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#072 - Dr. Patick McNamara MB BCH

McNamara Neoheart The Incubator Podcast

Hello Friends 👋

We are kicking off our coverage of NeoHeart 2022 🥳 We could not be happier to bring you some of the amazing speakers that will be presenting their work at this year's conference. We are starting our coverage with one of the pioneers in neonatal hemodynamics and world-renowned neonatologist: Dr. Patrick McNamara. Our coverage will continue for the duration of the conference and include 2-3 guests a day. Episodes will be shorter than usual (˜20mins) and will be available for free on the main incubator podcast. Enjoy! 🫀


Here are some of the links/papers we talked about with Dr. McNamara:


Short bio: Patrick McNamara graduated from Queens University Belfast in 1987, received his MRCPCH in Pediatrics in 1997 and Certificate of Completion of Specialist Training in Neonatal Medicine in 2002. He is currently a Staff Neonatologist, Director of the Division of Neonatology and Vice Chair for Inpatient Acute Care at the University of Iowa Stead Family Children’s Hospital, and Professor of Pediatrics and Internal Medicine, University of Iowa. He is the current chair of the PanAmerican Hemodynamic Collaborative and Paediatric Academic Society Neonatal Hemodynamics Advisory. His clinical and research interests include myocardial performance in the settings of a hemodynamically significant ductus arteriosus, pulmonary hypertension and targeted neonatal echocardiography.


The transcript of today's episode can be found below 👇

Ben 0:54

Welcome, not excited. Hello, everybody. Welcome back to the podcast. This is the first episode of this special series of podcast recordings covering this year's Neo Hart conference that is taking place from August 3 to August 6 In California, more specifically, Disneyland, California. Sorry about that. Governor, how's it going?

Daphna 1:27

I didn't know if you were going to ask me or you had more things to say. But we have so been looking forward to this series, haven't we? You know, it having this opportunity to cover a conference has been really exciting for us. And the fact that we'll be able to bring a little bit of the conference to people who, you know, aren't able to attend, I think is a really cool. And the the days are jam packed. So if people are listening to this one, and you and you haven't, you could still get a virtual registration. There's a lot.

Ben 2:00

Yeah, so there's the virtual registration. And why why are we doing this? Because obviously, first of all, we have no no ties to the new Heart Conference. This is just a partnership that, again, we thought could work because of, of our personal frustrations with conferences. So what do I mean by that? There's many conferences. So I don't we personally, I'm going to talk on behalf of myself here. And we're going to talk for myself, but I don't get the opportunity to go to every conference I want to go to during the year. And so you make you make a decision. And you you accept say I'm not going to go to this one this year. And then when the conference is ongoing, you still have this, this this anguished joke, oh, man, I wish I was there. I wish I could listen to what they're talking about. And then, and then you you scour Twitter and you like comment, maybe somebody will post like a little picture of one of the slides, and I'll get a little glimpse as to what they were saying. And even if I have access to the virtual, it's hard. Because let's be honest, if if I had the time to sit and watch the virtual stuff right now, then I would have been at the conference. So then you defer, because you say I have time later. And then we all know this. Yeah, we procrastinate. We never get it done. And so we were thinking, what if we could give you like a little bite size twice a day, you can get an episode in the morning on your way to work one on your way back from work and you get like 30 minutes, we highlight one presentation, something that or speaker that is that is quite special. And then you get something right, it will feel so good. And obviously we're going to not be we're not going to have the pretension that our episodes are going to be fully representative of the conference. They will not and we've picked our our guests for this coverage based on the fact that we are in neonatology podcast. So we haven't been we're not going to be speaking to a cardiothoracic surgeon about the latest, the latest material techniques, the latest material that they're using for baffles in VSD. But But, but we're hoping that this is going to provide some value to you guys. We want to thank the new Heart Conference, Amir Ashrafi, for being super forthcoming. They basically we pitched the idea to them, and they were like, Let's do it. And they gave us access to their guests list. They gave us access to the presentations that these guests have given us access to their presentation so that we could give you more content and not just like general questions and stuff like that. So it's all very exciting. And we thought we should kick off this series with with a bank correct Daphna so, so our guest

Daphna 4:45

was gonna say we're, you know, we don't we don't like, you know, pat ourselves on the back that often but I'm super proud of this lineup and I'm so grateful that people were so gracious with their time, you know, because that's a busy time and you know, right before the conference or during the conference, so, but we have had quite quite a number of superstars this week don't

Ben 5:10

quite a number of superstars. You're absolutely right. I mean, thank you to Amira Shafi again, and to our partner, Rooney, Tom's who is involved with a new heart conference and neonatal heart society, and helped us actually pick the people that he knew would be the best for our audience and for the current topics. So there's going to be some discussions about the PDA, obviously. And so it's fun. And and we could not be more proud of kicking this off with with our first guest this this week. Dr. Patrick McNamara. And this was a an episode with that was requested by so many of you people have been emailing us saying, Hey, when are you having Dr. McNamara on. And we were in the planning phases for it. And then when this opportunity came around, we're like, oh, this is the perfect venue to feature him on the show. And if you do not know who Dr. McNamara is, well, he graduated from medical school in 1987. He did his pediatrics and neonatal medicine that he completed in 2002. He is currently a staff neonatologist, Director of the Division of neonatology and vice chair for inpatient acute care at the University of Iowa stead Family Children's Hospital, and he is a professor of pediatrics and internal medicine for the University of Iowa. He is the current chair of the Pan American hemodynamic collaborative, and the pediatric academic society in neonatal neonatal hemodynamics advisory. His clinical interests are very than they include myocardial performance in the setting of hemodynamically significant ductus, they include pulmonary hypertension, targeted neonatal echocardiography has been one of the pioneers in the introduction of targeted neonatal echo in the NICU hemodynamics. The hemodynamics fellowship that he's that he's pioneered at the University of Iowa is world renowned. And so yeah, we could not be more proud to welcome to the show, Dr. Patrick McNamara. Dr. McNamara, welcome. Thank you for being on the other podcast and how are you?

Patrick McNamara 7:15

I'm not bad. I just got back from Europe at a two week vacation Ireland, and it didn't rain, can you believe can be 95 degrees, so beautiful.

Ben 7:28

Originating from Ireland is that happy thing or disappointing? Instance?

Patrick McNamara 7:34

It's very happy thing. I'm very I'm very proud. I wouldn't want to be born anywhere else in the world. Very good.

Ben 7:40

Very good. So we're very happy to have you on you. You will be speaking at the new Heart Conference this year. I think you have two sessions scheduled one of them on August 4, where you're going to talk about targeted neonatal echocardiography, scientific urine review, where you talk a little bit about haemodynamics point of care, ultrasound. And then again on Saturday, August 6, where you talk about your your talk is titled The pragmatic approach to PDA closure. So we wanted to talk to you a little bit about these two presentations, and maybe start off with your presentation on hemodynamics and point of care ultrasound. And can you in your presentation, you mentioned the origins of hemodynamics. And I think for a lot of people, it may feel like this is brand new. This started a few years ago, when in truth it has, it has quite a history already. Can you can you tell us a little bit about that?

Patrick McNamara 8:37

Yeah, so I think the the hemodynamics is not something new, okay. cardiovascular physiology is something that has been recognized to be important for a long period of time. The problem is our ability to decipher very clearly at the bedside, what mechanistically is going on with the patient was our limitation and that lend itself to a very blood pressure centric approach, making blood pressure, almost like a disease, as opposed to what it should be a symptom, one symptom of cardiovascular well being and, you know, we need to really thank Nick Evans, who was a British neonatologist to move to Australia had the skill of echocardiography and reported in 2000s, that up to 40% of NICUs in Australia, and we're performing bedside ultrasound bedside echocardiography to try and help enhance patient care. But the first real message from Nick's group was that we need to think about blood flow, not just blood pressure, but also think about blood flow. The next phase of evolution of the field came over the next five to 10 years and I In around the same time, I had been completing a two year ACO fellowship at SickKids in Toronto, and really started to appreciate that, yes, we recognize the blood pressure isn't enough blood flow is important. But even more important than that is what is the underlying pathophysiology. If we're to provide the best care to our babies, a symptom based approach is probably superficial. And we need to evolve to an approach based on you know, what is the underlying disease, you know, and recently, I kind of gave a talk at PHS of the Luck Club and drew the analogy to a mechanic, you take your car, it's, it's something is wrong, the edge is not working well, who would accept the mechanic just lifting the hood? Taking a superficial look and him saying the engine needs to be replaced? You're gonna say, No, I didn't know. Specifically, what's wrong? Okay. Is it the catalytic converter? Is it I again, I'm not a mechanic, that that level of precision diagnostically is important. And then when you go to that critically, Ill baby or critically ill premature baby, you know, how can we accept something so superficial? And, you know, pediatric cardiology is a very important field. And the work that they do is critically important, but the focus is different. The focus of hemodynamics is on physiology, and integrating physiology within the clinical context at the bedside. And, you know, that's what hemodynamics is. And it's super, super exciting. And certainly, you know, Neil heart has been an incredible partner in getting the message across that, you know, we as neonatologist really appreciate the importance of the heart. It's not just about anatomic heart disease, but there are many, many conditions that those babies carry just as sick if not sicker. And we need to be able to provide a higher level of care with more precision and so forth.

Ben 12:19

Yeah, it does. And I think you're right in saying that it's very exciting. I think a lot of the community shares this excitement about point of care, ultrasound and hemodynamics. And then then the question has to be asked, I mean, there's going to be a new generation, hopefully, that's going to come into the field that will get the opportunity to get adequate training. But how do we bring up to speed all the different unit ologists that are currently working that did not get the benefit of training during their training years? You mentioned in your presentation that 92% of division chiefs expressed interest in building hemodynamics program? So in your opinion, it's very, it's probably an extra it's probably a hard question. But what does that change? How does that change? What does that change look like? When when we get to disseminate hemodynamics and point of care, ultrasound throughout the country throughout the globe, and training people adequately?

Patrick McNamara 13:12

So I think the first thing that I that's important to say is that there is no race. Okay. I think the most important thing is that as you introduce imaging into the NICU, making sure that the individuals that are performing the assessments have the appropriate, not just imaging skill, but cognitive skills to understand how to integrate that physiologic information within the clinical context. And it's not easy, I can tell you, you know, some of our trainees that at the end of the year of human annex training, may have done 500 scans, and they still have questions about the physiology. And, you know, certainly in Canada when we built this, it was a thoughtful, slow progression, in which you start off with expert individuals and work collaboratively with pediatric cardiology to build a very synergistic program. And I think that's crucially important, you know, now, our extended group is affiliated with the American Society of eco as a specialty interest group. And what that has done is it has Rosch you know, a lot of recognition to the work that we do, not just the clinical work, but the scientific work and a real acknowledgement within the pediatric echocardiography field that this is important. And actually neonatologists we shouldn't be threatened by that. We should be working with them in a very supportive way to ensure that when programs are started off, it's done in a very, very symbiotic manner. So it really comes down to one, the extent of the training, to the indications specifically, and making sure that those two things align very, very clearly one can build a is a strong program. If you were to ask me, Should every neonatologist have comprehensive echo skills? The answer is no. And the reason it's no is because no one will be able to maintain competence. Ah, I think there are certain indications for hemodynamics, or certain indications for point of care ultrasound. And within point of care, ultrasound, I think that's where extended training to all intelligence, I think will become very, very important. But if we're thinking about the conditions, the complex sick patients with Palmer hypertension, and so forth, you know, if we are to build that bridge with cardiology, I think, recognizing that those patients need someone with hemodynamic expertise. Now, there may be then situations where an individual a point of care ultrasound skills can follow those patients and reevaluate and so forth. But I think that, you know, each program needs to ensure that for the specific indications and problems that you are using imaging, that the practitioners that have that skill, maintain competence, which means a critical value of exposure to those assessments. And I think if you get that, right, I think this is going to be highly, highly beneficial to neonatology. And I think the that's, that's the spirit that also will underline the next iteration of the guidelines for targeted neonatal echocardiography that we're currently working on. And just to share to the audience, you know, when, when we put the guidelines together in 2011, it was a very different era. The authors were 80%, pediatric cardiologists, 20%. And apologists. The next iteration of the guidelines are going to be 80% and autologous. And the training is going to Dr. nosh a very anatomic focus, but we need to have guidelines that trained people to assess Palmer hypertension to assess PDA, that's what should drive the education. As opposed to you must spend X number of months in an echo lab. You know, the other pieces were at a very different timeframe where there are lots of programs that have neonatologist with a lot of expertise. And in those programs, perhaps the amount of time that you need to go to the actual lab may not need to be six months, you may just need to go for one month to do a congenital heart disease rotation and so forth. So I think, you know, we got a lot of criticism that those guidelines are very applicable to North America. But we need to recognize that the rest of the world looks at as, as important. And if you're in the UK, if you're in France or in Germany, every NICU doesn't have an Ecolab, so then you're handcuffing people in terms of training and so forth. So with that spirit, I think those guidelines are going to be much more generalizable and beneficial to the to the broader community.

Ben 18:25

And we will post the link to the guidelines from the 2011 guidelines. That is the one that you're mentioning. And I think it could be confusing for neonatologist because these guidelines were published in the Journal of American Society for echocardiography and not in like pediatrics or, or general. And, but but they are but they are readily available. I think you described in your presentation, I think the difference in what we're trying to do from the neonatologist standpoint and hemodynamics in cardiology, I think there's a few aspects of of the work that needs to be done that doesn't completely overlap with what cardiologists are currently doing. And I think that involves both the hemodynamics assessment, which is not frequently something that the cardiologist get called for usually want to know structural heart disease, and also the freak and also the frequency. I think that's also something that where there's a lot of room for for us not to to really step on the toes of our cardiologist because you have shown through your work at the University of Iowa, that repeated measurements, focusing in with a focus on hemodynamics can help you understand the hemodynamics of the patient. And that's something that the cardiologists were never doing before and are probably not interested in being called to the NICU to echo every 12 Or every 18 hours to check on the hemodynamics. So why do you think that that's possibility that that could that's the way that we're going to be able to create a symbiosis between us and our consultants? Yeah,

Patrick McNamara 19:47

I think you know, number one, it's very difficult as a consultant service, to look at images and try to interpret them In the context of the baby, when you don't know what's going on with ventilation with fluid balance, electrolytes and all that stuff, and for that reason, a lot of physiologic base measurements really haven't gained a lot of favor within the world of pediatric cardiology, it's hard to interpret them. We build our protocols, they're very standardized, they have multiple parameters that tell you the same thing. And that's based on the recognition that, you know, all measurements have some variants, some reliability issues. But a multi parametric approach will help you be more certain that this is this is a problem. Of course, that remote model will work very well for anatomy, because the anatomy at nine o'clock in the morning will be the same at 10 o'clock at night and three o'clock the next day. But the physiology changes dynamically. And I think we have learned that and particularly in the transitional period, especially for extremely preterm babies, you know, we've some babies, we've seen some babies where their physiology changes three or four times over a 12 hour period. And at the bedside clinically, all you may notice are subtle changes in FY Oh, two and blood pressure and base deficit. But you may need to make changes. And if you don't have that correct information, you know, we shouldn't be surprised. And when we look at all of our trials, look at all of our observational data be surprised why our current approach to treatment, whether it's blood pressure, PDA, makes no difference, because we're really not measuring with precision, what we need to measure. The other point I wanted to make, which I think is really, really important, and I will just briefly mentioned this at the presentation at the heart. One of the I think probably most important publications in the last couple of years was in bishops' GS publication, looking at the experience of neonatologist performing the first echo that was highly controversial. At the time of the guidelines that no we will almost always be pediatric cardiologists because these babies have such a high risk of congenital heart disease. The message from Adrian's publication where in life, I think, like seven 800 patients, if you choose correctly, the vast majority of those patients don't have congenital heart disease. Okay, so the the numbers of those babies based on our indications was very low. But in those that did have congenital heart disease, that concordance was high.

Ben 22:35

I was I'm happy you meant I'm happy. You mentioned that because the slide is great. I was so shocked by the number, right? You point out in the slide that the concordance is not only high, it's like 98%.

Patrick McNamara 22:45

So I think I think that is crucial, because if you look at the guidelines, the role of the neonatologist is not necessarily to just to decipher with extreme precision, what that diagnosis is to recognize that the anatomy is abnormal. And what that paper basically showed was that, you know, we are not going beyond our scope. We're not intentionally scanning all these patients with congenital heart disease where that clinical suspicion is high. We're scanning patients who we think have physiologic problems. However, if we do stumble across a patient that does have anatomic heart disease, we recognize it. And we're able to recognize with extreme precision, you know, as recent I just came from one Amex review and just reviewed a baby that Regan, Geisinger just scanned this afternoon presented with kind of not that sick but borderline SATs and so forth. And the baby had TGA diagnosis invited in otologist, we call cardiology that confirmed the diagnosis, no need for any repeat images. The system works well. As long as you have that close collaboration. I think that's really, really important where neonatologist are doing imaging that they don't do it in isolation, that they build that bridge to pediatric cardiology. So there's transparency, quality assurance, and it's a team working together. And I think if you do that, we have nothing to be afraid of. Yeah. Well,

Daphna 24:13

I was just thinking, you've been alluding to this collaboration with cardiology, and that is just I think one of the amazing messages about Neil heart about how, you know, instead of each working in our own, like we say silos, how important for patient outcomes are collaboration between all of the different disciplines are and, you know, for a group hospital who's trying to start a program, you know, how can they show their value as the as the Neo group because, you know, the, the Neo team has something to offer the collaboration as well.

Patrick McNamara 24:53

Yeah, I think it gets back to what what, you know, Ben was was mentioning you know, There is a lot of fear in the pediatric cardiology community that and that's based on experiences with other professional groups that people with limited skill, doing assessments in patients with complex physiology are a high risk of heart disease are going to get themselves into trouble. And my experience in speaking to pediatric lab leads across the United States is when they recognize that, you know, these are highly trained people that have completed a significant amount of image training. You know, just to give you an idea, Daphne, the, you know, within our, within our one year fellowship, you know, these trainees may complete five 600 ankles, in a typical pediatric cardiology fellowship, you might only do 150 to 200 echos in a three year period. So, that is very reassuring. And I think, you know, in places trying to embrace this, I think that demonstration of rigor is crucial at the beginning. And I think once you get to the point whereby you have a strong foundation, then looking at phase two, which is, you know, you've got, you know, maybe two or three neonatologist with a lot of training, then how do you then build a bigger program whereby overnight or on weekends, other neonatologist that have some point of care ultrasound scanning, that may do some cardiac focus that can be integrated into the model, I think, I think that's the, the way in, which is most likely to be successful to have the most endorsement by pediatric cardiology.

Ben 26:51

In your presentation, you mentioned the number of publications, I was quite shocked by the fact that you bring up the number of 800 peer reviewed publication in the past 10 years, and you show the PubMed search for neonatal hemodynamics, from trained faculty, and there's this exponential growth in funding as well. Can you talk a little bit about the momentum that this has gathered? And when you hear 800 peer reviewed publication, it feels very significant. Do you think there's a lot more work coming down the pipe? And and if so, what are the priorities of the work that needs to be done in neonatal hemodynamics?

Patrick McNamara 27:31

Yeah, so that's that, that's a really important question. And again, it just gets back to the concept of the expert model. You know, I look it over the same time period. And I look at the number of people that have been trained in North America and between Canada and the United States and Mexico, over the same time period. In Australia, where individuals do push and perform ultrasound, it's a shorter training period. The two differences are that, although we have probably trained half of the people, everybody is still doing it. 100% of the people are still practicing. And more importantly, when I look at, who are the next generation of leaders that have come out of the field, I can list name after name after name in Canada, in the United States, you know, I don't want to leave anybody out. I'm not going to mention any names, oodles and oodles of people that they know who they are, that are the people that are publishing. And I think that brings significant credibility to the field. And I think that's, that's what's important. You know, we own hemodynamics. Okay, neonatology is driving this. And I think that's really, really important to recognize. And, as I said, you know, probably that, you know, two of the things that I'm most proud of in our own program here are number one, it has become a mandatory rotation for our pediatric cardiology fellows to spend time with us in hemodynamics. And secondly, one of our cardiologists who got recruited to be a division chief at another program in the US before he left said, Patrick, I need to build a human Amyx program. In my new program, you need to help me find someone to do that. Like that. That's, that tells you something that if you invest in building your program, well, not only is it valuable to the ontology was actually valuable to pediatric cardiology. And we got to work with cardiology, because with learning an advanced imaging, learning some of the newer technologies and like an ace now we have the opportunity to also work with industry to say, you know, we need higher frequency probes for extremely preterm babies. We need different ways of automating some of the imaging techniques we use you You know, that's, that's really important and it's super cool that people are recognizing that.

Ben 30:06

And it's exciting because it mirrors a little bit the path that neonatology has taken in throughout history. When you look at ventilators, for example, where we used to use more adult ventilators and eventually the tech adapted to the neonate. And today, we are able to provide ventilation options to neonates that are far superior than what was on before. So it's very exciting to know that the same path is being forged forward by the hemodynamics.

Patrick McNamara 30:31

I think I think that the other key piece here and this is slightly a tangent, but I got to say it anyway. neutrality has to be evolved. Today of that everybody is the same and everyone is a generalist that knows everything. Yes, we no need to know everything. But if we are to get better, you need to have sub specialists. And in addition, if we are to compete with all our other specialties, you know, now with neonatal hemodynamics individuals who may be before were torn between neonatology, pediatric cardiology, cardiac, ICU, et cetera, cetera, et Cie, Oh, I love the heart. I love intensive care. I could do hemodynamics. So I was,

Ben 31:12

I was one of these fellas, you're speaking? Yeah.

Patrick McNamara 31:16

And it's for that we have to, you know, we've learned the same thing through neonatal neuro intensive care, you know, your care is driving, you know, you have to have experts in that, so forth. So.

Ben 31:27

So before we move on to your your talk about the PDA, you mentioned, so many great resources in your presentation at Neil heart. I wanted to start you mentioned the website, obviously, neonatal hemodynamics that come? And and this is so good. Can you tell the audience who may not be aware of the website at all what they can find? And what are the resources available on the website?

Patrick McNamara 31:49

Yeah, so So I think, you know, there's been a lot of investment in, you know, how do we maximize the interface with people across the world? Before I talk about neonatal, I think it's important to let people know there are apps, there's a T and echo app available for people, there is the T and echo website, which again, gives a lot of instruction in how to acquire images. But neonatal was was actually the brainchild of avesh Chang, who's an intelligence to Montana Hospital in Toronto. And he remember the day he said to me, you know, we need to, you know, become virtual, we need to have a stronger interface with people, you know, all over the world. The What was our starting point was, we have trainees in different centers, but they're only exposed to the neonatologist in their center, and can we come up with this concept of a virtual fellowship program? That's kind of what it is whereby neonatal trainees engaged either in hemodynamics research, or doing formal human omics training meese regularly, under an education guys, almost like an academic half day, and we do this, we do this every month. And in addition to this, this virtual platform has developed a research arm. It's developed a clinical guidelines arm. So we're looking at how can we come forward with statements or guidelines for different aspects, the group just published in the journal parent ontology, the guidelines for the approach to hypoxemic, respiratory failure in term neonates. And then finally, cultivating collaborative research. You know, so we have an academic group that is starting to look at, you know, how can we, you know, help people. So, for example, if you're in your center, and you want to do human annex research, and you have a faculty, maybe they're a human Amyx person, maybe they're not. The first time you get expert hemodynamics review is when you submit your journal, your paper for review. And we need to evolve from that. Because if you don't do things, well, why are we waiting for your paper to be rejected? How nice would it be to have a mechanism whereby someone could present their project, present a grant to an expert panel that can give them feedback? You know, and I think a day will come it won't be needed, where there's lots of problems with lots of individuals, but for now, those trainees need people to help them they need the educational interface. They need an academic interface. So that's what neonatal As you know, the website shows according to region who are the programs that humanics programs who are the researchers are people doing it has educational sources and so forth. And that is also linked to our Pan American economics webinars, we have quarterly webinars for everybody, which across a broad range of topics and so forth. And actually, you know, I designed those webinars based on your heart, I was so impressed at what kind of Amir and John did with that concept of panels and more than one speaker and moving towards more discussion and less didactic, and we've taken that format and tried to replicate it. And, you know, it's, you know, when you have a person give a talk, and the talk ends in an hour and the people on the webinar saying, keep going, you know, you're, well,

Ben 35:45

that's good. We're gonna say something,

Rune 35:49

I just want to just say, Patrick, again, very eloquent description of hemodynamics. And it's really interesting also, to hear that somewhat of the history, and how you tie in the importance of kind of the slow progress that you've made, and slowly kind of advanced it. And also the whole concept of understanding physiology and the various diseases, the neonatal diseases, and I think it's very much a tribute to you, I would say, and the team that you built around you, with a collaborative spirit, which really has made it a success, mostly, I guess, in the US and Canada, and then in Europe, but so I just wanted to say that, first of all, and it also ties into nicely into the new art, like you said, again, this tearing down these silos, which is always kind of something we say. And in doing this collaboration, one quick question as a, as a finish. My comment was, you know, explain to the listeners a little bit also how hemodynamics can be newer protection, how it can be renal protection, and also maybe intestinal protection and such.

Patrick McNamara 37:02

That's a great question. And before I answer the question, Rooney, I want to, I want to say, you know, you know, kind of, I'm the facilitator, okay. The people that have come astounded me, they just astound me, you know, I think, you know, I think we built a strong foundation. But I know I can retire today. And this is going to continue, there are so many wonderful, wonderful people. And to be honest, the the individuals that have ended up applying for fellowships, and being trained and so forth, they're the cream of the crop. They're just superstars. And I think that lends itself very well, you know, for the future of the field, and so forth. So, thank you. I appreciate the nice comments, but I'm just just one person amongst an amazing group of people. Your second comment about kind of neuroprotective and organ protective and I think that that, that that that is crucially important because for too long, we have focused on organs in isolation. So people who are interested in he focused on the brand and the brand, researchers look at the brain, people interested in the lung look at the lung, and we really are starting to recognize that there are many modulators of end organ damage outside of the specific organ that we need to think about. And probably one of the best examples I can give you is Regan, Kissinger's work on RV dysfunction and modulating potentially neurological outcomes in infants with HIV despite cooling, we don't yet know how best to manage that. But certainly, what we do know is that there's an important signals, they're independent of the severity of Hae, that you need to recognize that the RV is dysfunctional, and probably earlier, recognition and better management is probably going to be better for for the brain. Plus also, guiding the rewarming process, I think is also going to be crucial from that perspective. But in managing and protecting the brand of extremely preterm babies, you know, we just presented our work at PHS on the impact of screening all extremely preterm babies with that goal between 12 and 18 hours in a program in Iowa that already has exceptional outcomes. We have a 60% survival at 22 weeks 80% or 23 weeks. And what we've been able to demonstrate is adding he wouldn't mix into that our ivh rate has been halved. We almost have abolished neck, like we had in the PDA treated population. And again, these babies under 27 weeks 40% to them are 22 and 23 weeks 40%? One baby head neck out of 150. Like that. That's just it's astounding. You know, this is not a randomized controlled trial. But what it is, it's the introduction of a program, which is exactly doing what Rooney said, how can we better manage the hemodynamics to protect the brain to prevent babies having major swings in physiology, major swings in kind of end organ, kind of abnormalities and metabolism and so forth. These are very, very fragile babies. But it's not just about not touching the babies, if there's abnormal physiologic states, identifying them, recognizing them, is very, very important. And, you know, when we, when we scan these tiny babies, you know, some of our faculty will do a full study of up to 100 images in less than 10 minutes. So it's not that we're exposing these babies to three, four hours of echoes that sometimes may happen if a trainee from another specialty is, you know, except we only have our best people do the echos and these tiny, tiny babies. And that that, that that's important. But you're absolutely right Rooney if we are to move the needle, in terms of preventing neck, optimizing brain perfusion, one needs to recognize that there may be cardiovascular states leading to disturbances of perfusion that are important to recognize. So thank you for bringing that up. Thank you.

Ben 41:41

Well, you're you're transitioning seamlessly to the PDA and and your presentation on the PDA is quite fascinating. And to me, it kept reminding me of the Albert Einstein quote, you know, that says that if he was given one hour to solve a problem, she would spend 59 minutes defining it, and the rest, resolving it. And I feel like your approach to the PDA really is where we're treating the PDA without knowing much about it and us understanding more about the PDA should help us be better clinician, can you tell us a little bit what your vision looks like from that standpoint?

Patrick McNamara 42:16

Yeah, I've not heard that expression before. I'm going to use that out because very well, you know, and I think that PDA is such a can of worms. And I think the reason it's such a can of worms is we, you know, we just have not paid enough attention to not just defining a significant PDA, but recognizing the variable role of the doctors, you know, like babies who have pulmonary hypertension, babies who have severe heart dysfunction, closing their PDA is not a good thing. And when we go back and look at all the trials have been conducted, there's not been a lot of attention, not just paying attention to definition, but also recognizing that there are certain times and situations in which closure of the ductus is probably not a good thing to do. You know, my back. And when we published that paper, or that review paper, towards the rational approach to the PDA, in 2007, there were really two messages. One, what I've just said that the role of the doctors is variable. But secondly, the diameter on its own is not going to help you solve this problem, because number one, you've got reliability issues of measurement. And number two, it doesn't necessarily tell you with certainty that there's absolute hemodynamic significance. And, you know, that's borne itself out in the trials the trials have not with a diameter selection process, we've not been able to show any difference in anything in any trial. Even the two reasons. Benedictus and baby ask or trial 1.5 millimeters and threshold. Babies randomize. No difference and I wasn't surprised. That's what I was expecting. Because we know that from looking at babies that there are many babies with PDA is 1.6 1.7 millimeters that are physiologically stable. And clinically, well, the echos unremarkable and we leave those babies alone and their PDAs close. Sometimes there are other babies that might have a 1.4 millimeter ductus and your 300 grams and actually can be hemodynamically significant. So I think therein lies you know, the message if we are to truly solve the PDA dilemma, there are two or three things that are crucial number one, trials need to enroll babies that truly have not just pathologic shunt but pathologic shunts that are not going to close. Okay, if the duct is closed spontaneously in two or three days, you're never going to show a difference. So you need shunts that stay open, that are truly pathologic. And secondly, you need an intervention of works. So we have translated the lack of efficacy of medical therapy into a problem is not a problem. We are actually answering the question, have you eliminated the problem? I think if you eliminate the problem, and nothing happens, then we have to say, Okay, well, maybe it's not a problem. We've never done that in the vast majority of the trials, medical therapies only efficacious in 50% of cases and so forth. And, you know, the the post hoc analysis of a fief Alpha cashes study showing that in patients in whom the problem had been solved early and you limit exposure, those babies seem to do well. And they're given us clues. That's all they are clues that there are some patients who have big shots, that if you solve those problems and solve them early, you can mitigate risk. Like what's very clear from the literature is prolonged exposure to bad shots. Doesn't seem to be a good thing. And we're, you know, one of the good things from a non interventional approach is it's telling us that, you know, there's there's Gabriel's work from Montreal, there's a group in Miami, and there's the group at from Alabama, that presented very nice work that a very strong association with prolonged exposure to shunts and pulmonary hypertension. So,

Ben 46:41

in your presentation, you mentioned the architectural considerations of the PDA. And I think the slide that you have there is, is quite eloquent because you can see how this the simple data point of a measurement of saying, well, the P is two millimeters, three millimeters, it really doesn't do justice to the to the nature of the PDA in its in its form and its shape. And And I'm assuming it will impact how likely these PDAs are to close? Do you think we need to better at defining these architectural considerations in the PDA to to manage it better?

Patrick McNamara 47:14

That's a really interesting question, Ben, it's actually something one of our fellows are looking at the moment how much of architectural differences are genetically driven. So Stephanie, and Cavaleiro has got a study looking at PDA genetics, and trying to match that because that may be important, because if there are certain genetic phenotypes, that are never going to respond to medical therapy, that's kind of important. You know, like in our practice, if we give, if we give a course of indomethacin, and nothing happens, we don't give another course. Like, nothing is going to happen the next day different. And so recognizing that when you do a very comprehensive assessment is much easier than if you're just reliant on diameter. The other the other important piece here is, you know, the reliability of the diameter measurement itself is questionable. And we just did a very nice study in collaboration with our interventional cardiologists where we did echoes in the cath lab at the same time, as they were doing. And un basically showed that at the poverty and the error is around point four millimeters at the Arctic, and it could be up to more than one centimeter. That's pretty significant when you then start to think randomizing babies just on that one measurement, if that one measurement can be so unreliable, why are we surprised that our trials are not showing any difference?

Ben 48:45

You do have some, I think you do have a slide that shows the concordance between the Echo and the calf. And it's and that's that's shocking.

Patrick McNamara 48:54

But it gets to, you know, in our philosophy of hemodynamics, and equid hemodynamics. For every assessment, whether it's assessing bodily function, how the function ductile, we never rely on one measurement. So if we're assessing our V function, we look at tapsee FSC. Tissue Doppler strain. If they're all abnormal, we're probably going to be confident that there's a problem. If only one measurement is abnormal. Well, let's just reevaluate. I think that's important. If you put all your chickens into one basket, you're probably not going to solve the problem.

Ben 49:31

I wanted to mention something obviously, because you do talk about it. And I think it's interesting when you you mentioned modulating BPD as a hemodynamic condition. I think this is something very interesting. And I think it combines two very popular topics always. BPD is always a source of great interest. hemodynamics as well. What's your vision on modulating BPD as a hemodynamic condition? What do you mean by that?

Unknown Speaker 49:55

How many hours do you have?

Ben 49:59

Nine seconds or less, please.

Patrick McNamara 50:04

Here's here's the bottom line. And I talked with this, it's a long cloud API is BPD is an awful definition because it's actually not the path of physiologic disease. It's you're receiving oxygen or you're on a ventilator that can happen for a multitude of reasons. And I think what we're learning is under the umbrella of BPD, there are many different physiologies. There may be some babies that truly have lung disease, or other babies that may have lung disease and pulmonary vascular disease. But there are some babies that may have shrunk physiology to the atrial level shunt, I think we have underappreciated the extra level shunt. There are some babies who may have pulmonary vein disease. And the most interesting phenotype that we're starting to learn about is that there are some babies that may actually have lung disease that relates to systemic hypertension, with a left heart phenotype of post capillary phenotype, in which there's intrinsic LV diastolic dysfunction causing pulmonary edema. And it masquerades as pulmonary vascular disease with PPD, as important to recognize because the approach to treatment, their pulmonary vasodilators will be not good for those babies because you're relaxing the pulmonary vascular bed in the presence of high left ventricular pressure. So I think my message on BPD as a human me coalition is number one, it's much more complex and just how much respiratory support you're needing. It's a very broad phenotype. The second, if you now think of how many randomised trials are conducted with BPD as an endpoint, if you're not sure that this is the disease you think it is, how much can you transmit that measurement as the primary outcome? For the randomized control trials? It's kind of scary when you think about it. But it's, it's it's very, very true. Going back to your Albert Einstein.

Ben 52:07

It is terrifying. It's terrifying. Imagine the problem, you know. So

Rune 52:13

Well, again, it shows for sure how you can integrate the hemodynamics and really understand the pathophysiology and define the pathophysiology and then take the discussion of BPD and needed so many different aspects of neonatology to a different level.

Ben 52:31

We're coming to the end of this recording. Thank you very much for your time, I wanted to ask you a last question is, which is that haemodynamics point of care ultrasound, we're talking about pdapp, it can be very daunting for people who are seeing this from the outside who never really got the training. And I wanted to know if you could share some words of encouragement for the people who are very interested in weather like this, is this too much? Like I'm not going to, I shouldn't bother. There's no way I'm going to manage to be proficient at this. What can you tell these folks who are a bit intimidated by the prospect of learning this new skill and learning this new way of doing things?

Patrick McNamara 53:08

So the first thing I would say is that, you know, in the year 2004, I visited Los Angeles is sensory had a conference there and I was talking about our experience in Canada. And I remember many neonatologist came up and said, This is great, this will never happen in the United States. First thing is it is happening. Okay, this is happening to us, and is going to get bigger, as more programs develop, the training potential is going to increase. What I would say to people out there is that, number one, there are critical mass of neonatologist now that have expertise, there are an increasing number of programs that are training programs that can provide an education and provide that that learning, I think, now that we have a, you know, a political situation whereby there's recognition by pediatric cardiology, that the ontology is not just need to do this, but they should be doing this and and that is so reassuring. Yes. Echo is not it's not easy. There's a lot of physiology to learn. But there's no reason why you can't learn it. If I've learned this, I've been able to do it, anybody can do it, you know, and it comes down to the mentorship, the support of your colleagues, I think anything is anything is possible. And there are also different ways in which to train. So for example, you know, if you're a faculty out there and you know, I think I can go to Iowa or I can go to Toronto or wherever to do a year. How can I be trained? We have had many individuals who have done some time with their own The lab, and they come to us for a short period of time, you know and get get some skill. So we've had people come for blocks of one to two months, they go back, and then they come back again six months later. There's many, many ways in which people can be trained. So if you really want to do this, don't give up on it. It is feasible, it is possible. But you need to be trained properly. Don't Don't Don't try to do it. Don't try to do it in the secret of nice in the darkness with nobody else. That's not going to work.

Ben 55:32

All right, right. Really any any parting questions or any parting comments?

Rune 55:36

Well, again, badger, you're so inclusive, and again, I think it comes through and everything you say. So I think this is going to be a very motivating episode for our listeners. So thank you, again, so much for sharing your expertise and knowledge. And

Ben 55:51

thank you and you ready? I think you're gonna get a lot of emails, maybe from me as well. I like that idea of, like, these options are out there and what you're doing with neuro neonatal hemodynamics of, of decentralizing these, these overseeing community scholarly oversight committees is phenomenal. So congratulations.

Patrick McNamara 56:09

Oh, thank you guys for actually having me talk about i for all that you're doing through this, you know, this is wonderful.


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