER doctors.
51:35What's the protocol for CPR with bad?
51:38Do you recommend holding compressions
51:40so we tell everyone to
51:42do CPR if they need CPR,
51:45there's some nuances. Obviously.
51:47Listen, make sure the device is
51:48going and then you're whoever's
51:49taking care of the device.
51:50If it's Kevin or his team to make
51:53sure that they're on the phone,
51:54but we would do CPR if there's if there's
51:57a need for CPR and they meet those criteria.
52:00If they you get ROSC,
52:02then you you know look at drive line
52:04sites and do chest xrays and echoes to
52:07see what has happened to the device.
52:09The only device we do not do CPR in,
52:12which isn't necessarily an
52:13issue for you guys right?
52:14This moment is the total artificial heart.
52:17Obviously that's not going to help,
52:19so that one is a little different,
52:21but everything else we would do CPR.
52:25OK, from from one of our cardiologists.
52:28Would you ever consider ads as
52:30destination therapy for patients with
52:32congenital heart disease like a Fontan?
52:34Yes, it's like I gave you that question.
52:35I love that question.
52:37I think it is definitely a way of the
52:40future because there's many fountains
52:42that aren't transplant candidates.
52:44They're not transplant candidates
52:45because they have antibodies to oregons
52:47or they have indoor organ failure,
52:48or they have been lost.
52:50I mean not that an adult congenital
52:52has ever been lost to follow up,
52:53but maybe they've been lost
52:54to follow up for a decade.
52:56Those are the patients that are great
52:59options for destination therapy and
53:01as we get better and better at this,
53:03I think it's going to be their option.
53:05I just don't think going to
53:06have enough organs.
53:09Alright, and I'm gonna.
53:10I think we have time for one
53:11last question so I'm gonna
53:12give it to our boss and David.
53:14I'll save your question for when you
53:15meet with Doctor Lawrence tomorrow.
53:17So he says thank you for a fantastic talk.
53:19Can you speak a bit to how you
53:20came to your career path and what
53:22supports and types of mentors you
53:23draw on and supported you as you
53:25developed an expertise in your
53:27learning network development?
53:30Interesting background in that I am a
53:33cardiac intensivist left that I see and
53:36I did basic science bench research.
53:38I had a patient who had a stroke.
53:40It's now been a decade.
53:41It's been he's 12 now so and his mom was
53:45a nurse and it really hit me that we
53:48needed to do better and so I left the ICU.
53:51I left the bench and I went and
53:54learned quality improvement.
53:55Science got my MBA.
53:58Thought about collaboration science.
54:01UM knew that we had to do
54:02something for this stroke issue,
54:04and that's when in 2017 it was five
54:06centers decided to work on this.
54:08I have a lot of mentorship because
54:11Cincinnati children host many learning
54:13networks, so the concept is very, very clear.
54:16In Cincinnati,
54:17Children's of this improved Care
54:18now is probably the biggest oldest,
54:21but NPC QIC,
54:22those cardiologists in the room know.
54:24So I was able to kind of model
54:26what we did after it,
54:28although we've really changed
54:29from just a learning network.
54:31Your research collaborative as well,
54:33because we have all these
54:34research studies going on,
54:35we have innovation projects
54:36that Kevin's involved in.
54:37We have the, you know,
54:38FDA relationships,
54:39so it it it has morphed into
54:42many different things.
54:44But the Learning Network concept
54:47is very very strong in Cincinnati.
54:52Perfect, I think we're going to
54:53end there because it's 1:00 o'clock
54:54and I want to be respectful.
54:56Everyone's time if anyone's interested.
54:57I put in the chat.
54:58We're going to be reviewing
55:00cases with Doctor Lawrence,
55:01Doctor Hall tomorrow morning,
55:02so anyone's welcome to join that and
55:04then we have some time carved out for
55:05you to meet with our fellows tomorrow.
55:07So thank you so much.