June 20, 2025 • 33 mins
This week we speak with Professor Vladimiro Vida of U. Padua about a recent ECHSA large scale study assessing surgical outcomes of newborn cardiac surgery in Europe. What trends have become apparent in the past 10 years and why are outcomes generally better overall in this complex patient group? Why have outcomes for single ventricle surgery not improved as much as other newborn surgeries? Is there a relationship between center volume and outcomes? What interventions might result in improvements in outcomes of Norwood palliation? Dr. Vida provides his insights this week.
https://doi.org/10.1016/j.athoracsur.2024.07.023
https://doi.org/10.1016/j.athoracsur.2024.07.023
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount sign i Hear in New York City. Thank
you for joining me for this three hundred and forty
fifth episode of Pdheart. I hope everybody enjoyed last week's
episode on the topic of ablation procedures in the post
operative period. For those of you interested in post operative
(00:38):
management as well as electrophysiology, I'd recommend you tech to
listen to last week's episode three forty four with doctor
Audrey Dione. As I say every week, if you'd like
to get in touch with me, my email is easy
to remember. It's pdheart at gmail dot com. This week
we move on to the world of congenital heart surgery.
The title of the work we'll be reviewing is Outcomes
(00:59):
of Neonatal Cardia Surgery, a European Congenital Heart Surgeons Association study.
The first author of this work is Claudia Catapan and
the senior author, Vladimiro el Vida. And the authors come
to us from multiple centers in Europe. Doctor Catapan and
doctor Vida come to us from the University of Patawa.
When we've done reviewing this paper. I'm excited to say
(01:20):
that doctor Vita will be speaking with us all the
way from Italy. Therefore, let's move straight onto this article
and then a conversation with its senior author. This week's
work begins with a number of comments about critical congenital
heart disease and how this form of disease, whereby an
intervention is required early in life, accounts for roughly one
fourth of all congenital heart defects. They then point to
(01:41):
the many.
Speaker 2 (01:41):
Factors that lead to higher risk in performing procedures like
cardiac surgery on this patient group, such as prematurity, smaller
size and anatomical structures, and just plain fragility of small patients,
and they explain that despite massive advancements in the care
of this patient group, thirty day mortality for this patient
group undergoing surgery is significant. They point to a twenty
(02:03):
twenty two paper from Egypt in Saudi Arabia that demonstrated
nine percent thirty day mortality rates and eleven percent in
hospital mortality rates. With this as a background, the authors
explained that the aim of this study was to comprehensively
assess the characteristic of patients and outcomes associated with neonatal
cardiac surgery from twenty thirteen to twenty twenty two and
(02:24):
hospitals associated with the European Congenital Heart Surgeons Association or ECHSA.
This was a retrospective multi center study using data from
the Congenital Database of the ECHSA, focusing on patients who
had surgery less center equal to thirty days of age
in the ten year period from twenty thirteen to twenty
twenty two. The author's review how the data in this
(02:47):
database is quite robust and is verified for accuracy. They
identified twelve benchmark surgeries and these were nor would procedure,
hybrid palliation for single ventricle, isolated arterial switch operation, archerial
switch operation with VSD arterial switch operation, and arch repair
a order correctation performed via lateral tharcotomy, the order coork
(03:09):
repair using bypass presumably via asternotomy, isolated interrupted arch a
ordic arch repair associated with another procedure, trunk is repair,
any kind of shunt such as an RV to PA
contu it or an A order pulmonary shunt, and finally
total anomalous pulmonary venus repair. The authors use multi variable
logistic regression models to determine which factors were associated with
(03:32):
thirty day mortality and in hospital mortality. The benchmark operations
were divided into three subcategories based upon the STAT category,
and these were Category one being STAT one to two,
Category two being STAT three to four, and Category three
being STAT five. The authors also looked at many other
co variables, including things like surgery, sex, age less than
(03:53):
ten days at the time of surgery, other non cardiac problems,
wait less than two and a half kilos, use of
cardiopulmonary bypass or circulatory arrest, EKMO needed before or after surgery,
and many other factors and onto the results. Well, there
are many data in this very large scale work, and
as usual I would encourage those interested to read this
(04:15):
work and the link as always will be in the
show notes. There were thirty thousand, nine hundred and thirty
one neonatal operations in the time period, but after excluding
procedures not in the targeted analysis, there were a total
of twenty two thousand, seven hundred and sixty three neonates
from ninety seven centers across thirty six countries that participated
(04:35):
in this work. For analysis, the foremost common procedures were
arterial switch operation, isolated corrotation repair, a shunt procedure, and
the Norwood PDA closure was included in the other category
and accounted for eight percent of neonatal heart surgery. Looking
at non cardiac diagnoses that were seen, the most common
(04:55):
was trisomy twenty one, accounting for one percent of all
surgical candidates, and twenty two Q eleven in zero point
nine three percent. The authors explained that truncus arteriosis patients
had the highest percentage of non cardiac disease in twelve
point eight percent, and the most common non cardiac disease
in the patient group of truncus arteriosis was twenty two
(05:16):
Q eleven deletion, accounting for nearly seventy five percent of
the non cardiac disease in that cohort. And so to
recap the foremost common procedures performed, they were the arterial
switch operation in fifteen point five per cent, correctation repair
in fourteen point one per cent, shunt procedures in ten
point three per cent, and finally the Norwood procedure in
(05:37):
nine point two percent. The thirtey D. Mortality for the
entire group was five point nine percent. It was three
point three per cent in the arterial switch operation, sixteen
percent in the NORWOOD operation, and fifteen point four percent
in the hybrid operation. In hospital, mortality overall was nine
point one percent, and it was four point one percent
(05:57):
for the arterial switch patients and twenty five percent for
the Norwood and thirty one percent for the hybrid procedure.
Cardiopulmonary bypass was used in sixty four percent of patients,
and the longest cardiopulmonary bypass times were seen in descending order,
first in the arterial switch operation with arch repair where
the median was two hundred and forty nine minutes, the
(06:17):
arterial switch with VSD closure where the median was one
hundred and eighty five minutes, followed by the norwood where
the median was one hundred and eighty six minutes. A
order cross clamp was used in fifty nine percent of patients,
and longer cross clamp times were associated with the arterial
switch operation with arch repair one hundred and forty six
minutes and arterial switch operation with VSD closure where the
(06:38):
median was one hundred and eleven minutes. Perhaps not surprisingly,
Norwood operations and Arterial Switch with Archery construction, with the
operations with the highest frequency of post operative complications at
sixty two percent and fifty five percent respectively. Post Operative
EKMO was used most commonly, following the Norwood where it
was employed nineteen percent of the time and the art
(06:59):
Te Materi'll switch with arch repair in eleven percent. The
median post operative ICU stay was six days, and longer
ICU stay was seen in the Norwood patients where the
median was thirteen days and Hybrid procedure where it was
eleven days. The median length of stay for all patients
was twenty six days, with the longest post operative stay
being twenty nine days for Norwood patients, followed by Hybrid
(07:23):
of twenty three days, and so. To reemphasize this important point,
which surgery had the highest mortality rate? Again, it was
the Norwood operation with a thirty day mortality of sixteen
percent and an in hospital mortality of twenty five percent,
followed by the Hybrid operation where the thirty day mortality
was fifteen point four percent and inhospital mortality thirty percent,
(07:45):
followed by Truncus arteriosis repair with the thirty day mortality
rate of nine point five percent and an inhospital mortality
rate of sixteen point three percent. In Table three on
page eight hundred and eighty five, the authors demonstrate that
when looking at the operations by STAT category, the in
hospital mortality and thirty day mortality rose when going from
(08:06):
category one, which you recall as STAT one in two
cases where in hospital mortality was four point seven percent,
to Category two, which again were STAT three and four
category cases where the mortality rate was nine point five percent,
and finally the STAT five category, where the mortality rate
was twenty five percent. Using a multivariable model as mentioned previously,
(08:28):
the authors determined that the major factors affecting mortality were
higher risk procedure meaning higher risk category with an odds
ratio of two point seventy four, and the need for EKMO,
where the odds ratio for mortality was nearly twelve. Interestingly,
when the authors divided the operations by era, separating the
group into the first five years versus the last five years,
(08:50):
there was no statistically different rate of mortality observed. In
their discussion, the authors state that these data reconfirmed the
notion that neonatal cardiac surgery continues to opposed significant challenges
for multiple reasons. They reference a paper from twenty ten
from this same organization showing that the mortality rate then
was nine point one per cent and it was five
(09:11):
point nine per cent in this work, suggesting improvement in
outcomes globally. Despite this, the authors bemoan the fact that
some of the more challenging or high risk procedures like norwoods,
had similar outcomes today to back then. They mentioned prior
works by the STS also demonstrating high mortality rates for
the Norwood, and mentioned that the all in in hospital
(09:32):
mortality of sixteen percent for the Norwood and thirty percent
for the hybrid highlight the need for continued innovation in
the management of these patients. They explained that their multi
variable analysis showed that the presence of non cardiac disease
increased the risk of thirty day mortality and in hospital mortality,
as well as smaller and younger infants, as has been
(09:53):
previously demonstrated. In regard to limitations, the authors mentioned the
profound variability in surgical techniques, postoperative care protocols, and patient
populations over such a diverse group of centers, which may
impact the generalizability of the findings. The authors conclude this
work by stating, and I quote our analysis of a
large multi institutional cohort of neonates who underwent cardiac surgery
(10:16):
during the last decade in centres affiliated with the ECHSA
provide new insights related to the characteristic of patients and
outcomes of neonatal cardiac surgery in Europe and documents decreased
mortality compared with previous epochs. These data can be used
to provide valuable benchmarking across Europe, identify opportunities for improvement,
(10:36):
and facilitate parental counseling. Accompanying this work is a very
brief editorial by doctor Jennifer Nelson, who is a cardiovascular
surgeon at Nemore's Children's Hospital in Orlando, Florida. I won't
review the entire comment, but she wonders aloud if her
general impression that mortality rates for single ventricles are higher
in this European study are in fact higher than in
(10:57):
the STS studies that have been previously published. She freely
admits that how the data are reported are different from
prior STS reports and in some regards This may be
a situation of comparing apples to oranges, but she does
raise this point. She wonders if the known higher rates
of termination for pregnancies of single ventrical patients in Europe
(11:17):
play a role, with the implication being that these cases
are therefore going to be less common, resulting in lower
levels of experience in these complex operations for the surgeons
in Europe. She wonders what relation detection rates in fetal
life have to outcomes and suggests that more international studies
on this topic are needed to ferret out risk factors,
and suggests that a focus on hybrid and surgical stage
(11:40):
one palliation approaches are needed.
Speaker 3 (11:42):
Well.
Speaker 2 (11:43):
This is an interesting work in that it sort of
gives the reader a general benchmark against which programs in
Europe can judge their outcomes, while also clearly demonstrating that
there is much room for improvement. I do find it
interesting that there is no obvious difference in outcomes for
single ventricles undergoing single ventrical palliation over the ten year period,
despite what we perceive to be improvements in care. I
(12:04):
also was interested to see these mortality figures and have
similar questions regarding why it may be that these outcomes
may be slightly worse than those reported in the United States.
I've always had a suspicion that there are differences of
opinion in general regarding the management and approach to these patients,
but this is clearly very difficult to prove. I wonder
if there is any evidence that larger centers had improved
(12:26):
outcomes versus smaller ones, as has been sometimes suggested by
data from the STS. In the interests of time, I
think we should move forward to our conversation with the
work's senior author. Doctor Vita. Joining us now to discuss
this week's work is the work's senior author, Doctor of
Ladimiro Vida. Professor of Ladimiro Vita, completed his medical studies
at the University of Pataua in Italy. He completed his
(12:49):
cardiac surgery residency in Italy, followed by a two year
clinical fellowship in Guatemala under the guidance of Professor Aldo Castaneda,
and then spent an additional two years at Boston Children's
Hospital Harvard Medical School. Following his training, he was appointed
as a consultant at the Pediatric and Cardiac Surgery unit
of Patawa. In twenty seventeen, he became Associate Professor of
(13:10):
Cardiac Surgery and subsequently, in twenty nineteen he was promoted
to full Professor of Cardiac Surgery, where he is now
the leader of the Pediatric and Cardiac Surgery Unit of Patawa.
It is indeed a great honor and pleasure to have
him join us this week to discuss this week's work.
Welcome doctor Vita to PDHRT.
Speaker 4 (13:28):
I'm here now with doctor Vladimirita Vita, who is speaking
with us all the way from Patawa, Italy. Doctor Vita,
thank you so much for joining us this week on pedihart.
Speaker 5 (13:37):
Hey, thanks so much Robert for inviting me.
Speaker 4 (13:38):
He's a privilege, real privilege and honor to have you.
You know, doctor Vita, I was wondering if you could
start by just sharing with the audience what were the
main motivations for you and the ECHSA for reviewing these
neonatal cardiac results as you do in this work.
Speaker 3 (13:54):
So, Robert, as you know, easy to say, own the
largest on Geneta cardiac surgery database in Europe since you know,
twenty five years and now. This database is pretty big
and accounting for you know, more than three hundred and
twenty thousand patients and three hundred and eighty thousand procedure
on Pediatric and Congenital Cardecy Corporation.
Speaker 5 (14:17):
So this kind of enormous volume.
Speaker 3 (14:19):
Of data has been used for you know, scientific support,
especially you know, for rare conditions which are not frequently
encounter even in larger centers, but also to support benchmark
benchmarking and center quality improvement initiative.
Speaker 5 (14:36):
Also important for.
Speaker 3 (14:37):
Physician you know, to individualize their practice and care decision.
So the primary motivation for this ACCESS study and myself
was to conduct you know, a kind of comprehensive assessment
of the characteristics of patients in the neonatal age group
and outcomes in a decade twenty thirteen, two thousand twenty
(15:00):
two within a hospital associated with ECHSA.
Speaker 5 (15:04):
And the main idea.
Speaker 3 (15:09):
Was to you know, comparing you know, the data from
this decade to a previously published stata from ACCESS which
was done you know, considering another decade nineteen nine, twenty
twenty eight, two thousand and eight, which was also published
in the Anstrastic Surgery. The idea of reassessing the outcome
ten years later was driven by the desire to investigate
(15:33):
if there was any you know, improvement in the.
Speaker 5 (15:36):
Management of congenital heart disease in Europe.
Speaker 3 (15:39):
And also you know that new metal correct surgery is
ighly specialized in an involving field. You know, we wanted
to determine if you know, advancing surgical technique can have
an impact you know, on the on the on the
postoperity carryings out within Europe.
Speaker 4 (15:53):
You know, I say, I say thank you very much.
You know, as Arcta Vida, your paper has so many results,
and again I want to encourage all who are listening
to the podcast to read the paper or link to
the paper will be in the note show notes of
this week's podcast. But among the many findings of your work,
I sometimes will ask the author if you might share
(16:14):
with the audience what you, as the senior author, were
most surprised about to discover when reviewing this really gigantic
database that you're reporting on.
Speaker 3 (16:22):
Well, yeah, Robert, well, actually, in a comparison you know
with the previous study comparing two different decades, we are surprised.
Speaker 5 (16:33):
But we have a kind of a similar distribution of procedure.
Speaker 3 (16:37):
So there were no you know, a procedure up on
another you know, during the last decade. But what we
noted is that we have a significant decrease in hospital
mortality actually three day MARTITI eight which now currently accounts
for from five point nine percent compared to the nine
point one percent almost you know, half of the of
the mortality in the new interperiod. Well give you the
(17:00):
significant advancing in pediatric during the last few years.
Speaker 5 (17:04):
We were impressing all because maybe the.
Speaker 3 (17:07):
Refinement strategical technique and the improvements for separative outcome can
ennounce you know, the possibility of having you know, different results. However,
although the overall operative mortality associated with your netor corllect
surgery within access was improved, certain procedures, especially the one
you know undertaken on single anthical hearts, you know, the
(17:30):
Norwood operation or the Eyeberd operation for HLHS, continues to
be associated with significantly higher mortality rate. You know, and
these findings compel us to you know, can to evaluate
you know, what's going on here, you know why?
Speaker 5 (17:45):
You know all these you know increasing but not these patients.
Speaker 3 (17:49):
So this is kind of a big question mark and
is the future opening towards you know, other studies.
Speaker 4 (17:54):
Yes, you know this uh top tails very nicely with
my next question, which is, you know, you did find,
just as you so nicely pointed out, that the Norwood
cases didn't seem to have a very significant change in mortality.
Speaker 5 (18:11):
And I'm wondering did this surprise you?
Speaker 4 (18:14):
I mean, you talked about how improvements have come in
many aspects of surgical care, both during in the operating
room and in the post top period, but in that
particular patient group, the mortality risk for the highest risk
cases didn't really change very much.
Speaker 5 (18:29):
Did this surprise you?
Speaker 4 (18:29):
And do you have any thoughts regarding why there wasn't
a significant observed change in outcomes for Norwoods over a
ten year period.
Speaker 3 (18:37):
Actually, well is a keen observation, you know, And in
our discussion we pointed out, you know, actually that also
we didn't expect. We tried to expect an advantage over
the years, you know, but actually even if he split
the ten year period in two separate five year period, we.
Speaker 5 (19:00):
Didn't find any difference, you know. And I guess that.
Speaker 3 (19:05):
Even the Norwood is a kind of a well codified
procedure within the correct surgery world, you know, I think
five year period simply isn't a sufficient timeframe to have
kind of definitely changes within you know, the the operative mortality.
Speaker 5 (19:22):
So I guess that sturgical innovation of.
Speaker 3 (19:26):
K improved, but maybe for other pathology, not for unarticular hardware.
You have that you have a complex physiology, complex protoperative
course and also the other innovation science since the you know,
we didn't find any difference between the type of chance
we utilize our VP a versus BT. In North America,
(19:46):
we had a great you know as VR trial where
you compare both and you find different results, but actually
the results similar for us, and I guess that what
we found is that within our time frame there were
no changes, but there were some changes within the previous
decades with the ten percent reduction immortite, so actually we
(20:09):
improved result. But still this kind of pathology for union
articular information treated by you know, the pathway or the
Norwood operation or the Ibory procedure still.
Speaker 5 (20:23):
Remain very very high. This is a kind of very
interesting thing to point out.
Speaker 4 (20:28):
Yes, yes, well, you know, prior works, largely in the US,
have suggested that higher volume centers have better outcomes on
average with some of the more higher re surgeries such
as STAT four or five category operations. Did you analyze
this to any degree in your cohort and do you
do you have any observations regarding outcomes in European centers
(20:52):
that had larger or smaller volumes.
Speaker 3 (20:54):
Well touch upon you know, kind of a crucial point,
you know, within the realm of complex correct surgery, because
what we call volume outcome relationship or center effect is
something that we analyze.
Speaker 5 (21:10):
Actually, you know, in.
Speaker 3 (21:12):
Our cohort, we conducted, dedicated some analysis to investigate this phenomenon,
the center effect, and what we found was a positive
correlation between the center volume and better.
Speaker 5 (21:27):
Outcomes for patients.
Speaker 3 (21:28):
You know, this aligning what with with other hypothesies or
other study that previously published this you know, relationship with
high high volume center and bet the result. However, I
think there are a few limitations to take into account,
and also there are several applications recent from some other
(21:50):
US center where actually they demonstrate you know, the opposite.
Speaker 5 (21:54):
You know, I think that the limitation.
Speaker 3 (21:57):
Is that we have a higher high number of centers
included in the in the data inserction within the database.
And actually there is a lot of variability ateroterogenicity between
different centers. You know, we have different you know, internal resourcers,
resource allocation specific approaches to passion management. So it's very
(22:21):
difficult even in large center to find something which is
very consistent.
Speaker 5 (22:27):
During the years, you know.
Speaker 3 (22:28):
And also we covered a ten year span of you know,
of of surgical treatment in Europe, and this can also
add the other other changes because not all the center
consistently insert data through the ten years, you know. And
also this can expose to another variability. So in other words,
(22:52):
the center effect still have.
Speaker 5 (22:54):
A positive value.
Speaker 3 (22:56):
Means that you need to concentrate in a large amount
onto volume, maybe especially for very complex pathology like the
unit tical heart in some in some centers that to
try to increase result. But we found that there are
a lot of limitation. So it's good to concentrate. But
sometimes you have a small center with you know, less
(23:20):
heterogentitity of treatment and the better you know results than
the bigger centers, you know, So it's difficult to find.
Speaker 5 (23:30):
The real, the real, the real, the real solution. Yeah.
Speaker 4 (23:34):
Yeah, Well for those in the audience, it is actually
quite late at night and part of a doctor Vito
was nice enough to speak with us after a long
day operating here in New York. It's only in a
late afternoon, So I'm going to finish up with last question.
You know, we just talked about the signal vetricles and
you are obviously a very experienced surgeon, and based on
(23:54):
your experience, your knowledge and the analysis of these data,
wondering if you have any insights into possible actionable interventions
that can be made to improve single ventrical outcomes in Europe.
You talked about center effects and potentially cohorting them into
certain centers. Any other thoughts on how to improve these
(24:15):
outcomes given that this one little area, although all the
surgeries were generally better outcomes in the last ten years,
this was the one area where there wasn't as much
much improvement. Any thoughts on how maybe not only in
Europe but everywhere these outcomes could be improved.
Speaker 3 (24:32):
Well, I guess this is kind of a very difficult
question to answer, you know, but I had some experience,
you know, in talking with other friends from you know,
the STS, you know, which is you know, your association,
big association in the US. And actually when I'm talking
about you know, study from the STS database, they're talking
(24:54):
to me about you know, a different range of mortality
within the US, which ranges between eleven and fifteen percent.
Speaker 5 (25:00):
Which actually much less than what we.
Speaker 3 (25:03):
Had in Europe, you know, even for normal operation than
for and also for you know, hybrid average and stage
one procedures. I guess that well, we have a different
regional phenomenon possible influence in normal outcome in the US,
because as you know, in Europe, we have a higher
(25:23):
rate of pregnacy termination, which is you know, due to
you know, an increase you know, prenatal diagnosis, which is
mainly for a very complex congenital heard. This brings to
you know, the interruption of pregnancy, and this is you know,
a contribute to decrease the number of cases per center
and the load volume for its center in dealing with
these special particular anatomies. However, I think that we are
(25:47):
now trying to get in touch with the STS because
I believe that a future comparative study between the STS
database and the EXTRA database, we actually are the two
largest largest database in the world about conjen the heart disease,
can allow us to understand maybe the difference in treatment
in anatomy, in indication, and in the postaperity treatment.
Speaker 5 (26:10):
It possibly can.
Speaker 3 (26:11):
Align you know, the European system to the US system.
There were a lot of you know, different strategical strategies
that change the world of treatment for utical heart you know,
the Sumo shant and others you know, like the eyebrid
procedure which is particularly in low birth weight kids, or
(26:31):
with other you know, extra cordec anomalies can increase the results,
even though we notice that these are the worst case
you know, because usually present their unstable low birth by
the other pathologies. So in my mind, we need to learn,
you know, from each other. So I guess that conducting
some you know, combined study, combining different reality within the
(26:54):
US and Europe can help in the alignment of treatment
and also possibly ameliorating the results for this special and
very compless conjct or disease, which still affect in our
minds because it's the most difficult treat pathology to treat.
And I guess this kid need to have a great
(27:14):
consideration and our effort to improve the quality of the
treatment you're offering to our patients.
Speaker 4 (27:20):
Yes, all very interesting and important points, and I think
actually doctor Nelson in her editorial comment talked about possibly
doing exactly what you just suggested, which is to do
some comparative work with sts and try to figure out
why there are differences, and there may not be differences
actually because you are measuring it slightly differently than they are,
(27:43):
but definitely is worthwhile, I think. Well, doctor Vida, I
can't thank you enough for joining us this week on
the podcast. It's been a great honor to have you,
and I want to congratulate you and your many many
co authors and the many many centers in Europe that
participated in this registry study. Really a wonderful work. I
can't even imagine all the work that went into creating
(28:05):
this paper. I think some people would have turned this
into six papers there's so much data in it. But
I really appreciate your time and again, congratulations.
Speaker 3 (28:14):
Now for me was a great honor and a great
experience to stay with you in this podcast. Thank you
for allowing me to participate. I would thank you all
the author that you helped me in doing this job
and hope.
Speaker 5 (28:25):
To see you in the near future. Thank you so much.
Speaker 6 (28:27):
Well, I'm sure you gained a lot from listening to
doctor Vita. I think he offered a number of important
points regarding his data set, and I find that his
final comments about potentially doing work with the other gigantic
and general heart surgical database that of STS to be
especially exciting both to better understand outcomes and to also
help both organizations with quality improvement efforts. Off air, doctor
(28:51):
Vita shared with me the wonderful time he had learning
under doctor Castaneda during his year's training in Guatemala. I
can't imagine how wonderful it must have been to learn
from that giant and operate with them, but we all
know how wonderful a surgeon doctor Castaneda was, and doctor
Vida shared with me how doctor Castaneda taught him the
difference between being a chief and being a mentor, and
(29:14):
certainly in saying that, his comments echo those by many
who were lucky enough to work with that master of surgery,
including doctor John Lamberti, who spoke to us a bit
about doctor Castaneda and the important role that he played
in his training forty years earlier back in Podcast two
twenty five from three years ago in twenty twenty two.
(29:35):
As doctor Vita was uncommonly clear in his comments, I
won't add any more other than to thank him for
taking time from his very busy schedule to speak with
us this week on ped Heart to conclude this three
hundred and forty fifth episode of ped Heart Pediatric Cardiology.
Today we hear the wonderful Italian soprano Rosa Feola sing
the beautiful song by gastoldon Musica Prohibita. Miss Fiola is
(29:59):
becoming a giant in the world of opera, and.
Speaker 2 (30:01):
She started her career in Italy, having been born in
San Nicola l'astrada in Caserta, Italy. She has sung at
most of the great opera houses of the world, including
here in New York City at the Metropolitan Opera, and
has starred in many of the great operatic soprano repertoire.
It's easily apparent why she is so valued in the
world of opera hearing her beautiful voice in this lovely
(30:22):
famous Italian song from the late eighteen hundreds. Thank you
very much for joining me for this episode, and thanks
once again to doctor Vita. I hope I'll have a
good week ahead.
Speaker 5 (30:32):
Oh jees to cool.
Speaker 7 (31:05):
The co Jack could cool comment, quanto, macroni, compre spere
(31:27):
and grub check all come to work. It of piety,
(31:53):
we invent God voice. I loved Texcuse me, it's not
(32:22):
massuk lossing team was spotty open when the Sky of
(32:47):
Hope Sami came. Ten oh that said, the
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount sign i Hear in New York City. Thank
you for joining me for this three hundred and forty
fifth episode of Pdheart. I hope everybody enjoyed last week's
episode on the topic of ablation procedures in the post
operative period. For those of you interested in post operative
(00:38):
management as well as electrophysiology, I'd recommend you tech to
listen to last week's episode three forty four with doctor
Audrey Dione. As I say every week, if you'd like
to get in touch with me, my email is easy
to remember. It's pdheart at gmail dot com. This week
we move on to the world of congenital heart surgery.
The title of the work we'll be reviewing is Outcomes
(00:59):
of Neonatal Cardia Surgery, a European Congenital Heart Surgeons Association study.
The first author of this work is Claudia Catapan and
the senior author, Vladimiro el Vida. And the authors come
to us from multiple centers in Europe. Doctor Catapan and
doctor Vida come to us from the University of Patawa.
When we've done reviewing this paper. I'm excited to say
(01:20):
that doctor Vita will be speaking with us all the
way from Italy. Therefore, let's move straight onto this article
and then a conversation with its senior author. This week's
work begins with a number of comments about critical congenital
heart disease and how this form of disease, whereby an
intervention is required early in life, accounts for roughly one
fourth of all congenital heart defects. They then point to
(01:41):
the many.
Speaker 2 (01:41):
Factors that lead to higher risk in performing procedures like
cardiac surgery on this patient group, such as prematurity, smaller
size and anatomical structures, and just plain fragility of small patients,
and they explain that despite massive advancements in the care
of this patient group, thirty day mortality for this patient
group undergoing surgery is significant. They point to a twenty
(02:03):
twenty two paper from Egypt in Saudi Arabia that demonstrated
nine percent thirty day mortality rates and eleven percent in
hospital mortality rates. With this as a background, the authors
explained that the aim of this study was to comprehensively
assess the characteristic of patients and outcomes associated with neonatal
cardiac surgery from twenty thirteen to twenty twenty two and
(02:24):
hospitals associated with the European Congenital Heart Surgeons Association or ECHSA.
This was a retrospective multi center study using data from
the Congenital Database of the ECHSA, focusing on patients who
had surgery less center equal to thirty days of age
in the ten year period from twenty thirteen to twenty
twenty two. The author's review how the data in this
(02:47):
database is quite robust and is verified for accuracy. They
identified twelve benchmark surgeries and these were nor would procedure,
hybrid palliation for single ventricle, isolated arterial switch operation, archerial
switch operation with VSD arterial switch operation, and arch repair
a order correctation performed via lateral tharcotomy, the order coork
(03:09):
repair using bypass presumably via asternotomy, isolated interrupted arch a
ordic arch repair associated with another procedure, trunk is repair,
any kind of shunt such as an RV to PA
contu it or an A order pulmonary shunt, and finally
total anomalous pulmonary venus repair. The authors use multi variable
logistic regression models to determine which factors were associated with
(03:32):
thirty day mortality and in hospital mortality. The benchmark operations
were divided into three subcategories based upon the STAT category,
and these were Category one being STAT one to two,
Category two being STAT three to four, and Category three
being STAT five. The authors also looked at many other
co variables, including things like surgery, sex, age less than
(03:53):
ten days at the time of surgery, other non cardiac problems,
wait less than two and a half kilos, use of
cardiopulmonary bypass or circulatory arrest, EKMO needed before or after surgery,
and many other factors and onto the results. Well, there
are many data in this very large scale work, and
as usual I would encourage those interested to read this
(04:15):
work and the link as always will be in the
show notes. There were thirty thousand, nine hundred and thirty
one neonatal operations in the time period, but after excluding
procedures not in the targeted analysis, there were a total
of twenty two thousand, seven hundred and sixty three neonates
from ninety seven centers across thirty six countries that participated
(04:35):
in this work. For analysis, the foremost common procedures were
arterial switch operation, isolated corrotation repair, a shunt procedure, and
the Norwood PDA closure was included in the other category
and accounted for eight percent of neonatal heart surgery. Looking
at non cardiac diagnoses that were seen, the most common
(04:55):
was trisomy twenty one, accounting for one percent of all
surgical candidates, and twenty two Q eleven in zero point
nine three percent. The authors explained that truncus arteriosis patients
had the highest percentage of non cardiac disease in twelve
point eight percent, and the most common non cardiac disease
in the patient group of truncus arteriosis was twenty two
(05:16):
Q eleven deletion, accounting for nearly seventy five percent of
the non cardiac disease in that cohort. And so to
recap the foremost common procedures performed, they were the arterial
switch operation in fifteen point five per cent, correctation repair
in fourteen point one per cent, shunt procedures in ten
point three per cent, and finally the Norwood procedure in
(05:37):
nine point two percent. The thirtey D. Mortality for the
entire group was five point nine percent. It was three
point three per cent in the arterial switch operation, sixteen
percent in the NORWOOD operation, and fifteen point four percent
in the hybrid operation. In hospital, mortality overall was nine
point one percent, and it was four point one percent
(05:57):
for the arterial switch patients and twenty five percent for
the Norwood and thirty one percent for the hybrid procedure.
Cardiopulmonary bypass was used in sixty four percent of patients,
and the longest cardiopulmonary bypass times were seen in descending order,
first in the arterial switch operation with arch repair where
the median was two hundred and forty nine minutes, the
(06:17):
arterial switch with VSD closure where the median was one
hundred and eighty five minutes, followed by the norwood where
the median was one hundred and eighty six minutes. A
order cross clamp was used in fifty nine percent of patients,
and longer cross clamp times were associated with the arterial
switch operation with arch repair one hundred and forty six
minutes and arterial switch operation with VSD closure where the
(06:38):
median was one hundred and eleven minutes. Perhaps not surprisingly,
Norwood operations and Arterial Switch with Archery construction, with the
operations with the highest frequency of post operative complications at
sixty two percent and fifty five percent respectively. Post Operative
EKMO was used most commonly, following the Norwood where it
was employed nineteen percent of the time and the art
(06:59):
Te Materi'll switch with arch repair in eleven percent. The
median post operative ICU stay was six days, and longer
ICU stay was seen in the Norwood patients where the
median was thirteen days and Hybrid procedure where it was
eleven days. The median length of stay for all patients
was twenty six days, with the longest post operative stay
being twenty nine days for Norwood patients, followed by Hybrid
(07:23):
of twenty three days, and so. To reemphasize this important point,
which surgery had the highest mortality rate? Again, it was
the Norwood operation with a thirty day mortality of sixteen
percent and an in hospital mortality of twenty five percent,
followed by the Hybrid operation where the thirty day mortality
was fifteen point four percent and inhospital mortality thirty percent,
(07:45):
followed by Truncus arteriosis repair with the thirty day mortality
rate of nine point five percent and an inhospital mortality
rate of sixteen point three percent. In Table three on
page eight hundred and eighty five, the authors demonstrate that
when looking at the operations by STAT category, the in
hospital mortality and thirty day mortality rose when going from
(08:06):
category one, which you recall as STAT one in two
cases where in hospital mortality was four point seven percent,
to Category two, which again were STAT three and four
category cases where the mortality rate was nine point five percent,
and finally the STAT five category, where the mortality rate
was twenty five percent. Using a multivariable model as mentioned previously,
(08:28):
the authors determined that the major factors affecting mortality were
higher risk procedure meaning higher risk category with an odds
ratio of two point seventy four, and the need for EKMO,
where the odds ratio for mortality was nearly twelve. Interestingly,
when the authors divided the operations by era, separating the
group into the first five years versus the last five years,
(08:50):
there was no statistically different rate of mortality observed. In
their discussion, the authors state that these data reconfirmed the
notion that neonatal cardiac surgery continues to opposed significant challenges
for multiple reasons. They reference a paper from twenty ten
from this same organization showing that the mortality rate then
was nine point one per cent and it was five
(09:11):
point nine per cent in this work, suggesting improvement in
outcomes globally. Despite this, the authors bemoan the fact that
some of the more challenging or high risk procedures like norwoods,
had similar outcomes today to back then. They mentioned prior
works by the STS also demonstrating high mortality rates for
the Norwood, and mentioned that the all in in hospital
(09:32):
mortality of sixteen percent for the Norwood and thirty percent
for the hybrid highlight the need for continued innovation in
the management of these patients. They explained that their multi
variable analysis showed that the presence of non cardiac disease
increased the risk of thirty day mortality and in hospital mortality,
as well as smaller and younger infants, as has been
(09:53):
previously demonstrated. In regard to limitations, the authors mentioned the
profound variability in surgical techniques, postoperative care protocols, and patient
populations over such a diverse group of centers, which may
impact the generalizability of the findings. The authors conclude this
work by stating, and I quote our analysis of a
large multi institutional cohort of neonates who underwent cardiac surgery
(10:16):
during the last decade in centres affiliated with the ECHSA
provide new insights related to the characteristic of patients and
outcomes of neonatal cardiac surgery in Europe and documents decreased
mortality compared with previous epochs. These data can be used
to provide valuable benchmarking across Europe, identify opportunities for improvement,
(10:36):
and facilitate parental counseling. Accompanying this work is a very
brief editorial by doctor Jennifer Nelson, who is a cardiovascular
surgeon at Nemore's Children's Hospital in Orlando, Florida. I won't
review the entire comment, but she wonders aloud if her
general impression that mortality rates for single ventricles are higher
in this European study are in fact higher than in
(10:57):
the STS studies that have been previously published. She freely
admits that how the data are reported are different from
prior STS reports and in some regards This may be
a situation of comparing apples to oranges, but she does
raise this point. She wonders if the known higher rates
of termination for pregnancies of single ventrical patients in Europe
(11:17):
play a role, with the implication being that these cases
are therefore going to be less common, resulting in lower
levels of experience in these complex operations for the surgeons
in Europe. She wonders what relation detection rates in fetal
life have to outcomes and suggests that more international studies
on this topic are needed to ferret out risk factors,
and suggests that a focus on hybrid and surgical stage
(11:40):
one palliation approaches are needed.
Speaker 3 (11:42):
Well.
Speaker 2 (11:43):
This is an interesting work in that it sort of
gives the reader a general benchmark against which programs in
Europe can judge their outcomes, while also clearly demonstrating that
there is much room for improvement. I do find it
interesting that there is no obvious difference in outcomes for
single ventricles undergoing single ventrical palliation over the ten year period,
despite what we perceive to be improvements in care. I
(12:04):
also was interested to see these mortality figures and have
similar questions regarding why it may be that these outcomes
may be slightly worse than those reported in the United States.
I've always had a suspicion that there are differences of
opinion in general regarding the management and approach to these patients,
but this is clearly very difficult to prove. I wonder
if there is any evidence that larger centers had improved
(12:26):
outcomes versus smaller ones, as has been sometimes suggested by
data from the STS. In the interests of time, I
think we should move forward to our conversation with the
work's senior author. Doctor Vita. Joining us now to discuss
this week's work is the work's senior author, Doctor of
Ladimiro Vida. Professor of Ladimiro Vita, completed his medical studies
at the University of Pataua in Italy. He completed his
(12:49):
cardiac surgery residency in Italy, followed by a two year
clinical fellowship in Guatemala under the guidance of Professor Aldo Castaneda,
and then spent an additional two years at Boston Children's
Hospital Harvard Medical School. Following his training, he was appointed
as a consultant at the Pediatric and Cardiac Surgery unit
of Patawa. In twenty seventeen, he became Associate Professor of
(13:10):
Cardiac Surgery and subsequently, in twenty nineteen he was promoted
to full Professor of Cardiac Surgery, where he is now
the leader of the Pediatric and Cardiac Surgery Unit of Patawa.
It is indeed a great honor and pleasure to have
him join us this week to discuss this week's work.
Welcome doctor Vita to PDHRT.
Speaker 4 (13:28):
I'm here now with doctor Vladimirita Vita, who is speaking
with us all the way from Patawa, Italy. Doctor Vita,
thank you so much for joining us this week on pedihart.
Speaker 5 (13:37):
Hey, thanks so much Robert for inviting me.
Speaker 4 (13:38):
He's a privilege, real privilege and honor to have you.
You know, doctor Vita, I was wondering if you could
start by just sharing with the audience what were the
main motivations for you and the ECHSA for reviewing these
neonatal cardiac results as you do in this work.
Speaker 3 (13:54):
So, Robert, as you know, easy to say, own the
largest on Geneta cardiac surgery database in Europe since you know,
twenty five years and now. This database is pretty big
and accounting for you know, more than three hundred and
twenty thousand patients and three hundred and eighty thousand procedure
on Pediatric and Congenital Cardecy Corporation.
Speaker 5 (14:17):
So this kind of enormous volume.
Speaker 3 (14:19):
Of data has been used for you know, scientific support,
especially you know, for rare conditions which are not frequently
encounter even in larger centers, but also to support benchmark
benchmarking and center quality improvement initiative.
Speaker 5 (14:36):
Also important for.
Speaker 3 (14:37):
Physician you know, to individualize their practice and care decision.
So the primary motivation for this ACCESS study and myself
was to conduct you know, a kind of comprehensive assessment
of the characteristics of patients in the neonatal age group
and outcomes in a decade twenty thirteen, two thousand twenty
(15:00):
two within a hospital associated with ECHSA.
Speaker 5 (15:04):
And the main idea.
Speaker 3 (15:09):
Was to you know, comparing you know, the data from
this decade to a previously published stata from ACCESS which
was done you know, considering another decade nineteen nine, twenty
twenty eight, two thousand and eight, which was also published
in the Anstrastic Surgery. The idea of reassessing the outcome
ten years later was driven by the desire to investigate
(15:33):
if there was any you know, improvement in the.
Speaker 5 (15:36):
Management of congenital heart disease in Europe.
Speaker 3 (15:39):
And also you know that new metal correct surgery is
ighly specialized in an involving field. You know, we wanted
to determine if you know, advancing surgical technique can have
an impact you know, on the on the on the
postoperity carryings out within Europe.
Speaker 4 (15:53):
You know, I say, I say thank you very much.
You know, as Arcta Vida, your paper has so many results,
and again I want to encourage all who are listening
to the podcast to read the paper or link to
the paper will be in the note show notes of
this week's podcast. But among the many findings of your work,
I sometimes will ask the author if you might share
(16:14):
with the audience what you, as the senior author, were
most surprised about to discover when reviewing this really gigantic
database that you're reporting on.
Speaker 3 (16:22):
Well, yeah, Robert, well, actually, in a comparison you know
with the previous study comparing two different decades, we are surprised.
Speaker 5 (16:33):
But we have a kind of a similar distribution of procedure.
Speaker 3 (16:37):
So there were no you know, a procedure up on
another you know, during the last decade. But what we
noted is that we have a significant decrease in hospital
mortality actually three day MARTITI eight which now currently accounts
for from five point nine percent compared to the nine
point one percent almost you know, half of the of
the mortality in the new interperiod. Well give you the
(17:00):
significant advancing in pediatric during the last few years.
Speaker 5 (17:04):
We were impressing all because maybe the.
Speaker 3 (17:07):
Refinement strategical technique and the improvements for separative outcome can
ennounce you know, the possibility of having you know, different results. However,
although the overall operative mortality associated with your netor corllect
surgery within access was improved, certain procedures, especially the one
you know undertaken on single anthical hearts, you know, the
(17:30):
Norwood operation or the Eyeberd operation for HLHS, continues to
be associated with significantly higher mortality rate. You know, and
these findings compel us to you know, can to evaluate
you know, what's going on here, you know why?
Speaker 5 (17:45):
You know all these you know increasing but not these patients.
Speaker 3 (17:49):
So this is kind of a big question mark and
is the future opening towards you know, other studies.
Speaker 4 (17:54):
Yes, you know this uh top tails very nicely with
my next question, which is, you know, you did find,
just as you so nicely pointed out, that the Norwood
cases didn't seem to have a very significant change in mortality.
Speaker 5 (18:11):
And I'm wondering did this surprise you?
Speaker 4 (18:14):
I mean, you talked about how improvements have come in
many aspects of surgical care, both during in the operating
room and in the post top period, but in that
particular patient group, the mortality risk for the highest risk
cases didn't really change very much.
Speaker 5 (18:29):
Did this surprise you?
Speaker 4 (18:29):
And do you have any thoughts regarding why there wasn't
a significant observed change in outcomes for Norwoods over a
ten year period.
Speaker 3 (18:37):
Actually, well is a keen observation, you know, And in
our discussion we pointed out, you know, actually that also
we didn't expect. We tried to expect an advantage over
the years, you know, but actually even if he split
the ten year period in two separate five year period, we.
Speaker 5 (19:00):
Didn't find any difference, you know. And I guess that.
Speaker 3 (19:05):
Even the Norwood is a kind of a well codified
procedure within the correct surgery world, you know, I think
five year period simply isn't a sufficient timeframe to have
kind of definitely changes within you know, the the operative mortality.
Speaker 5 (19:22):
So I guess that sturgical innovation of.
Speaker 3 (19:26):
K improved, but maybe for other pathology, not for unarticular hardware.
You have that you have a complex physiology, complex protoperative
course and also the other innovation science since the you know,
we didn't find any difference between the type of chance
we utilize our VP a versus BT. In North America,
(19:46):
we had a great you know as VR trial where
you compare both and you find different results, but actually
the results similar for us, and I guess that what
we found is that within our time frame there were
no changes, but there were some changes within the previous
decades with the ten percent reduction immortite, so actually we
(20:09):
improved result. But still this kind of pathology for union
articular information treated by you know, the pathway or the
Norwood operation or the Ibory procedure still.
Speaker 5 (20:23):
Remain very very high. This is a kind of very
interesting thing to point out.
Speaker 4 (20:28):
Yes, yes, well, you know, prior works, largely in the US,
have suggested that higher volume centers have better outcomes on
average with some of the more higher re surgeries such
as STAT four or five category operations. Did you analyze
this to any degree in your cohort and do you
do you have any observations regarding outcomes in European centers
(20:52):
that had larger or smaller volumes.
Speaker 3 (20:54):
Well touch upon you know, kind of a crucial point,
you know, within the realm of complex correct surgery, because
what we call volume outcome relationship or center effect is
something that we analyze.
Speaker 5 (21:10):
Actually, you know, in.
Speaker 3 (21:12):
Our cohort, we conducted, dedicated some analysis to investigate this phenomenon,
the center effect, and what we found was a positive
correlation between the center volume and better.
Speaker 5 (21:27):
Outcomes for patients.
Speaker 3 (21:28):
You know, this aligning what with with other hypothesies or
other study that previously published this you know, relationship with
high high volume center and bet the result. However, I
think there are a few limitations to take into account,
and also there are several applications recent from some other
(21:50):
US center where actually they demonstrate you know, the opposite.
Speaker 5 (21:54):
You know, I think that the limitation.
Speaker 3 (21:57):
Is that we have a higher high number of centers
included in the in the data inserction within the database.
And actually there is a lot of variability ateroterogenicity between
different centers. You know, we have different you know, internal resourcers,
resource allocation specific approaches to passion management. So it's very
(22:21):
difficult even in large center to find something which is
very consistent.
Speaker 5 (22:27):
During the years, you know.
Speaker 3 (22:28):
And also we covered a ten year span of you know,
of of surgical treatment in Europe, and this can also
add the other other changes because not all the center
consistently insert data through the ten years, you know. And
also this can expose to another variability. So in other words,
(22:52):
the center effect still have.
Speaker 5 (22:54):
A positive value.
Speaker 3 (22:56):
Means that you need to concentrate in a large amount
onto volume, maybe especially for very complex pathology like the
unit tical heart in some in some centers that to
try to increase result. But we found that there are
a lot of limitation. So it's good to concentrate. But
sometimes you have a small center with you know, less
(23:20):
heterogentitity of treatment and the better you know results than
the bigger centers, you know, So it's difficult to find.
Speaker 5 (23:30):
The real, the real, the real, the real solution. Yeah.
Speaker 4 (23:34):
Yeah, Well for those in the audience, it is actually
quite late at night and part of a doctor Vito
was nice enough to speak with us after a long
day operating here in New York. It's only in a
late afternoon, So I'm going to finish up with last question.
You know, we just talked about the signal vetricles and
you are obviously a very experienced surgeon, and based on
(23:54):
your experience, your knowledge and the analysis of these data,
wondering if you have any insights into possible actionable interventions
that can be made to improve single ventrical outcomes in Europe.
You talked about center effects and potentially cohorting them into
certain centers. Any other thoughts on how to improve these
(24:15):
outcomes given that this one little area, although all the
surgeries were generally better outcomes in the last ten years,
this was the one area where there wasn't as much
much improvement. Any thoughts on how maybe not only in
Europe but everywhere these outcomes could be improved.
Speaker 3 (24:32):
Well, I guess this is kind of a very difficult
question to answer, you know, but I had some experience,
you know, in talking with other friends from you know,
the STS, you know, which is you know, your association,
big association in the US. And actually when I'm talking
about you know, study from the STS database, they're talking
(24:54):
to me about you know, a different range of mortality
within the US, which ranges between eleven and fifteen percent.
Speaker 5 (25:00):
Which actually much less than what we.
Speaker 3 (25:03):
Had in Europe, you know, even for normal operation than
for and also for you know, hybrid average and stage
one procedures. I guess that well, we have a different
regional phenomenon possible influence in normal outcome in the US,
because as you know, in Europe, we have a higher
(25:23):
rate of pregnacy termination, which is you know, due to
you know, an increase you know, prenatal diagnosis, which is
mainly for a very complex congenital heard. This brings to
you know, the interruption of pregnancy, and this is you know,
a contribute to decrease the number of cases per center
and the load volume for its center in dealing with
these special particular anatomies. However, I think that we are
(25:47):
now trying to get in touch with the STS because
I believe that a future comparative study between the STS
database and the EXTRA database, we actually are the two
largest largest database in the world about conjen the heart disease,
can allow us to understand maybe the difference in treatment
in anatomy, in indication, and in the postaperity treatment.
Speaker 5 (26:10):
It possibly can.
Speaker 3 (26:11):
Align you know, the European system to the US system.
There were a lot of you know, different strategical strategies
that change the world of treatment for utical heart you know,
the Sumo shant and others you know, like the eyebrid
procedure which is particularly in low birth weight kids, or
(26:31):
with other you know, extra cordec anomalies can increase the results,
even though we notice that these are the worst case
you know, because usually present their unstable low birth by
the other pathologies. So in my mind, we need to learn,
you know, from each other. So I guess that conducting
some you know, combined study, combining different reality within the
(26:54):
US and Europe can help in the alignment of treatment
and also possibly ameliorating the results for this special and
very compless conjct or disease, which still affect in our
minds because it's the most difficult treat pathology to treat.
And I guess this kid need to have a great
(27:14):
consideration and our effort to improve the quality of the
treatment you're offering to our patients.
Speaker 4 (27:20):
Yes, all very interesting and important points, and I think
actually doctor Nelson in her editorial comment talked about possibly
doing exactly what you just suggested, which is to do
some comparative work with sts and try to figure out
why there are differences, and there may not be differences
actually because you are measuring it slightly differently than they are,
(27:43):
but definitely is worthwhile, I think. Well, doctor Vida, I
can't thank you enough for joining us this week on
the podcast. It's been a great honor to have you,
and I want to congratulate you and your many many
co authors and the many many centers in Europe that
participated in this registry study. Really a wonderful work. I
can't even imagine all the work that went into creating
(28:05):
this paper. I think some people would have turned this
into six papers there's so much data in it. But
I really appreciate your time and again, congratulations.
Speaker 3 (28:14):
Now for me was a great honor and a great
experience to stay with you in this podcast. Thank you
for allowing me to participate. I would thank you all
the author that you helped me in doing this job
and hope.
Speaker 5 (28:25):
To see you in the near future. Thank you so much.
Speaker 6 (28:27):
Well, I'm sure you gained a lot from listening to
doctor Vita. I think he offered a number of important
points regarding his data set, and I find that his
final comments about potentially doing work with the other gigantic
and general heart surgical database that of STS to be
especially exciting both to better understand outcomes and to also
help both organizations with quality improvement efforts. Off air, doctor
(28:51):
Vita shared with me the wonderful time he had learning
under doctor Castaneda during his year's training in Guatemala. I
can't imagine how wonderful it must have been to learn
from that giant and operate with them, but we all
know how wonderful a surgeon doctor Castaneda was, and doctor
Vida shared with me how doctor Castaneda taught him the
difference between being a chief and being a mentor, and
(29:14):
certainly in saying that, his comments echo those by many
who were lucky enough to work with that master of surgery,
including doctor John Lamberti, who spoke to us a bit
about doctor Castaneda and the important role that he played
in his training forty years earlier back in Podcast two
twenty five from three years ago in twenty twenty two.
(29:35):
As doctor Vita was uncommonly clear in his comments, I
won't add any more other than to thank him for
taking time from his very busy schedule to speak with
us this week on ped Heart to conclude this three
hundred and forty fifth episode of ped Heart Pediatric Cardiology.
Today we hear the wonderful Italian soprano Rosa Feola sing
the beautiful song by gastoldon Musica Prohibita. Miss Fiola is
(29:59):
becoming a giant in the world of opera, and.
Speaker 2 (30:01):
She started her career in Italy, having been born in
San Nicola l'astrada in Caserta, Italy. She has sung at
most of the great opera houses of the world, including
here in New York City at the Metropolitan Opera, and
has starred in many of the great operatic soprano repertoire.
It's easily apparent why she is so valued in the
world of opera hearing her beautiful voice in this lovely
(30:22):
famous Italian song from the late eighteen hundreds. Thank you
very much for joining me for this episode, and thanks
once again to doctor Vita. I hope I'll have a
good week ahead.
Speaker 5 (30:32):
Oh jees to cool.
Speaker 7 (31:05):
The co Jack could cool comment, quanto, macroni, compre spere
(31:27):
and grub check all come to work. It of piety,
(31:53):
we invent God voice. I loved Texcuse me, it's not
(32:22):
massuk lossing team was spotty open when the Sky of
(32:47):
Hope Sami came. Ten oh that said, the
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