Hello friends 👋
In this episode of From The Heart, hosts Dr. Nim Goldshtrom and Dr. Adrianne Bischoff explore the latest research in neonatal cardiac care, focusing on congenital heart disease (CHD) and its impact on premature infants. They discuss a study analyzing survival trends in preterm infants with CHD, highlighting the “double jeopardy” these babies face due to both prematurity and congenital cardiac anomalies. Another study compares neurodevelopmental outcomes between preterm infants and those with CHD, revealing that term infants with CHD exhibit similar motor and cognitive challenges as preterm infants, yet receive less developmental support. The conversation then shifts to emerging research showing a decline in postoperative brain injuries in CHD patients, possibly due to improved surgical and perioperative care. Finally, they discuss a survey on neonatal cardiac care models, emphasizing the evolving role of neonatologists in managing CHD patients and the need for better integration between NICUs and CICUs. Nim and Adrianne reflect on the importance of specialized care teams, advocating for neonatologists to play a greater role in optimizing outcomes for this vulnerable population. Tune in for a compelling discussion on bridging the gaps in neonatal cardiac care.
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The articles covered on today’s episode of the podcast can be found here 👇
Higgins BV, Levy PT, Ball MK, Kim M, Peyvandi S, Steurer MA.Pediatr Cardiol. 2025 Apr;46(4):939-946. doi: 10.1007/s00246-024-03519-4. Epub 2024 Jun 12.PMID: 38864860 Free PMC article.
Wehrle FM, Bartal T, Adams M, Bassler D, Hagmann CF, Kretschmar O, Natalucci G, Latal B.J Pediatr. 2022 Nov;250:29-37.e1. doi: 10.1016/j.jpeds.2022.05.047. Epub 2022 Jun 2.PMID: 35660491 Free article.
Peyvandi S, Xu D, Barkovich AJ, Gano D, Chau V, Reddy VM, Selvanathan T, Guo T, Gaynor JW, Seed M, Miller SP, McQuillen P.J Am Coll Cardiol. 2023 Jan 24;81(3):253-266. doi: 10.1016/j.jacc.2022.10.029.PMID: 36653093 Free PMC article.
Hamrick SEG, Ball MK, Rajgarhia A, Johnson BA, DiGeronimo R, Levy PT; Children’s Hospital Neonatal Consortium (CHNC) Cardiac Focus Group.J Perinatol. 2021 Jul;41(7):1774-1776. doi: 10.1038/s41372-021-01117-3. Epub 2021 Jun 17.PMID: 34140645 No abstract available.
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The transcript of today's episode can be found below 👇
Adrianne Bischoff (00:00.792)
Hi everyone, I'm Dr. Adrianne Bischoff, a neonatal hemodynamics specialist passionate about advancing care for our tiniest patients. Neonatal Cardiac and hemodynamics care is at the heart of what I do and I can't wait to share insights with you.
and I'm Dr. Nim Goldstrom, a neonatal cardiac intensive care physician. Together we'll be exploring the fascinating world of neonatal cardiac function, diving into the challenges, innovations, and clinical pearls that shape how we care for critically ill neonates.
From groundbreaking therapies to real world applications, we're bringing you conversations that go beyond the basics because this is from the heart.
Join us on the incubator for a series filled with heart, science, and the care these low patients deserve.
Hi Nim, how are you doing?
Nim Goldshtrom (00:47.054)
I'm doing great. How are you?
Good, thank you. I'm excited to be recording another episode.
I am as well. can't believe the time flies so fast, right?
Yeah. Today we have a selection of articles which we will be linking on the show notes as usual. And we will be focusing mostly on congenital heart disease, which is a topic near and dear to Nim's heart, much more than even mine. But I'm happy to discuss this and highlight some of the newest literature that is out there and some of the things that I believe that we all as neonatologists should be thinking more about.
learning about for our premature babies and the babies that do come to our units even if it's for a short period of time.
Nim Goldshtrom (01:34.146)
Yeah, and for some unique centers, it's not even that short period of time, right? They come, they stay, and they stay much longer. And so, yes, we're going to really abuse this from the heart, you know, mnemonic here about how things are going. But yeah, it's wonderful to kind of look at the different landscapes, right, of cardiac function and cardiac disease, right? Structural heart disease versus functional impairments in a variety of new physiologies. And here we have a smoldering of
congenital heart disease related topics and how this population both premature as they grow up is developing, right? And what we may as a field be able to help add for the next generation of patients to their level of care. And we're going to start it off with kind of like, you know, the meat and potatoes, right? Prematurity and congenital heart disease, an article titled Double Jeopardy? A distinct mortality pattern among preterm infants with congenital heart disease.
first author here is Brennan Higgins and the last author is Martina Stewart from UCSF, one of the only other programs with multiple neonatologists in their cardiac ICU outside of our wonderful center at Columbia. The background here is again, CHD is overrepresented as a malformation, particularly in preterm infants. In some gestational age groupings, up to five-fold increase with decreasing gestational age. In this sense, preterm infants
with CHD experience would take her all, know, affectionately double jeopardy, right? You have all the risks of preterm birth and the mortality and morbidity associated with that burden of condition and the congenital heart disease spectrum, both from the cyanotic and potentially the acyanotic lesions, although their risk profiles are different. There is limited data available using gestational age as a continuous rather than dichotomized variable, right? Most studies from single centers or registries don't have the luxury of size and volume. And so it's easy to just split things
below 37 weeks or into large chunks of preemie groups. And it doesn't really give you granular answers. And so the study used wonderful CDC data to get to that question. And the authors used contemporary US national population-based data to look at these problems. And so as of the mid-2014s, the CDC required a listing of congenital heart disease. And so they went back to that birth, death, registry in this study from 2014 to 2019 of all live-born preterm infants.
Nim Goldshtrom (03:59.362)
between 21 to 36 weeks gestation. They clustered into five groupings of gestational age categories that you can read about in the paper. They defined and they only took congenital heart disease and here they turned it cyanotic congenital heart disease, CCHD. And again, a lot of studies you'll see CCHD referred to as critical congenital heart disease, right, as for a ductal dependent or those who can't leave a hospital potentially. Here they're defining it as cyanotic, which is another proxy term versus the acyanotic ones like.
ASDs and VSDs that may not need interventions prior to going home. The primary outcome in this study was one year survival between those preterm infants with and without cyanide heart disease as stratified by the gestational groupings. And they also had secondary outcomes in early mortality. So that is mortality before three days of age where they tried to stratify babies who never even actually potentially made it to surgery and for a variety of reasons, which they discuss in the paper, to avoid confounding with operative mortality. And lastly, they compare these trends
over the five-year period to see if there's any trend over time in outcomes between the two groups. They used proportions as a display data characteristic and calculated both crude and adjusted risk differences for survival and mortality between the two groups, adjusted for basic covariates like gender or sex, multiple gestations, and IUGR specifically, and also produced risk differences for risk by year using a logistic model for mortality and the year of the data set per year as a predictor.
What they found was about 2.7, almost 2.7 million preterm infants for between 21 to 36 weeks in the US over that five year span, which is about 11 and a half percent of all live births in that time period. Ultimately, they were able to whittle down to about 3619 subjects, which is 0.13 % of that population that had a documented cyanotic and general heart disease. The highest representation between 25 and 28 weekers. And the lowest representation actually in the late premiums, 35 to 36 weekers. Preterm infants with cyanotic
congenital heart disease were less likely to be multiples, but more likely to be IGR and smaller in gestational age than those who did not have CHD. And additionally, the cyanotic congenital heart disease population had more representation from maternal problems such as gestational diabetes and diabetes mellitus and hypertension and maternal gestational hypertension, as well as being non-Hispanic white and having more private insurance, which is think a fascinating mix of representations. And ultimately in one year survival,
Nim Goldshtrom (06:26.062)
the preterm infant population with no heart disease had survivals anywhere from 18 to up to greater than 90 % were moving between gestational ages of 21 to 27 weeks. And that probably rings true for most of us in this field. By 27 weeks, we don't really talk to families about the significance of high mortality risks for the preterm infant without significant congenital anomalies, let alone congenital heart disease. But for the cyanotic heart disease population, survival went from 16.7 % only to 54%.
between 21 and 31 weeks. And actually plateaued at around this 54 % mark and only improved to about 76, 77 % by 36 weeks gestation. And this showed a statistically significant risk difference between basically the entire gestational age cohort between preterm infants with and without heart disease, between the 23 and 36 week marks. The greatest risk difference is actually in the 28 to 31 weekers, which was around a 37 % risk difference between being born with and without heart disease.
When it comes to early mortality, those without heart disease, the early mortality in the first few days declined rapidly to greater than 90%, from greater than 90 % in extreme prematurity to half that, about 46%, all the way by 25 weeks gestation. But with heart disease, early mortality accounted to half or nearly three quarters of the deaths between 23 and 30 weeks, and only declined starting at around 31 weeks gestation. So like an entire month and a half gap between when early mortality
stratifies itself out between those with and without heart disease. Here the largest difference was actually in the smaller babies, somewhere around 24 and 26 weeks. And lastly, we're looking at the time trends, right? For the non-CHD population, there was a small but statistically significant decrease in one-year mortality, which was seen greatest in the smallest babies, less than 25 weeks. However, for the congenital heart disease population, there was not a statistically significant trend, but if anything, a trend for
increased mortality in all the gestational ages between 2014 and 2019. And the worst of it seemed to be in the 35 and 36 weeks gestation. So just a fascinating population-based study on where things are going in two similar-ish groups differentiated by a major congenital malformation.
Nim Goldshtrom (08:47.448)
clearly represents the trend that we see, I'm sure, in most of our units and in the literature in general. We are doing better. We're getting to 22-weekers, right? We're getting to 21-weekers. I don't have to tell a program in Iowa about that as well. And we're doing better and better in striving for the preterm infant and the ability to get them through survival and through the morbidities. Those gains are not being realized in the congenital heart population. And there's a lot of speculation potentially about why, which we can discuss and do, but Adrian, I'd love to hear your thoughts on that.
on the paper and then what struck out to you as interesting or different from what you already had been aware of.
Thank you. That was great, Nim. I think we can probably do a discussion kind of overall of what some of these articles are going to talk about in conjunction. So I'm just going to go right ahead into the next one, which is a similar kind of topic. Does that seem reasonable?
Yeah, yeah, no, it's not a bad idea actually to kind of just consolidate everything at the end. Because it's better message that way. Yeah. Yeah, let's go for that.
All right, so the next one we wanted to talk about is similarities and differences in the neurodevelopmental outcome of children with congenital heart disease and children born very preterm at school entry. This is a study by, I hope I'm saying it right, Verli et al. And it came out on the Journal of Pediatrics in November of 2022. And for this article, they were comparing cognitive motor and behavioral outcomes
Adrianne Bischoff (10:23.246)
in patients with congenital heart disease and very preterm children. And the main message is that it underscores the need for tailored follow-up programs that will address unique challenges in each of these groups. So this study examined the neurodevelopmental outcomes of 155 congenital heart disease children after cardiopulmonary bypass and 251 very preterm children.
They used, of course, standardized assessments. The results were analyzed through hypothesis and equivalence testing, which was kind of new for me to read about, in order to identify differences and similarities. So here's how I summarize some of the results that they had. In terms of cognitive and motor outcomes, both groups demonstrated normal IQs.
with mild impairments being more prevalent in the very preterm children. But the motor deficits were more pronounced in the congenital heart disease children, especially when it comes to dynamic balance. So, Nim, actually, let me ask you a question. How do you tailor developmental interventions in kind of the NICU CVICU setting, which is where you work, in these groups specific for...
motor and cognitive challenges. Are there any interventions that you have found that are particularly effective for congenital heart disease related motor deficits?
Not that I'm aware of. mean, we employ the same surveillance, evaluation, and interventions that we would do for any other neonate who's in the NICU, a former premium who's getting to a mature age, right? We utilize speech, physical therapists, and occupational therapists. We try to, when possible and when safe and when, you know, the amount of intensive care or lines allow it, to do parental holding.
Nim Goldshtrom (12:25.194)
Skin to skin even for the more mature child right like there are benefits to these practices even outside the scope of preterm infants and to kind of Move them when they can be moved right like these kids who are sitting in bed all day It is not helping their about development and getting parents to come into unit that again gives them 24-hour access the ability to try to stay at the bedside engagement what possible and so again, I think
our unit is unique in that sense where it's easy to apply that craft when you have a general NICU that you come from and nurses that come from there and therapists that are straddling both units as one larger unit, right? We are part of a heart center, but the cardiac NICU also functions both as a CICU and a NICU until we get the benefit of both worlds.
Yeah. Good opportunity here for us to give a shout out to all these therapists that did not get as much recognition as they certainly deserve and the critical role that they play in our babies in the NICU and CVICU settings. Anyway, thank you. Back to my results. All right. What else did this article look at? So they also looked at behavioral challenges.
And both of the groups experienced behavioral difficulties, both through peer problems and therefore they have kind of like a shared vulnerability. In terms of therapy utilization, there was disparities. There was significantly underutilized for congenital heart disease children, which was about 23 % compared to the very preterm infants. Even though
As I just said, the congenital heart disease children are more likely to have motor impairments when compared to the very preterms. And I just wanted to highlight a little bit of the figures and tables that they have in this paper, where they, if you look at it in detail, and I recommend that everyone opens these PDFs at the end of listening to us, hopefully, where they emphasize...
Adrianne Bischoff (14:32.674)
these unique motor deficits of the congenital heart disease children compared to kind of the fine motor skills of the very preterms and the lack of equivalent therapy access and the systemic gaps that we're seeing. Another important question that I wanted to ask you, sorry, Neymar, I'm going to put you on the spot here, but you're in a very unique place for today's discussion is from your experience, how do you think follow-up programs for congenital heart disease children?
can mirror this structured support that is available for the very preterms that we have it all over.
boy, we do not have enough time in one podcast to answer that question, but it is a great opportunity for a future case to look at the highlights of follow-up in the preterm infant who gets potential hemodynamic consultations versus the preterm infant who has CHD. Because, you know, I'll give you my personal experience at our center. It is challenging. It is challenging to get a congenital heart population to come back in.
that is not a criticism or in any way to imply that the challenge goes in one direction or it's just a family or it's a center or it's a cardiologist. I think there is some, again, this is my just personal bias and experience, subtle misconception that a term child with congenital heart disease who has bypass surgery and then comes out of a hospital with what you would call minimal residual lesions, no significant morbidities, didn't get a...
surgical site infection, didn't have Kyle, has a functioning heart without a lot of stenosis and valves at work and things like that, is now at no risk. And that is not to say that that's how they're being counseled or that's how they're being informed in their cardiology visits, hardly from it. But I think this data just shows so much that they are basically like our preterm infants, And I don't think we just get that
Nim Goldshtrom (16:36.15)
on a collective group because it's just such a much bigger pool of people who are caring for them. And then they lean on their cardiologists so heavily and rightly so, right? Because they're the ones following them up with serial echoes and following up their progress and their growth and development. And I think the cardiologists have a large swath of things that they need to do where for us, right? Once a baby leaves, it's a lot of things to do. And our major, major focus is, hey, are you meeting milestones, right? You need to come back in and we need to do those developmental assessments because
I mean, you know, we'll talk about it at the end of all these papers, but like the discrepancy here is not that they don't have the same problems. It's they're clearly not utilizing the same services, at least from this paper in this one center. And I worry that we, as a community in the CHD world, it's a bigger pool of people impacting on the team of care and that the emphasis on neurodevelopment is potentially lost because their term otherwise and they're leaving the hospital.
Maybe there's a subtle misconception that the risk is gone and it's wonderful to see this data as troubling as it is to shine a light on is that No, they are functionally the same term child with CHD and a preterm infant literally need the same a degree of counseling therapy potentially to not miss those potential gains and windows of opportunities to actually get to their full potential
Yeah, thank you. Yeah, I think it summarizes that we do have a very pressing need to close these kind of therapy gaps and follow up. And I think future research should continue to explore what are some of the systemic solutions that we can do to improve equity, access and outcomes for both of these populations.
It's an incredible point and to further kind of now move into kind of physiological stuff surrounding this area. You know, the next article I wanted to highlight is, know, where could be the sources of these problems, right? Like, why is it that we're seeing, you know, survival mortality rates across preterm infants with or without CHD be so discrepant? And at the same time,
Nim Goldshtrom (18:40.502)
A term baby with CHD appears to have functional impairments akin to a preterm infant, right? Although having maturity that is far beyond it. Part of what we know from other studies, which we'll highlight with this next paper, which also comes from a group of authors who have highlighted the problem of CHD babies having smaller brain volumes and feed life and already being kind of growth limited as compared to term babies without CHD, is that they are always constantly being exposed to a degree of neurological impairment and injury.
And these changing practices that we have may be actually part of the solution. And so the next paper we have here, entitled, Declining Incidents of Postoperative Neural Brain Injury in Congenital Heart Disease, comes from another UCSF group. First author, Shah Peyvandi, a great researcher in both cardiac neurodevelopmental outcomes and neuroimaging, and last author, Patrick McQuillan. Again, neurodevelopmental outcomes are really the most common morbidity in congenital heart disease population.
Survival has been improving drastically for several decades due to improved surgical technique and physiological understanding of the post-operative state and treatment of low cardiac output and early recognition of, you know, near arrest and arrest physiologies. The risk of brain injury is anywhere from 10 to 35 % preoperatively, but it doubles to about 33 to 75 % in the post-operative period. And white matter injury is the most common form, right, that is similar outside of our
intraventricular hemorrhage group of preterm infants, white matter injury then becomes kind of the second most common injury in the preterm population. These data are account for the declines in rates in neonatal brain injury in preterm infants, right? All the gains we see in survival, the morbidity improvements, they're also seeing that we're doing better with neonatal brain injury in the preterm infant and actually less injury, right? Ag age, especially in some white matter injury over time.
And so this study wanted to look at these trends in a cohort study of two centers over 20 year periods, right? To evaluate trains in brain injury and neonates with complex CHD. Similar how today, you know, their other colleagues looked at the trends between preterm and infants with or without congenital heart disease. So this study was between 2001 and 2021, but in full term newborns with congenital heart disease, having a neonatal operation. So within the first 30 days between two collaborating sites, the University of San Francisco and British Columbia's.
Nim Goldshtrom (21:03.096)
There's a prospective study designed with a preoperative, postoperative MRI, and neurodevelopmental follow-up into childhood for several years. They excluded here, again, any preterm infants or anyone less than 37 weeks, those with known congenital infections, congenital malformations, and suspected or confirmed genetic anomalies. So that's an important distinction, right, because there's our mixed population. We know that the CAG population is also very highly represented.
by genetic conditions anywhere from 15 to 30 % of CHG can have genetic conditions. we're also removing a much higher risk group here and talking about ones who we can affectionately call out say isolated congenital heart disease without another associated malformation. The primary cohort here actually contained a tremendous amount of just d-loop transposition of the great arteries and single ventricle physiologies of which almost three quarters were just hypoplastic left hearts.
And so the majority of those single ventricles received the neural word operation, which is performing an aortic archways construction and their pulmonary flow was provided through a Sano primarily with only five patients receiving a modified right BTT shunt. There were a very small number of other diagnosis, which on the paper that we'll post you guys can go into such as a hyperplastic white heart and doors and TETs and things like that. MRIs were done preoperatively again at the earliest time available.
when they were stable. And post-operatively, they were done outside of the perioperative care window when that was completed. And they quoted a mean average of about 15 days separation between preoperative and post-operative MRIs. They were ultimately read by blinded neuroradiologists, blinded to the clinical care of the child. And they categorized brain injuries in a few ways. They did it one by major conditions, stroke, white matter injury, IVH, global hypoxic ischemic injury. And there was also a post-op read
limited to newly acquired lesions that were not evident on the preoperative screen. Two trained raters and a neurologist read them, and they also quantified something called white matter injury volume as another quantitative measure to figure out the burden of injury in these MRIs. They stratified, they cohort into four epochs of about five years each, 2001 to five, six to 10, 11 to 15, and so on. And the primary outcome here was the presence of white matter injury.
Nim Goldshtrom (23:25.71)
both pre and post operative, with the primary exposure being the epoch, the four or five year period of time in this 20 year study. And logistical regression was used for analysis. They had 270 participants and about 246 received a pre-op MRI, 220 with a post MRI. And ultimately they had 258, which is nearly 90 % of the study, had either a pre and or post-op MRI together. In pre-op MRI findings, they noted that
There was an increased rate of prenatal diagnosis rates in the preop population over time. There was less blue natriocytostomies as the epochs went from earliest to most recent. And there was no change in preoperative white MRI, I'm sorry, white matter injury on preoperative MRIs across a 20 year period, which hovered around 20%. And there was a trend, but not statistically significant for less stroke. Postoperatively though, there was a statistically significant difference.
and decrease in white matter injury over time, both by sight and by cardiac lesion type, primarily the DTGA and single ventricles. Post-maternal age was also a significant predictor, right? So the later you had it, the less findings you found. And this was also when you're controlling for a variety in the epoch as well. So there was an 18 % decrease from epoch one, so 2001 era, to the later 2016 to 2020 era. And the odds of a new post-op white matter injury
Epoch 4 was actually the same as Epoch 1, even though there was a decreasing incidence of finding. Between, again, the two ventricle DTGA and single ventricle physiology, both had longer bypass times over the 20-year period, longer cross-caliber times, and both showed higher blood pressure parameters over time as well, but no substantial change in the VIS. So, VIS, vasoinotropic score, is a aggregate feature generated by all the different inotropes you used in different ratios.
To create kind of the total burn or inotropy experiencing in the post-operative period. And so despite blood pressures going up, the VIS actually didn't change. It wasn't at a cost of more drugs. It was actually because of different drug choices. And so they saw over time a real drop in the use of domino and a significant increase between those two centers in epinephrine and dopamine. And additionally in that time, preoperatively white matter volume, white matter injury volumes were about the same, but post-operative.
Nim Goldshtrom (25:46.742)
injury volumes decreased over time with the largest difference between the third and the fourth epochs in the last 10 years. And cardiac lesions seem to have the biggest impact on the variants and single ventricles seem to have even more white matter injury than DTGA, which is also not surprising. So it's still happening. And what's fascinating here is it's happening preoperatively. It seems like there are some gains which we can talk about in a bit postoperatively and why that might be. But there is clearly a physiologic
pathologic injury pattern here that sets these kids up along with all the human-to-demand disturbances of bypass surgery and the recovery and the law of which states for a physical brain injury that leads to of the outcomes that you were describing in the last paper.
Yeah, that's great. And it's actually a great segue to the last article that we wanted to discuss, which is not the same format as the other ones. This is a letter to the editor. So this article is integrated cardiac care models of neonates with congenital heart disease, the evolving role of the neonatologist. And this one, although not
quite as brand new. It's from June of 2021. We thought it would fit really well into this theme, especially having NIMH right here, which I'm very proud of. And they basically talk about how neonatologists can contribute to the perioperative management of babies with congenital heart disease and highlighting that these patients face care transitions, right? All the time between NICUs.
CICUs, surgical teams, and therefore there's a lot of complexity and the risk of some communication gaps. So this study was actually a survey of 22 North American level four NICUs to examine the admission policies, the neonatologist's roles, and the care variability. And although it was comprehensive,
Adrianne Bischoff (27:54.572)
the lack of correlation between practices and outcomes kind of limits the findings, but does provide some opportunities for future research, and mostly for me to gather NIMS insights on this important population. So some of their key results were that, yes, neonatologists are involved in the prenatal counseling of babies with congenital heart disease in about 85 %
well, 86 % of the centers. In terms of where do these babies go and are admitted, the decision to admit in the CICU versus NICU is mostly based on factors like gestational age, birth weight, and cardiac lesion. In terms of post-operative care, it's not surprising, but most of the babies are
taken care of in a CICU setting, even if they are preterm infants. And that's probably just because they most often have to wait until they are bigger before their repair. But I guess Nim can give us some insights of what type of babies Columbia is operating on, even when they are little and could kind of stay in a NICU setting in other places.
Yeah, Nim, before I move on, do you want to share a little bit of your experience in this combined unit and how we can optimize the transitions and what type of babies would be better served in one versus another setting when we don't have the ability to have a unit like you guys have over there?
Again, how much time are they going to let us have on this journal club? It's a complex answer. But I think what you're showing is the practice around the world, or let's say, excuse me, not around the world, around these US-based institutions that are all CICUs shows some consistency in some kind of at least rubric for how they make decisions.
Nim Goldshtrom (30:09.56)
This is care by committee, right? Like when you meet certain criteria, you go here. Then when you're in a different phase of care, you'll go there. And then when you're in a different phase of care, you go somewhere else. And you know, for a lot of populations, that'll probably work well. This is kind of going to bleed into the three papers that we just talked about, but let's look at the outcomes that the three papers we just described talked about. So the preterm infant with and without congenital heart disease, right?
massive discrepancy in mortality over a very recent period of time, 2014 to 2019, term babies with congenital heart disease having the same degree of neurological development of school age as preterm infants, and yet not engaging in services as much. And despite that, you know, it seems like in last 20 years, we're doing a better job maybe in post-operative management because we're seeing white matter injury improve when we're
adjusting the parameters, right? There's historical reasons why from the last paper by Shabnam Peyvandi et al that, know, Milrinone went out of a favor and Epinephrine went up. And some of that is, you know, what we're understanding about, you know, the fears we used to have about single ventricle and SVR versus PVR versus the need to maintain like normal parameters also as a competing interest. But, you know, those are the outcomes and are,
colleagues in CSU are describing these varied practices. again, what Columbia and the vision that our creators in Ganga Krishnamurthy and Emile Bacha at that time of creating thought was specialized high risk patients probably deserve special teams, And like consistency is going to help. And I think that's the message is not to, I hope poke holes in these practices that everyone's reflecting on, but.
You know what we are doing and it seems like what UCSF is doing as well, which is, you know, having more dedicated neonatologists directly involved again, are unique things that are potentially hard to replicate. Um, which is why we think that, you know, rather replicating us as a model, think about the concept of employing specialized team, right? Take a look at what you do in Iowa, right? You don't rotate a whole bunch of floating nurses to your small baby units at 21, 22 and 23 weeks and 24 weeks to run your protocols of like.
Nim Goldshtrom (32:32.258)
multiple echoes over multiple days of time with concerted efforts about changing physiology. You put dedicated teams together and you train people into those teams. And you don't necessarily just, without having to put less experienced people in situations where they're not going to have the opportunity to succeed. Our view is very similar. The neonate preterm or term with congenital heart disease is a unique and special population.
even among all congenital heart disease kids. And again, the PICU scene, the older children, the redo operations, the kids with bad genetic conditions and poor lymphatics and Kyle, every time you open their chest and do anything, those are hard things that a CICU has to deal with for sure. And they deal with it two or three times the volume, right, that they deal with neonates. However, the neonate physiology is also unique. And so, I can see in the landscape that we're at, where you have intensivists who have to cover a myriad degree of physiologies, right?
neonatal physiology of pre-op single ventricle and then shunted physiology. And then the next bed, it's a four op fast track, you know, conduit revision. And then the next bed, it's your heart failure kid on a Berlin heart waiting for their transplant for two months, right? And you're talking about anticoagulation and feeding and salt intake because they're in heart failure. Like those are a lot of different high functioning tasks to have to remember all the time.
And so, know, the most specialist populations, another example is that, you know, heart failure and transplant, they've had dedicated teams for years, right? Like you don't even have regular cardiologists in most hospitals. You bring in specialists just to deal with the mechanical hearts and the mechanical support and the artificial hearts and the transplants. In hearing, you know, what the landscape of the state is, is, you know, the neonates, again, in our opinion, probably divide these specialized team. You know, our models are examples of what can be achieved.
But they're definitely not the only thing. Our hope is to encourage that the idea of specialists, that these kids should have specialized teams, just like Iowa does for their most extreme premature infants. And your outcomes are fantastic compared to the nation. And this is what I hope these kind of articles can show. These are the problems for the congenital heart disease population. Look how similar, sadly, they look to the preterm infant population. Even a term age.
Nim Goldshtrom (34:54.318)
And this is why neonatologists should get involved. Not to take away things from our other highly involved and highly important colleagues of cardiologists and intensivists and cardiac intensivists, but to find a way to marry that input and drive specialized team for this population as well.
Yeah, that's great. But I will also highlight that you don't need only the neonatologist's expertise, but the neonatologists also need to be more prepared and better educated on how to manage these kids. Because I will say the reality is even here where we have a hemodynamics program, our bread and butter is normal structural hearts, right? So even when we do admit a preemie that has
congenital heart defect, which is the standard of care is for them to be in the NICU until they are ready for surgery and then they will move on to the PICU, we still have to manage those patients. And I do feel like there's still a big gap in knowledge and in how to manage these babies. And because the cardiology team does come and help, but they are also not intensive. So it's just messy, right? And then you...
We kind of have to rely on our colleagues from CICU and ask for their input as well. But then how do you merge that CICU knowledge with NICU preterm knowledge with cardiac lesion specific knowledge? And I think we all need to do a better job at that.
Yeah. And, and look, the models are there. I mean, you did it yourself, right? You spent extra time just learning a brand new skill and the physiological underpinnings. forget, you know, preterm cardiovascular physiology, like enchanting physiology and the aspect of, you know, premature myocardium, but then also like echo technique, right? Like what are the limitations of the tool, how to use it? cardiologists and intensivists.
Nim Goldshtrom (36:50.964)
in the pediatric field have been doing additional training for decades, Heart failure, electrophysiology, dual boarding. For the neonatal population, again, in our opinion, to gain more of this value, it's a little bit of competing interest because to say for neonatologists, you should go get extra training is great and it is what it takes, unfortunately. You have to be able to beat the glue.
which is again how we see ourselves in this model. Cause I don't round alone. I have a cardiologist with me on every single patient all the time. I can't have the bandwidth to be looking at echo at such a high level that I can make perfect reads like an echocardiographer or cardiologist. I need someone to also spend the time with updating surgeons if we have to, there's too many things versus updating parents versus doing procedures, which is what we're good at. And that cardiologist is heavily dependent on. So this team approach, what
we do with the extra training that we did is we are the glue, right? We have learned, we spent more time doing an extra year of training. And again, there's, there's roadmaps for this and the neonatology trainees can consider doing just like you guys have set up for, neonatologist who want to come in and like dedicate a year or those who want to come in for a couple of months, right? There's, there's ways you can cut this by, but someone has to be the glue that can know the language of all the players in the room, right? And that's what additional training can do. And that's how you can build towards specialized processes is by
you know, these little extra training spots that show your ability to connect the things that you're not getting in your primary fellowship, which is okay. But that's the value of that extra training is to you're going to add more value to these patients wherever they end up getting going to and be part of that a very, very important part of those dedicated teams wherever you go.
Yeah, and I think this is all part of a big cultural shift that is happening in neonatal intensive care over the last couple of years and will probably only continue, right? If you look back 10, 15 years ago, the neonatologist had to know everything and feel like they were the expert about every single aspect of a baby's care, whereas the knowledge is just so exponential that we cannot be experts on everything.
Adrianne Bischoff (39:02.892)
And there, that's why we're seeing models like here at the University of Iowa, we have neuro critical care team, hemodynamics team, chronic lung team, or like you have in Columbia with your CICU combined with NICU team, because some people will do have to take that extra mile and we have to work together. And it does have to compartmentalize in some way so that we can take the best out of the expertise of everyone, especially for the sickest patients. Right.
Of course, I still need to know about nutrition. I still need to know about how to feed the baby. I still need to know about how to use the ventilator, but I don't need to be the expert on how to use all the inotropes, vasoactive drugs, scanning, and know how to manage the most complex chronic lung disease patients that are now 60 weeks corrected, and know that it's just not possible, right? So there is a cultural shift in how we move forward and the...
This world of NICU CICU is definitely part of that.
No, absolutely. I see so many parallels in what you guys are trying to push forward at the edge of viability, right? And the resources and tools it takes to survive those kids and what neonates across the country and across the world who have congenital heart disease could potentially be benefiting by just a little bit more specialty, right? Like just getting specialized people. And again, we harp on it because we're talking to an Indian-intelligent audience. And again, highly encourage those who are interested in pursuing interest training because it is
It is the only way to bridge the gap wherever you end up going. But this really could be for anyone, right? A PICU person who wants to spend more time in Neonatal Cardiac Intensive Care Unit can gain the same skills of cardiologists as well. You need glue people, right? Who can talk to divisions and both sides and get them to trust in their kind of management practices and then be in a place where they can get training and just see thing again and again and again, and just feed into those practices and just understand them at a base level.
Nim Goldshtrom (41:00.524)
of like, here's the rationale, here's why we do what we do, here's how, you know, our feeding TPN strategy pre-op and post-op. All those nuances that, you know, add it together, right? Like, again, we have PTOT that comes in all the time. Like, whenever the second the baby is safe to do, I don't know if that happens in a lot of CSUs, it may or may not, but like that is a dedicated part of our process. We have donor milk now and we built it up alongside our NICU, right? And so that may or may not be available, but we've also had, thankfully, a slow decreasing incidence of neck.
pre and post-operatively over time. There's the temporal correlation to donor milk. again, those slow processes are because we're trying to be the glue between cardiac ICU practices and neonatal practices. And this may be where the gains are potentially coming from. It's just going to take more people to come in and replicate those things in other places through combined training.
Thanks for your advocacy and for you and your team being that glue. The patients in Columbia are very lucky to have a team like you guys.
Well, 21 and 22 weekers are lucky to have you guys because I do not know what I would do if I needed to get an echo every 12 hours on an edge of viability patient. That is not a resource I have at my disposal.
Yeah. Great. Well, I think this was a great discussion and I learned a lot. And I am very thankful that I had you to share some of your insights with me and hopefully our audience will enjoy it as well.
Nim Goldshtrom (42:31.49)
Yeah, and we're going to keep finding those pearls in cardiovascular physiology and hear what the audience wants to hear.
Nim Goldshtrom (42:42.562)
great talking to you again. See you next time.
See you next time.
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