December 5, 2025 • 34 mins
ECMO is the topic of this week’s episode of Pediheart. We speak with Assistant Professor of Pediatrics and cardiac critical care specialist at Northwell Health, Dr. Ivana Capin about a recent ELSO database study she conducted to assess outcomes in single ventricle patients who were treated with ECMO prior to single ventricle palliation. What factors were associated with worse overall outcomes? Can this therapy be used to stabilize the HLHS patient with an intact atrial septum? Why have outcomes for this high risk patient group not appreciably improved in the recent decade? How can these data improve prognostic clarity when speaking with families in this difficult situation.
Also joining us briefly is Associate Professor of Pediatrics at the Icahn School of Medicine at Mount Sinai, Dr. Scott Aydin to discuss his co-author and mentor, Dr. George Ofori-Amanfo as we approach the 4th anniversary of his untimely and tragic passing.
Also joining us briefly is Associate Professor of Pediatrics at the Icahn School of Medicine at Mount Sinai, Dr. Scott Aydin to discuss his co-author and mentor, Dr. George Ofori-Amanfo as we approach the 4th anniversary of his untimely and tragic passing.
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Episode Transcript
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Speaker 1 (00:16):
Welcome to Pdiheart 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 Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
sixty fourth episode of Pdheart. I hope everybody enjoyed last
week's replay episode, in which we spoke with doctor Tony
(00:36):
Past and doctor David Brown about fellowship for Cardiology. For
those of you interested in education, I'd certainly recommend you
tech to listen to last week's episode. As I say
most weeks, my email is easy to remember. It's pdheart
a's gmail dot com. This week we move on to
the world of mechanical support, and the title of the
work we'll be reviewing is extra Corporeal Membrane Oxigenation a
(01:01):
Bridge to palliation in single ventrical Physiology. The first author
of this work is Ivanna Capin, and the rest of
the authors are Giorgio Foria Mamfo, Maria Esperanza Ragov Murthy,
Gary Oldenberg, Jacqueline Lamore, Christy Glotzbeck, and the senior author
Scott Eiden, and this work comes to us from the
Division of Pediatric Cardiology and Pediatric Critical Care from my
(01:24):
own institution, Mount Sinai Cravis Children's Hospital. When we'res une
reviewing this paper, the first author, doctor Capin, has graciously
agreed to speak with us about it. Therefore, let's move
straight onto this article and then a conversation with the
work's first author. The work begins with some comments about EKMO,
reviewing its many roles as a bridge to recovery or transplantation,
(01:44):
or decision making when there is my cardioty compensation or
cardiopulmonary failure. They then reference prior works demonstrating that it
has been used successfully during the various stages of single
ventrical palliation, and how hypoplastic left heart syndrome patients are
the subgroup of single ventrical patients who've had the highest
usage of this form of support. The author's end quote
(02:05):
a prior work demonstrating forty percent survival to discharge when
EKMO is used in the hypoplastic left heart syndrome patients
during palliative procedures. They then contrast the knowledge base we
have in the general use of ECHMO in the single
ventrical patient with what they view as a dearth of
information regarding its role or the outcomes prior to single
(02:25):
ventrical palliation, and they explain that this setting of a
single ventrical patient whose failing prior to surgery is relatively unstudied,
and so with this as a background, the authors explained
that quote, our aim is to examine the outcomes of
patients with single ventrical physiology who were supported with echmo
oxygenation as a bridge to palliation, with survival to discharge
(02:46):
as the primary outcome. Secondary outcomes included evaluating the preoperative
and extracorporeal membrane oxygenation related variables that may influence mortality.
We hypothesize that extra corporeal membrane oxygenation can be used
successfully as a bridge appalliation in patients with single ventrical physiology.
This was a retrospective registry review of data from the
(03:08):
very large ILSO or Extra Corporeal Life Support Organization Registry
from January first, twenty sixteen to December thirty first, twenty
twenty one. There are over two hundred and fifty centers
in this registrate and it includes both US and international
centers worldwide the authors review the codes that they use
to identify the single ventrical patients and review also all
(03:30):
the varied information that they collected such as demographics, diagnoses, procedures,
reason for ECMO, cannulation types, and many more data related
both to the conduct of EKMO and the hospitalization and
patient related factors. The authors then review for us the
multi variable analysis that they performed and explained that this
included hours on ECHMO, need for renal replacement therapy FIO,
(03:52):
two peak end expratory pressure, and the presence of surgical bleeding,
which were all included in the model that they created.
Speaker 2 (04:00):
So the results.
Speaker 1 (04:01):
There were sixty five patients in the study time period
requiring EKMO prior to stage one palliation. The meeting age
at canulation was ten days with a meeting weight of
three point two kilograms, and thirty one percent or twenty
of the patients had hypoplastic left heart syndrome, followed by
eleven patients or seventeen percent having an unspecified single ventricle,
(04:21):
nine patients or fourteen percent having double atlok right ventricole,
and eight patients with pulmonary treasia constituting twelve percent And
what were the reasons for Ekmo's support, well, fifty four
of sixty five or eighty four percent needed it for
what was termed cardiac decompensation, with four patients or six percent,
having respiratory arrests and seven patients or eleven percent, received
(04:45):
ECHMO during CPR. Interestingly, there were no differences in survival
related to the reason for EKMO. And here's the important question,
what was survival like if you needed EKMO before your
stage one surgery? Wealth thirty eight patients or fifty eight
percent died prior to discharge, with twenty four patients or
(05:05):
sixty three percent of those who died dying while on EKMO,
and fourteen patients or thirty six percent of those who
died dying either during the palliat of surgery or in
the post operative period. Importantly, duration of ekmos support was
significantly different between non survivors, in which the mean length
was one hundred and ninety nine hours versus survivors in
(05:26):
which it was fifty nine hours. Non survivors had a
significantly higher peak inspiratory pressure prior to EKMO, and if
the peak inspiratory pressure was equal to or greater than,
twenty millimeters of mercury prior to EKMOS support, the patient
was more likely to die prior to discharge, with an
ODDS ratio of ten point six. The authors completed a
multivariate model with logistic regression as we were reviewed previously,
(05:50):
and after adjusting for FIO, TiO, and PEEP, the model
demonstrated that longer duration of EKMO was significantly associated with mortality. Additionally,
the model demonstrated that requiring renal replacement therapy seen in
forty two percent of those on EKMO, was associated with
mortality prior to discharge. So, just to summarize once more,
(06:11):
forty two percent of those who required EKMO survived to discharge,
with thirty seven percent of patients dying while on EKMO
before palliation could be performed, and amongst those who died,
they had significantly longer ECHMO runs in comparison to survivors
and on multivariate analysis, longer ECHMO duration and the need
for renal replacement treatment were both associated with the higher
(06:33):
risk of death, and there were no significant demographic differences
in regards to age, sex, and weight between survivors and
non survivors. In their discussion, the authors re review the
findings that I just summarized and compare it to the
very limited prior data on this topic, referencing a prior
work on EKMO as a bridge to congenital heart disease
surgery in which survival was sixty two percent, which is
(06:55):
superior to the forty two percent seen in this single
metrical cohort, But they mentioned the very small numbers of
patients in that prior work and the smaller number of
single ventrical patients, making a comparison tenuous at best. They
mentioned that outcomes in general were poor and did not
seem to be improving, and I'll mention that a study
by misfelt at All, which was an administrative database also
(07:18):
analysis that demonstrated nearly identical survival for single ventrical patients
needing EKMO from two thousand to two thousand and nine,
and the authors make some suggestions regarding why it is
it believed that outcomes may not be improving with time.
The authors review some limited data on renal injury and
ekmo's survival and show that this has been previously identified
(07:38):
as a risk factor for patients in general needing EKMO,
but certainly this is one of the few studies assessing
this issue in the single ventrical patient. They mention other
studies showing that renal dysfunction and liver injury after single
ventrical palliation has also been associated with worse outcomes. In
regards to limitations, the authors point to the limitations of
the also database as well as incomplete data fields completion,
(08:02):
and they offer as an example the fact that they
could not reliably report on what percentage of patients on
ECHMO were treated with prostaglandin prior to EKMO, which clearly
would be an important factor in survival, as well as
perhaps offer insights into why a patient prior to single
ventrical palliation would even need ACHMO. The office point to
the multi center nature of this which, though having many advantages,
(08:24):
does bring profound variability regarding canulation strategies and anti coagulation practices,
which may have important impacts on outcomes. They also point
to the overall small sample size and inability to have
sufficient power to draw important conclusions, and so they conclude
patients supported with extra corporeal membrane oxygenation prior to their
(08:45):
first stage of surgical palliation are at high risk of
mortality without improvement in the last decade renal injury requires
renal replacement therapy, and those who suffer from multi complications
are at increased risk of mortality. This study may serve
to set exposts for clinicians as they counsel families on
the risks and benefits of EKMO support prior to their
(09:07):
first stage single ventrical palliation. Well, the findings of this
work are certainly somewhat sobering, though perhaps not unexpected. Of course,
it's of interest to see that only forty two percent
of these extremely ill inferens are surviving to discharge. There
are two ways to view this group, who without EKMO
would have one hundred percent mortality rate. However, it's clear
that needing EKMO before you even have had palliation is
(09:30):
a bad prognostic sign. I do wonder about the single
vetrical patient who has an intact atrial septum and whether
any of the patients in this cohort had this, and
if they survived, and if there is any signal regarding
outcome in comparison to running to the cathlic for urgent septoplasty,
which is always a frightening proposition. I also wonder how
(09:50):
doctor Capin believes these data can practically help the management
of these patients at the bedside. In the interest of time, therefore,
let's move forward to our conversation with the world first author,
doctor Evanna Capan, joining us now to discuss this week's
work is the first author, Evanna Capin. Doctor Capan is
a pediatric critical care medicine specialist at Northwell Health in
(10:11):
Long Island, New York. She's a graduate of the University
of Limerick Graduate Entry Medical School and she completed her
residency at Staten Island University Hospital. Following this, she performed
a fellowship in Pediatric Critical Care Medicine at the Icon
School of Medicine at Mount Sinai, followed by Pediatric Cardiology
fellowship at the Icon School of Medicine at Mount Sinai.
(10:32):
It is a delight to have my former fellow and friend,
doctor Capin join us this week to discuss her work.
Welcome doctor Capan to PD Heart. I'm here now with
doctor Evanna Capan of Northwell Health. Evanna, thank you very
much for joining us this week on Pdheart.
Speaker 3 (10:45):
Hi, doctor pass, thank you so much for that introduction
and for having me on the podcast as an avid listener.
I'm very excited to be here.
Speaker 2 (10:52):
Thank you very kind of you, you know, Ivana.
Speaker 4 (10:54):
I often will start out these interviews and ask the author,
you know, as the authors conversant with the data of
this work, I wondered if you might, for the audience
be able to briefly summarize what you think are the
three or foemost important observations of your work.
Speaker 3 (11:10):
Yeah, of course, so in terms of our most important observations.
First and foremost, our work suggests overall survival to hospital
discharge for neonates with single ventrical physiology supported with prepaliation
ECHMO remained low about forty two percent, just highlighting how
sick this population remains despite our most extreme efforts. Second,
(11:31):
and not surprising, the duration of ECMO support was a
strong predictor of outcome. Infants who did not survive had
substantially longer ECHMO runs than those who did not. Surprisingly, again,
the need for renal replacement therapy was associated with markedly
higher mortality. And Finally, patients who accumulated multiple complications, especially
bleeding or mechanical issues, also had significantly worse outcomes. Taken together,
(11:55):
these observations highlight just how fragile these pre palliation single
ventricle infants are when they reach the point of meaning ekmo.
Speaker 2 (12:03):
Yeah. Great, really wonderful summary. Thank you very much.
Speaker 4 (12:07):
You know, prior works on echmo and single ventricles seem
to have demonstrated similar survival rates as your more up
to date, more recent work, and I wondered if you
could offer for us some ideas as to why you
think that single ventrical echmo patient survival has not really
substantially improved despite what we know are very substantial improvements
(12:31):
in critical care cardiology delivery in the same time period.
Speaker 3 (12:35):
That's a key point, and our data really echoes what
has been observed historically. I think there are a few
reasons why survival hasn't meaningly meaningfully improved. Survival for single
ventricle patients seeing ekmo has plateaued because the physiology is
just so unforgiving. By the time these patients require echmo,
they almost always have significant multi organ injury, and while
(12:55):
ECMO can't support them, it can't always reverse the damage
that has been done and the underlying instability of their
unique circulations. Advances in care of improved outcomes broadly, but
the narrow subset that ends up on ACHMO remains the sickest,
most high risk group, so their outcomes unfortunately have not
really moved, and in the case of the pre stage
one group specifically, the physiology is even more fragile. These
(13:19):
babies often present with profound shock or cardiac arrest before canulation.
Once they reach the threshold for ECHMO, they've usually already
accumulated severe end organ injury. So for this group, ECHIMO
main fact be a marker of irreversibility, which is why
survival has remained so low. And I'll briefly touch on
threshold for ECHIMO. Threshold for canulation remains variable and center specific,
(13:42):
and while it is often employed after cardiac arrest or
profound shock, that may be too late, and LEE as
a community haven't found that sweet spot just yet. The
challenge truly is balancing the risks of ECHMO against the
high mortality associated with late initiation. All this to say,
despite improvements in technology and care delivery, the physiologic limitations
(14:03):
of single ventrical circulation and the severity of presentation probably
explains why survival really has Plateauedah.
Speaker 2 (14:11):
All very good points.
Speaker 4 (14:12):
You know, I've always said that with these single ventrical patients,
you pretty much get only one shot. And I think
it's the same reason why if the surgery isn't pretty
close to perfect, the patients generally do poorly because there
really is no second chance. And I guess that's true
also with their physiology before surgery as well. And as
I say in my comments, which you haven't heard yet,
(14:34):
one could view this very optimistically. Although forty two percent
survival sounds bad, the reality is that without this support,
I'm sure the survival would be zero. So I guess
it just depends on your perspective. You know, renal replacement therapy,
as you explain to us on ECHMO, and this prepalliative
single ventrical patient population was associated with higher mortality risk,
(14:57):
and I wondered if you might be able to posit
for us why you think this might be. Do you think,
for example, that this is just a surrogate for worst
general body perfusion, or do you think that the renal
injury itself may be the reason and the need for
renal replacement maybe the reason for the increased mortality. And
(15:18):
I wondered if you were able to assess other factors
like the presence of elevation and LFTs, or maybe even
maximal lactate levels and outcomes.
Speaker 3 (15:27):
Yeah, that's a great question. I mean, in our view,
renal replacement therapy is most likely a surrogate marker of
more severe systemic illness. When a prepalliation single ventrical neonate
develops enough renal dysfunction to require dialysis, that almost always
reflects significant global hypoperfusion, inflammation and or multi organ compromise.
(15:47):
That said, the kidney injury itself can also worsen the
trajectory through fluid overload, electroly abnormalities, and challenges with anti coagulation,
so it's probably a combination of both. As for the
other organ injury markers that you commented on, the data
set didn't provide complete enough information to reliably analyze things
like peat lacte, liver enzymes, or detailed fluid overload metrics,
(16:11):
so we can't formally test whether renal injury remains independently
predicted when adjusting for those other parameters. But based on
clinical patterns and prior literature, renal replacement therapy is a
strong marker of overall severity rather than an isolated renal issue.
Speaker 4 (16:27):
Yeah, you know the next question. I don't know if
your data set answers this, but I've always been frightened
of the hypoplast with an intact atrial septum. I think
all interventional cardiologists have a similar feeling about this because
it's one of the most difficult procedures we do, and
it has to be done faster than almost any other procedure,
so it's sort of like a witch's brew of complexity
(16:49):
and difficulty, and traditionally I've always been told that an
intact atrial septum in the hypoplast cannot be palliated with
EKMO prior to septoplasty or state one, and it's associated
even with higher mortality than if you do it the
more quote unquote traditional way of going urgently to the
cath lab for trans catheter relief. I wondered if you
(17:11):
had any data on single ventrical patients who were candidates
for stage one palliation who had an intact atrial septum
and were placed on ACMO, and whether any of those
patients did okay.
Speaker 3 (17:23):
You know, that's a great question, and it's something that
doctor Scott aid in my mentor for this project, and
I've spoken at great lengths and something we're very interested
in addressing and exploring. Unfortunately, at this time we do
not have that data. The registry did not reliably capture
intact atrial septum, so we couldn't identify or analyze a
subset of hypoplastic left heart infants with that specific physiology.
(17:46):
We are aware that historical recommendations suggests EKMO for intact
septum is associated with extremely poor outcomes compared to the
urgent cathter based decompression cohorts, but again, our data set
just wasn't granular enough to speak to that sub group specifically,
So stay tuned, hopefully for the future.
Speaker 4 (18:03):
Yeah, I mean, I guess it's very similar to a THAPVR.
ECHMO doesn't do very much for that either, so I think,
at least for now, we're still stuck having to do
what we do, which is to get that septim open
as fast as possible without the need of support. Well,
for those in the audience, doctor Capan was kind enough
to give us time today in a busy afternoon. She's
(18:24):
also a very busy mom as well, so I don't
even know how she handles all of that. So I'm
going to finish up with the last question and I
wondered if you believe there are any takeaways from your
work that might help inform or improve the care of
patients on ECHMO in this very difficult, horrible situation. Do
you feel that the impact of this work is mostly
(18:46):
in providing prognostic data to families, or do you think
that there may be some medical management impact from your
work as well.
Speaker 3 (18:53):
I think there are really two main takeaways from this
research project, the first being prognostic clarity. This data suggests
and helps US council families more transparently and honestly both
about the overall survival likelihood and the significance of things
such as prolonged ECHMO runs, renal replacement therapy, or accumulating complications.
(19:14):
The second being clinical management implications. While the study doesn't
specifically test certain interventions, the associations suggest a key priorities.
Speaker 2 (19:22):
I think we have to.
Speaker 3 (19:23):
Identify and support and organ function early, especially avoiding fluid
overload states, and with that consider earlier escalation or intervention
before multi organ injury accumulates. So while much of the
impact in the study is in realistic prognostication, I do
think there are actionable insights that may refine how we
manage this very high risk group going forward. With that
(19:45):
being said, more work has to be done in the
area of the decompensating single ventricle requiring echmo prepalliation, because,
as we discussed earlier, outcomes have very much plateaued.
Speaker 2 (19:56):
Well excellent points.
Speaker 4 (19:58):
Well, Ivon, I want to find thank you very much
for taking time from your busy schedule to speak with
us this week on the podcast. I want to congratulate
you doctor Aiden and all the multiple authors, and.
Speaker 2 (20:10):
Thank you so much for coming on the podcast this week.
Thank you, doctor Paz, Thank you well.
Speaker 4 (20:14):
As I'm apt to say, when the guest is good,
there's really not much to say, and I think you'll
agree with me that doctor Capin was uncommonly clear in
her many comments and I'm thrilled once again to have
an up and coming superstar on the podcast. As we spoke,
I really came to better understand the value of this
work and to use her terminology the value it offers
(20:35):
us in so called prognostic clarity when speaking with families.
This concept of prognostic clarity is something that fetal cardiologists
wrestle with all the time while advising parents, but being
able to guide families through these critical and challenging times.
Is similarly very important for critical care physicians, and I
(20:56):
do believe that doctor Capan's work will provide meaningful information
that families and providers can use together through shared decision
making to make the right decision for an individual patients
and family. Once again, I'd like to thank doctor Capan
for taking time from her schedule to speak with us
this week on Pdheart. At this point in the podcast,
(21:16):
when I would normally go to the music, I realized
that it is actually sadly four years since we lost
my dear friend, doctor Giorgio Furia Momfo, who was the
director of pediatric Critical Care here at my own institution,
Mount Sinai and full Professor of Pediatrics at the Icon
School of Medicine at Mount Sinai. For those of you interested,
I did an entire tribute episode one hundred and ninety
(21:39):
two four years ago on doctor Alforia Momfo, and I
would certainly recommend anyone interested in learning about a real hero,
a wonderful guy, take a listen to that episode. Given
that it is four years, given that doctor Olforia Momfo
is actually a co author on this paper, and given
that the senior author is doctor Scott Iden, who was
(21:59):
a dear friend and mentee of doctor Alforia Momfo. I
thought it would be nice to briefly speak with Scott
about doctor Alforia Momfo, his role in this project, and
to just reflect on.
Speaker 5 (22:10):
Our good friend George.
Speaker 1 (22:12):
Doctor Scott Iiden needs no introduction, as he is a
well known figure in the fields of pediatric cardiac critical care.
He is Associate Professor of Pediatrics at the Icon School
of Medicine at Mount Sinai, where he is the director
of the Pediatric cardioc Critical Care Unit here at Cravis
Children's Hospital at Mount Sinai. It is a delight to
welcome back my friends and colleague doctor Iden to Pdheart.
(22:33):
Welcome Scott to Pdhart.
Speaker 4 (22:35):
I'm here now with doctor Scott Iden, who's the senior
author of this week's paper. Scott, given that it's almost
exactly four years since we lost our dear friend George,
I thought I would mention him with you today and
remember him a little bit. So thank you and welcome
to Pdhart. Thanks Robert, you know it's a pleasure to
join you.
Speaker 6 (22:54):
I think this will be my second time on the podcast,
so it's always a.
Speaker 4 (23:00):
Thank you, well after actually I think it's the third
and it's but it's been eight years that the podcast
is goix there you go. Well, you know, I noticed,
obviously when I was reading this paper, the first thing
that jumped out to me, other than that you are
the senior author, is who the second author is, which
is our very dear friend, Georgio Furia Momfa.
Speaker 2 (23:21):
I was wondering, how did George.
Speaker 4 (23:24):
My understanding is he was central to the development of
this paper's concept. Maybe you could share with us how
how what his role was and the genesis of this
work that we're reviewing this week.
Speaker 6 (23:36):
Sure, you know George, as you know, George's was a
ideas guy and you know, at our previous institution where
we were you know, colleagues, and he was you know,
you know obviously my mentor there. And you know, we
had you know, a couple of patients that kind of
fitted into this category. And as you know, George would
(23:58):
always do, is you know, you start to you know,
talk about you know, you know, what the literature says
and what the data shows and the lack thereof in
this particular population of patients that you know, get supported
on EKMO, and you know, he kind of just you know,
says to you know, the junior folks and the fellas,
(24:18):
you know, we should look at this, We should you know,
take a look at this. See if there's data out there,
see what we can learn from this. And so, you know,
that was really his his role was kind of you know,
pushing us, you know, junior folks who was myself and
one of my other colleagues at the time, Christy Glotzbach
who we were junior attendings, and he kind of you know,
(24:42):
encouraged us to look at that. And then you know,
unfortunately the situation happened where you know, both George and
I moved institutions, and so that project, you know, went
on the back burner and then here, you know, we
kind of re reinvigorated it and decided to a look
at it. And you know what I learned from George was,
(25:03):
you know, passed the opportunities on to junior faculty fellows
and that was how we were, you know, kind of
suggested it to one of our fellows to take it
on and go with it. Well, that's a.
Speaker 4 (25:17):
Wonderful story, George inspiring us even years after his passing.
It's really nice to hear that. You know, Scott, I
know you're one of his very dearest friends, and certainly
I think one of his prime mentees. And I was wondering,
you know, it's at the end of this month, it's
going to be four years.
Speaker 2 (25:37):
That we lost George. Really unbelievable. It seems like yesterday.
Speaker 4 (25:42):
And I'm thinking, you know, thinking back on all your many, many,
many interactions with George, I'm wondering, you know, what is
it that stands out as you now that we have
a little bit of time, a little bit of perspective,
what do you what do you think back on George
and say, you know, this is really what why I
so love the guy.
Speaker 6 (26:02):
Yeah, I think more than anything, he was just just
a good friend, uh, you know, more than you know,
a mentor and someone that would you know, take the
time to teach and you know, try to impart his
experience and wisdom. He was ultimately just a good friend.
And and you know, what I've come to learn is
(26:25):
that there really isn't a person that has come into
contact with George that didn't feel the warmth and his
kindness and his willingness to to help and and and
lend his time to people, and even if he only
met you for you know, a few hours at a conference,
next time you interact with him, it would be like,
(26:46):
you know, you were long lost friends and you know,
catching up. And I think that type of warmth is
is you know, you don't find that every everywhere. And
you know that's one of the things that I've I've
learned of him is to maintain those connections, those relationships
and and you know I learned that from from George
(27:08):
almost you know a lot of other things.
Speaker 4 (27:10):
Yeah, yeah, that's that certainly rings true, Scott and I
I just when I think back so many great things
about George. But I was thinking about this myself this morning,
and I think probably the thing I missed the most
and remember the most was how funny George was. And
he had a great sense of humor that you know,
(27:31):
you could you could make fun of him, and he'd make.
Speaker 2 (27:34):
Fun of you. And I was just a load of fun.
Speaker 4 (27:37):
I remember, you know, when he was a cardiology fellow
at he and his co fellows doctor ashwind Prakash, doctor
Jared Lecord, and I was not a fellow anymore as
an attending, but we were all roughly the same agent
we would go work out in the gym, and he
was so proud of the fact that he was the
gym member of the month. Yelled at old for me
(28:00):
for years, and it always seemed that he worked out
the least of all.
Speaker 2 (28:04):
Of us, but always seemed to be in the best
physical shape. But he always he enjoyed, He enjoyed making
me aware of that as often as he could.
Speaker 6 (28:12):
It's just that's that's definitely George. And you know, he
always had his you know, dumbbells in his office, and
you know, I always, you know, tease him. You know,
I've never you know, I never saw him lift those
at all. You know, you know, I work out when
I'm on call, and you know, i'd always you know, yes,
call bs on that, you know.
Speaker 2 (28:32):
But it's funny. I did the exact same thing.
Speaker 4 (28:35):
He had these extremely heavy tumbbells, and I would always
say that there's no way you lift those things. He's like, oh, yes,
I do, But he was I think he was kidding.
Helped his image, I guess. Well, Scott, I really appreciate
your spending a few moments with us to remember our
dear friend. For those of you in the audience who
may not have had the great luck and pleasure of
(28:56):
having known doctor o'fori, or for those of you who
remember for him as fondly as we do, and I
know most who knew him do feel the same way.
I would certainly recommend you take a listen to episode
one hundred and ninety two from just at the very
beginning of twenty twenty two, in January of twenty twenty two,
in which we have a whole hodgepodge of many, many
people who knew and loved doctor Afori. You can share
(29:20):
his story with us. Scott, thank you very much, and
once again I want to congratulate you and all of
your co investigators on a really terrific paper.
Speaker 6 (29:27):
Well, I appreciate it. Rob thanks for having me on pleasure.
Speaker 1 (29:31):
To conclude this three hundred and sixty fourth episode of
ped Hart Pediatric Cardiology. Today we hear the wonderful rising
Bolivian Albanian soprano Carolina Lopez Moreno singing the heartbreaking duet
from the final act of Buccini's l'arndine with the great
American tenor Michael Fabiano and alive rehearsal of the opera
(29:51):
from a few years ago. In this duet, Malcta leaves
her great love Ruguero in order to save him. The
love between these two is pal poole and this duet
sung so winningly by Lopez, Moreno and Fabiano. Thank you
once more for joining me for this week's podcast, and
thanks once again to doctor Capan.
Speaker 5 (30:10):
I hope I'll have a good week ahead.
Speaker 7 (31:00):
On the hop.
Speaker 8 (31:26):
So to speedy, deep steps and.
Speaker 6 (32:03):
S.
Speaker 7 (32:04):
Didn't coming up your sloping hole?
Speaker 9 (32:10):
Clon the son recorded.
Speaker 8 (32:25):
Did din?
Speaker 7 (32:46):
Was it say.
Speaker 9 (32:54):
Beauty plain? Knowing you?
Speaker 8 (33:01):
He loved your big
Speaker 7 (33:21):
He said
Welcome to Pdiheart 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 Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
sixty fourth episode of Pdheart. I hope everybody enjoyed last
week's replay episode, in which we spoke with doctor Tony
(00:36):
Past and doctor David Brown about fellowship for Cardiology. For
those of you interested in education, I'd certainly recommend you
tech to listen to last week's episode. As I say
most weeks, my email is easy to remember. It's pdheart
a's gmail dot com. This week we move on to
the world of mechanical support, and the title of the
work we'll be reviewing is extra Corporeal Membrane Oxigenation a
(01:01):
Bridge to palliation in single ventrical Physiology. The first author
of this work is Ivanna Capin, and the rest of
the authors are Giorgio Foria Mamfo, Maria Esperanza Ragov Murthy,
Gary Oldenberg, Jacqueline Lamore, Christy Glotzbeck, and the senior author
Scott Eiden, and this work comes to us from the
Division of Pediatric Cardiology and Pediatric Critical Care from my
(01:24):
own institution, Mount Sinai Cravis Children's Hospital. When we'res une
reviewing this paper, the first author, doctor Capin, has graciously
agreed to speak with us about it. Therefore, let's move
straight onto this article and then a conversation with the
work's first author. The work begins with some comments about EKMO,
reviewing its many roles as a bridge to recovery or transplantation,
(01:44):
or decision making when there is my cardioty compensation or
cardiopulmonary failure. They then reference prior works demonstrating that it
has been used successfully during the various stages of single
ventrical palliation, and how hypoplastic left heart syndrome patients are
the subgroup of single ventrical patients who've had the highest
usage of this form of support. The author's end quote
(02:05):
a prior work demonstrating forty percent survival to discharge when
EKMO is used in the hypoplastic left heart syndrome patients
during palliative procedures. They then contrast the knowledge base we
have in the general use of ECHMO in the single
ventrical patient with what they view as a dearth of
information regarding its role or the outcomes prior to single
(02:25):
ventrical palliation, and they explain that this setting of a
single ventrical patient whose failing prior to surgery is relatively unstudied,
and so with this as a background, the authors explained
that quote, our aim is to examine the outcomes of
patients with single ventrical physiology who were supported with echmo
oxygenation as a bridge to palliation, with survival to discharge
(02:46):
as the primary outcome. Secondary outcomes included evaluating the preoperative
and extracorporeal membrane oxygenation related variables that may influence mortality.
We hypothesize that extra corporeal membrane oxygenation can be used
successfully as a bridge appalliation in patients with single ventrical physiology.
This was a retrospective registry review of data from the
(03:08):
very large ILSO or Extra Corporeal Life Support Organization Registry
from January first, twenty sixteen to December thirty first, twenty
twenty one. There are over two hundred and fifty centers
in this registrate and it includes both US and international
centers worldwide the authors review the codes that they use
to identify the single ventrical patients and review also all
(03:30):
the varied information that they collected such as demographics, diagnoses, procedures,
reason for ECMO, cannulation types, and many more data related
both to the conduct of EKMO and the hospitalization and
patient related factors. The authors then review for us the
multi variable analysis that they performed and explained that this
included hours on ECHMO, need for renal replacement therapy FIO,
(03:52):
two peak end expratory pressure, and the presence of surgical bleeding,
which were all included in the model that they created.
Speaker 2 (04:00):
So the results.
Speaker 1 (04:01):
There were sixty five patients in the study time period
requiring EKMO prior to stage one palliation. The meeting age
at canulation was ten days with a meeting weight of
three point two kilograms, and thirty one percent or twenty
of the patients had hypoplastic left heart syndrome, followed by
eleven patients or seventeen percent having an unspecified single ventricle,
(04:21):
nine patients or fourteen percent having double atlok right ventricole,
and eight patients with pulmonary treasia constituting twelve percent And
what were the reasons for Ekmo's support, well, fifty four
of sixty five or eighty four percent needed it for
what was termed cardiac decompensation, with four patients or six percent,
having respiratory arrests and seven patients or eleven percent, received
(04:45):
ECHMO during CPR. Interestingly, there were no differences in survival
related to the reason for EKMO. And here's the important question,
what was survival like if you needed EKMO before your
stage one surgery? Wealth thirty eight patients or fifty eight
percent died prior to discharge, with twenty four patients or
(05:05):
sixty three percent of those who died dying while on EKMO,
and fourteen patients or thirty six percent of those who
died dying either during the palliat of surgery or in
the post operative period. Importantly, duration of ekmos support was
significantly different between non survivors, in which the mean length
was one hundred and ninety nine hours versus survivors in
(05:26):
which it was fifty nine hours. Non survivors had a
significantly higher peak inspiratory pressure prior to EKMO, and if
the peak inspiratory pressure was equal to or greater than,
twenty millimeters of mercury prior to EKMOS support, the patient
was more likely to die prior to discharge, with an
ODDS ratio of ten point six. The authors completed a
multivariate model with logistic regression as we were reviewed previously,
(05:50):
and after adjusting for FIO, TiO, and PEEP, the model
demonstrated that longer duration of EKMO was significantly associated with mortality. Additionally,
the model demonstrated that requiring renal replacement therapy seen in
forty two percent of those on EKMO, was associated with
mortality prior to discharge. So, just to summarize once more,
(06:11):
forty two percent of those who required EKMO survived to discharge,
with thirty seven percent of patients dying while on EKMO
before palliation could be performed, and amongst those who died,
they had significantly longer ECHMO runs in comparison to survivors
and on multivariate analysis, longer ECHMO duration and the need
for renal replacement treatment were both associated with the higher
(06:33):
risk of death, and there were no significant demographic differences
in regards to age, sex, and weight between survivors and
non survivors. In their discussion, the authors re review the
findings that I just summarized and compare it to the
very limited prior data on this topic, referencing a prior
work on EKMO as a bridge to congenital heart disease
surgery in which survival was sixty two percent, which is
(06:55):
superior to the forty two percent seen in this single
metrical cohort, But they mentioned the very small numbers of
patients in that prior work and the smaller number of
single ventrical patients, making a comparison tenuous at best. They
mentioned that outcomes in general were poor and did not
seem to be improving, and I'll mention that a study
by misfelt at All, which was an administrative database also
(07:18):
analysis that demonstrated nearly identical survival for single ventrical patients
needing EKMO from two thousand to two thousand and nine,
and the authors make some suggestions regarding why it is
it believed that outcomes may not be improving with time.
The authors review some limited data on renal injury and
ekmo's survival and show that this has been previously identified
(07:38):
as a risk factor for patients in general needing EKMO,
but certainly this is one of the few studies assessing
this issue in the single ventrical patient. They mention other
studies showing that renal dysfunction and liver injury after single
ventrical palliation has also been associated with worse outcomes. In
regards to limitations, the authors point to the limitations of
the also database as well as incomplete data fields completion,
(08:02):
and they offer as an example the fact that they
could not reliably report on what percentage of patients on
ECHMO were treated with prostaglandin prior to EKMO, which clearly
would be an important factor in survival, as well as
perhaps offer insights into why a patient prior to single
ventrical palliation would even need ACHMO. The office point to
the multi center nature of this which, though having many advantages,
(08:24):
does bring profound variability regarding canulation strategies and anti coagulation practices,
which may have important impacts on outcomes. They also point
to the overall small sample size and inability to have
sufficient power to draw important conclusions, and so they conclude
patients supported with extra corporeal membrane oxygenation prior to their
(08:45):
first stage of surgical palliation are at high risk of
mortality without improvement in the last decade renal injury requires
renal replacement therapy, and those who suffer from multi complications
are at increased risk of mortality. This study may serve
to set exposts for clinicians as they counsel families on
the risks and benefits of EKMO support prior to their
(09:07):
first stage single ventrical palliation. Well, the findings of this
work are certainly somewhat sobering, though perhaps not unexpected. Of course,
it's of interest to see that only forty two percent
of these extremely ill inferens are surviving to discharge. There
are two ways to view this group, who without EKMO
would have one hundred percent mortality rate. However, it's clear
that needing EKMO before you even have had palliation is
(09:30):
a bad prognostic sign. I do wonder about the single
vetrical patient who has an intact atrial septum and whether
any of the patients in this cohort had this, and
if they survived, and if there is any signal regarding
outcome in comparison to running to the cathlic for urgent septoplasty,
which is always a frightening proposition. I also wonder how
(09:50):
doctor Capin believes these data can practically help the management
of these patients at the bedside. In the interest of time, therefore,
let's move forward to our conversation with the world first author,
doctor Evanna Capan, joining us now to discuss this week's
work is the first author, Evanna Capin. Doctor Capan is
a pediatric critical care medicine specialist at Northwell Health in
(10:11):
Long Island, New York. She's a graduate of the University
of Limerick Graduate Entry Medical School and she completed her
residency at Staten Island University Hospital. Following this, she performed
a fellowship in Pediatric Critical Care Medicine at the Icon
School of Medicine at Mount Sinai, followed by Pediatric Cardiology
fellowship at the Icon School of Medicine at Mount Sinai.
(10:32):
It is a delight to have my former fellow and friend,
doctor Capin join us this week to discuss her work.
Welcome doctor Capan to PD Heart. I'm here now with
doctor Evanna Capan of Northwell Health. Evanna, thank you very
much for joining us this week on Pdheart.
Speaker 3 (10:45):
Hi, doctor pass, thank you so much for that introduction
and for having me on the podcast as an avid listener.
I'm very excited to be here.
Speaker 2 (10:52):
Thank you very kind of you, you know, Ivana.
Speaker 4 (10:54):
I often will start out these interviews and ask the author,
you know, as the authors conversant with the data of
this work, I wondered if you might, for the audience
be able to briefly summarize what you think are the
three or foemost important observations of your work.
Speaker 3 (11:10):
Yeah, of course, so in terms of our most important observations.
First and foremost, our work suggests overall survival to hospital
discharge for neonates with single ventrical physiology supported with prepaliation
ECHMO remained low about forty two percent, just highlighting how
sick this population remains despite our most extreme efforts. Second,
(11:31):
and not surprising, the duration of ECMO support was a
strong predictor of outcome. Infants who did not survive had
substantially longer ECHMO runs than those who did not. Surprisingly, again,
the need for renal replacement therapy was associated with markedly
higher mortality. And Finally, patients who accumulated multiple complications, especially
bleeding or mechanical issues, also had significantly worse outcomes. Taken together,
(11:55):
these observations highlight just how fragile these pre palliation single
ventricle infants are when they reach the point of meaning ekmo.
Speaker 2 (12:03):
Yeah. Great, really wonderful summary. Thank you very much.
Speaker 4 (12:07):
You know, prior works on echmo and single ventricles seem
to have demonstrated similar survival rates as your more up
to date, more recent work, and I wondered if you
could offer for us some ideas as to why you
think that single ventrical echmo patient survival has not really
substantially improved despite what we know are very substantial improvements
(12:31):
in critical care cardiology delivery in the same time period.
Speaker 3 (12:35):
That's a key point, and our data really echoes what
has been observed historically. I think there are a few
reasons why survival hasn't meaningly meaningfully improved. Survival for single
ventricle patients seeing ekmo has plateaued because the physiology is
just so unforgiving. By the time these patients require echmo,
they almost always have significant multi organ injury, and while
(12:55):
ECMO can't support them, it can't always reverse the damage
that has been done and the underlying instability of their
unique circulations. Advances in care of improved outcomes broadly, but
the narrow subset that ends up on ACHMO remains the sickest,
most high risk group, so their outcomes unfortunately have not
really moved, and in the case of the pre stage
one group specifically, the physiology is even more fragile. These
(13:19):
babies often present with profound shock or cardiac arrest before canulation.
Once they reach the threshold for ECHMO, they've usually already
accumulated severe end organ injury. So for this group, ECHIMO
main fact be a marker of irreversibility, which is why
survival has remained so low. And I'll briefly touch on
threshold for ECHIMO. Threshold for canulation remains variable and center specific,
(13:42):
and while it is often employed after cardiac arrest or
profound shock, that may be too late, and LEE as
a community haven't found that sweet spot just yet. The
challenge truly is balancing the risks of ECHMO against the
high mortality associated with late initiation. All this to say,
despite improvements in technology and care delivery, the physiologic limitations
(14:03):
of single ventrical circulation and the severity of presentation probably
explains why survival really has Plateauedah.
Speaker 2 (14:11):
All very good points.
Speaker 4 (14:12):
You know, I've always said that with these single ventrical patients,
you pretty much get only one shot. And I think
it's the same reason why if the surgery isn't pretty
close to perfect, the patients generally do poorly because there
really is no second chance. And I guess that's true
also with their physiology before surgery as well. And as
I say in my comments, which you haven't heard yet,
(14:34):
one could view this very optimistically. Although forty two percent
survival sounds bad, the reality is that without this support,
I'm sure the survival would be zero. So I guess
it just depends on your perspective. You know, renal replacement therapy,
as you explain to us on ECHMO, and this prepalliative
single ventrical patient population was associated with higher mortality risk,
(14:57):
and I wondered if you might be able to posit
for us why you think this might be. Do you think,
for example, that this is just a surrogate for worst
general body perfusion, or do you think that the renal
injury itself may be the reason and the need for
renal replacement maybe the reason for the increased mortality. And
(15:18):
I wondered if you were able to assess other factors
like the presence of elevation and LFTs, or maybe even
maximal lactate levels and outcomes.
Speaker 3 (15:27):
Yeah, that's a great question. I mean, in our view,
renal replacement therapy is most likely a surrogate marker of
more severe systemic illness. When a prepalliation single ventrical neonate
develops enough renal dysfunction to require dialysis, that almost always
reflects significant global hypoperfusion, inflammation and or multi organ compromise.
(15:47):
That said, the kidney injury itself can also worsen the
trajectory through fluid overload, electroly abnormalities, and challenges with anti coagulation,
so it's probably a combination of both. As for the
other organ injury markers that you commented on, the data
set didn't provide complete enough information to reliably analyze things
like peat lacte, liver enzymes, or detailed fluid overload metrics,
(16:11):
so we can't formally test whether renal injury remains independently
predicted when adjusting for those other parameters. But based on
clinical patterns and prior literature, renal replacement therapy is a
strong marker of overall severity rather than an isolated renal issue.
Speaker 4 (16:27):
Yeah, you know the next question. I don't know if
your data set answers this, but I've always been frightened
of the hypoplast with an intact atrial septum. I think
all interventional cardiologists have a similar feeling about this because
it's one of the most difficult procedures we do, and
it has to be done faster than almost any other procedure,
so it's sort of like a witch's brew of complexity
(16:49):
and difficulty, and traditionally I've always been told that an
intact atrial septum in the hypoplast cannot be palliated with
EKMO prior to septoplasty or state one, and it's associated
even with higher mortality than if you do it the
more quote unquote traditional way of going urgently to the
cath lab for trans catheter relief. I wondered if you
(17:11):
had any data on single ventrical patients who were candidates
for stage one palliation who had an intact atrial septum
and were placed on ACMO, and whether any of those
patients did okay.
Speaker 3 (17:23):
You know, that's a great question, and it's something that
doctor Scott aid in my mentor for this project, and
I've spoken at great lengths and something we're very interested
in addressing and exploring. Unfortunately, at this time we do
not have that data. The registry did not reliably capture
intact atrial septum, so we couldn't identify or analyze a
subset of hypoplastic left heart infants with that specific physiology.
(17:46):
We are aware that historical recommendations suggests EKMO for intact
septum is associated with extremely poor outcomes compared to the
urgent cathter based decompression cohorts, but again, our data set
just wasn't granular enough to speak to that sub group specifically,
So stay tuned, hopefully for the future.
Speaker 4 (18:03):
Yeah, I mean, I guess it's very similar to a THAPVR.
ECHMO doesn't do very much for that either, so I think,
at least for now, we're still stuck having to do
what we do, which is to get that septim open
as fast as possible without the need of support. Well,
for those in the audience, doctor Capan was kind enough
to give us time today in a busy afternoon. She's
(18:24):
also a very busy mom as well, so I don't
even know how she handles all of that. So I'm
going to finish up with the last question and I
wondered if you believe there are any takeaways from your
work that might help inform or improve the care of
patients on ECHMO in this very difficult, horrible situation. Do
you feel that the impact of this work is mostly
(18:46):
in providing prognostic data to families, or do you think
that there may be some medical management impact from your
work as well.
Speaker 3 (18:53):
I think there are really two main takeaways from this
research project, the first being prognostic clarity. This data suggests
and helps US council families more transparently and honestly both
about the overall survival likelihood and the significance of things
such as prolonged ECHMO runs, renal replacement therapy, or accumulating complications.
(19:14):
The second being clinical management implications. While the study doesn't
specifically test certain interventions, the associations suggest a key priorities.
Speaker 2 (19:22):
I think we have to.
Speaker 3 (19:23):
Identify and support and organ function early, especially avoiding fluid
overload states, and with that consider earlier escalation or intervention
before multi organ injury accumulates. So while much of the
impact in the study is in realistic prognostication, I do
think there are actionable insights that may refine how we
manage this very high risk group going forward. With that
(19:45):
being said, more work has to be done in the
area of the decompensating single ventricle requiring echmo prepalliation, because,
as we discussed earlier, outcomes have very much plateaued.
Speaker 2 (19:56):
Well excellent points.
Speaker 4 (19:58):
Well, Ivon, I want to find thank you very much
for taking time from your busy schedule to speak with
us this week on the podcast. I want to congratulate
you doctor Aiden and all the multiple authors, and.
Speaker 2 (20:10):
Thank you so much for coming on the podcast this week.
Thank you, doctor Paz, Thank you well.
Speaker 4 (20:14):
As I'm apt to say, when the guest is good,
there's really not much to say, and I think you'll
agree with me that doctor Capin was uncommonly clear in
her many comments and I'm thrilled once again to have
an up and coming superstar on the podcast. As we spoke,
I really came to better understand the value of this
work and to use her terminology the value it offers
(20:35):
us in so called prognostic clarity when speaking with families.
This concept of prognostic clarity is something that fetal cardiologists
wrestle with all the time while advising parents, but being
able to guide families through these critical and challenging times.
Is similarly very important for critical care physicians, and I
(20:56):
do believe that doctor Capan's work will provide meaningful information
that families and providers can use together through shared decision
making to make the right decision for an individual patients
and family. Once again, I'd like to thank doctor Capan
for taking time from her schedule to speak with us
this week on Pdheart. At this point in the podcast,
(21:16):
when I would normally go to the music, I realized
that it is actually sadly four years since we lost
my dear friend, doctor Giorgio Furia Momfo, who was the
director of pediatric Critical Care here at my own institution,
Mount Sinai and full Professor of Pediatrics at the Icon
School of Medicine at Mount Sinai. For those of you interested,
I did an entire tribute episode one hundred and ninety
(21:39):
two four years ago on doctor Alforia Momfo, and I
would certainly recommend anyone interested in learning about a real hero,
a wonderful guy, take a listen to that episode. Given
that it is four years, given that doctor Olforia Momfo
is actually a co author on this paper, and given
that the senior author is doctor Scott Iden, who was
(21:59):
a dear friend and mentee of doctor Alforia Momfo. I
thought it would be nice to briefly speak with Scott
about doctor Alforia Momfo, his role in this project, and
to just reflect on.
Speaker 5 (22:10):
Our good friend George.
Speaker 1 (22:12):
Doctor Scott Iiden needs no introduction, as he is a
well known figure in the fields of pediatric cardiac critical care.
He is Associate Professor of Pediatrics at the Icon School
of Medicine at Mount Sinai, where he is the director
of the Pediatric cardioc Critical Care Unit here at Cravis
Children's Hospital at Mount Sinai. It is a delight to
welcome back my friends and colleague doctor Iden to Pdheart.
(22:33):
Welcome Scott to Pdhart.
Speaker 4 (22:35):
I'm here now with doctor Scott Iden, who's the senior
author of this week's paper. Scott, given that it's almost
exactly four years since we lost our dear friend George,
I thought I would mention him with you today and
remember him a little bit. So thank you and welcome
to Pdhart. Thanks Robert, you know it's a pleasure to
join you.
Speaker 6 (22:54):
I think this will be my second time on the podcast,
so it's always a.
Speaker 4 (23:00):
Thank you, well after actually I think it's the third
and it's but it's been eight years that the podcast
is goix there you go. Well, you know, I noticed,
obviously when I was reading this paper, the first thing
that jumped out to me, other than that you are
the senior author, is who the second author is, which
is our very dear friend, Georgio Furia Momfa.
Speaker 2 (23:21):
I was wondering, how did George.
Speaker 4 (23:24):
My understanding is he was central to the development of
this paper's concept. Maybe you could share with us how
how what his role was and the genesis of this
work that we're reviewing this week.
Speaker 6 (23:36):
Sure, you know George, as you know, George's was a
ideas guy and you know, at our previous institution where
we were you know, colleagues, and he was you know,
you know obviously my mentor there. And you know, we
had you know, a couple of patients that kind of
fitted into this category. And as you know, George would
(23:58):
always do, is you know, you start to you know,
talk about you know, you know, what the literature says
and what the data shows and the lack thereof in
this particular population of patients that you know, get supported
on EKMO, and you know, he kind of just you know,
says to you know, the junior folks and the fellas,
(24:18):
you know, we should look at this, We should you know,
take a look at this. See if there's data out there,
see what we can learn from this. And so, you know,
that was really his his role was kind of you know,
pushing us, you know, junior folks who was myself and
one of my other colleagues at the time, Christy Glotzbach
who we were junior attendings, and he kind of you know,
(24:42):
encouraged us to look at that. And then you know,
unfortunately the situation happened where you know, both George and
I moved institutions, and so that project, you know, went
on the back burner and then here, you know, we
kind of re reinvigorated it and decided to a look
at it. And you know what I learned from George was,
(25:03):
you know, passed the opportunities on to junior faculty fellows
and that was how we were, you know, kind of
suggested it to one of our fellows to take it
on and go with it. Well, that's a.
Speaker 4 (25:17):
Wonderful story, George inspiring us even years after his passing.
It's really nice to hear that. You know, Scott, I
know you're one of his very dearest friends, and certainly
I think one of his prime mentees. And I was wondering,
you know, it's at the end of this month, it's
going to be four years.
Speaker 2 (25:37):
That we lost George. Really unbelievable. It seems like yesterday.
Speaker 4 (25:42):
And I'm thinking, you know, thinking back on all your many, many,
many interactions with George, I'm wondering, you know, what is
it that stands out as you now that we have
a little bit of time, a little bit of perspective,
what do you what do you think back on George
and say, you know, this is really what why I
so love the guy.
Speaker 6 (26:02):
Yeah, I think more than anything, he was just just
a good friend, uh, you know, more than you know,
a mentor and someone that would you know, take the
time to teach and you know, try to impart his
experience and wisdom. He was ultimately just a good friend.
And and you know, what I've come to learn is
(26:25):
that there really isn't a person that has come into
contact with George that didn't feel the warmth and his
kindness and his willingness to to help and and and
lend his time to people, and even if he only
met you for you know, a few hours at a conference,
next time you interact with him, it would be like,
(26:46):
you know, you were long lost friends and you know,
catching up. And I think that type of warmth is
is you know, you don't find that every everywhere. And
you know that's one of the things that I've I've
learned of him is to maintain those connections, those relationships
and and you know I learned that from from George
(27:08):
almost you know a lot of other things.
Speaker 4 (27:10):
Yeah, yeah, that's that certainly rings true, Scott and I
I just when I think back so many great things
about George. But I was thinking about this myself this morning,
and I think probably the thing I missed the most
and remember the most was how funny George was. And
he had a great sense of humor that you know,
(27:31):
you could you could make fun of him, and he'd make.
Speaker 2 (27:34):
Fun of you. And I was just a load of fun.
Speaker 4 (27:37):
I remember, you know, when he was a cardiology fellow
at he and his co fellows doctor ashwind Prakash, doctor
Jared Lecord, and I was not a fellow anymore as
an attending, but we were all roughly the same agent
we would go work out in the gym, and he
was so proud of the fact that he was the
gym member of the month. Yelled at old for me
(28:00):
for years, and it always seemed that he worked out
the least of all.
Speaker 2 (28:04):
Of us, but always seemed to be in the best
physical shape. But he always he enjoyed, He enjoyed making
me aware of that as often as he could.
Speaker 6 (28:12):
It's just that's that's definitely George. And you know, he
always had his you know, dumbbells in his office, and
you know, I always, you know, tease him. You know,
I've never you know, I never saw him lift those
at all. You know, you know, I work out when
I'm on call, and you know, i'd always you know, yes,
call bs on that, you know.
Speaker 2 (28:32):
But it's funny. I did the exact same thing.
Speaker 4 (28:35):
He had these extremely heavy tumbbells, and I would always
say that there's no way you lift those things. He's like, oh, yes,
I do, But he was I think he was kidding.
Helped his image, I guess. Well, Scott, I really appreciate
your spending a few moments with us to remember our
dear friend. For those of you in the audience who
may not have had the great luck and pleasure of
(28:56):
having known doctor o'fori, or for those of you who
remember for him as fondly as we do, and I
know most who knew him do feel the same way.
I would certainly recommend you take a listen to episode
one hundred and ninety two from just at the very
beginning of twenty twenty two, in January of twenty twenty two,
in which we have a whole hodgepodge of many, many
people who knew and loved doctor Afori. You can share
(29:20):
his story with us. Scott, thank you very much, and
once again I want to congratulate you and all of
your co investigators on a really terrific paper.
Speaker 6 (29:27):
Well, I appreciate it. Rob thanks for having me on pleasure.
Speaker 1 (29:31):
To conclude this three hundred and sixty fourth episode of
ped Hart Pediatric Cardiology. Today we hear the wonderful rising
Bolivian Albanian soprano Carolina Lopez Moreno singing the heartbreaking duet
from the final act of Buccini's l'arndine with the great
American tenor Michael Fabiano and alive rehearsal of the opera
(29:51):
from a few years ago. In this duet, Malcta leaves
her great love Ruguero in order to save him. The
love between these two is pal poole and this duet
sung so winningly by Lopez, Moreno and Fabiano. Thank you
once more for joining me for this week's podcast, and
thanks once again to doctor Capan.
Speaker 5 (30:10):
I hope I'll have a good week ahead.
Speaker 7 (31:00):
On the hop.
Speaker 8 (31:26):
So to speedy, deep steps and.
Speaker 6 (32:03):
S.
Speaker 7 (32:04):
Didn't coming up your sloping hole?
Speaker 9 (32:10):
Clon the son recorded.
Speaker 8 (32:25):
Did din?
Speaker 7 (32:46):
Was it say.
Speaker 9 (32:54):
Beauty plain? Knowing you?
Speaker 8 (33:01):
He loved your big
Speaker 7 (33:21):
He said
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