#290 – 🫀 From the Heart - Preemies with CHD, Post op Brain Injury & The Neonatologist’s Role in Cardiac Care

Hello friends 👋

In this episode of From The Heart, hosts Dr. Nim Goldshtrom and Dr. Adrianne Bischoff explore the latest research in neonatal cardiac care, focusing on congenital heart disease (CHD) and its impact on premature infants. They discuss a study analyzing survival trends in preterm infants with CHD, highlighting the “double jeopardy” these babies face due to both prematurity and congenital cardiac anomalies. Another study compares neurodevelopmental outcomes between preterm infants and those with CHD, revealing that term infants with CHD exhibit similar motor and cognitive challenges as preterm infants, yet receive less developmental support. The conversation then shifts to emerging research showing a decline in postoperative brain injuries in CHD patients, possibly due to improved surgical and perioperative care. Finally, they discuss a survey on neonatal cardiac care models, emphasizing the evolving role of neonatologists in managing CHD patients and the need for better integration between NICUs and CICUs. Nim and Adrianne reflect on the importance of specialized care teams, advocating for neonatologists to play a greater role in optimizing outcomes for this vulnerable population. Tune in for a compelling discussion on bridging the gaps in neonatal cardiac care.

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The articles covered on today’s episode of the podcast can be found here 👇

Double Jeopardy: A Distinct Mortality Pattern Among Preterm Infants with Congenital Heart Disease.

Higgins BV, Levy PT, Ball MK, Kim M, Peyvandi S, Steurer MA.Pediatr Cardiol. 2025 Apr;46(4):939-946. doi: 10.1007/s00246-024-03519-4. Epub 2024 Jun 12.PMID: 38864860 Free PMC article.

Similarities and Differences in the Neurodevelopmental Outcome of Children with Congenital Heart Disease and Children Born Very Preterm at School Entry.

Wehrle FM, Bartal T, Adams M, Bassler D, Hagmann CF, Kretschmar O, Natalucci G, Latal B.J Pediatr. 2022 Nov;250:29-37.e1. doi: 10.1016/j.jpeds.2022.05.047. Epub 2022 Jun 2.PMID: 35660491 Free article.

Declining Incidence of Postoperative Neonatal Brain Injury in Congenital Heart Disease.

Peyvandi S, Xu D, Barkovich AJ, Gano D, Chau V, Reddy VM, Selvanathan T, Guo T, Gaynor JW, Seed M, Miller SP, McQuillen P.J Am Coll Cardiol. 2023 Jan 24;81(3):253-266. doi: 10.1016/j.jacc.2022.10.029.PMID: 36653093 Free PMC article.

Integrated cardiac care models of neonates with congenital heart disease: the evolving role of the neonatologist.

Hamrick SEG, Ball MK, Rajgarhia A, Johnson BA, DiGeronimo R, Levy PT; Children’s Hospital Neonatal Consortium (CHNC) Cardiac Focus Group.J Perinatol. 2021 Jul;41(7):1774-1776. doi: 10.1038/s41372-021-01117-3. Epub 2021 Jun 17.PMID: 34140645 No abstract available.

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

Adrianne Bischoff

Hi everyone, I'm Dr. Adrianne Bischoff, a neonatal hemodynamics specialist passionate about advancing care for our tiniest patients. Neonatal cardiac and hemodynamics care is at the heart of what I do, and I can't wait to share insights with you.

Nim Goldshtrom

And I'm Dr. Nim Goldstrom, a neonatal cardiac intensive care physician. Together we'll be exploring the fascinating world of neonatal cardiac function, diving into the challenges, innovations, and clinical pearls that shape how we care for critically ill neonates.

Adrianne Bischoff

From groundbreaking therapies to real world applications, we're bringing you conversations that go beyond the basics. because this is from the heart.

Nim Goldshtrom

Join us on the incubator for a series filled with heart, science, and the care these low patients deserve.

Adrianne Bischoff

Hi Nim, how are you doing?

Nim Goldshtrom

I'm doing great. How are you?

Adrianne Bischoff

Good, thank you. I'm excited to be recording another episode.

Nim Goldshtrom

I am as well. I can't believe the time flies so fast, right?

Adrianne Bischoff

Yeah. Today we have a selection of articles, which we will be linking on the show notes as usual. We will be focusing mostly on congenital heart disease, which is a topic near and dear to Nim's heart, much more than even mine! I'm happy to discuss this and highlight some of the newest literature that is out there, and some of the things that I believe that we all as neonatologists should be thinking more about and learning about for our premature babies, and the babies that do come to our units, even if it's for a short period of time.

Nim Goldshtrom

For some unique centers, it's not even that short period of time, right? They come, they stay, and they stay much longer. And so we're going to really abuse this “from the heart” mnemonic about how things are going! It's wonderful to kind of look at the different landscapes of cardiac function and cardiac disease, structural heart disease versus functional impairments in a variety of new physiologies. Here we have a smoldering of congenital heart disease-related topics, and how this premature population develops. We discuss what we may, as a field, be able to help add for the next generation of patients to their level of care.

We're going to start it off with the meat and potatoes, prematurity and congenital heart disease: an article titled “Double Jeopardy: A Distinct Mortality Pattern Among Preterm Infants with Congenital Heart Disease.” First author here is Brennan Higgins and the last author is Martina Steurer. Both are from UCSF, one of the only other programs with multiple neonatologists in their cardiac ICU, outside of our wonderful center at Columbia. The background here is that CHD is overrepresented as a malformation, particularly in preterm infants; in some gestational age groupings, it is up to five-fold increase with decreasing gestational age. In this sense, preterm infants with CHD experience what some would call affectionately double jeopardy: you have all the risks of preterm birth, and the mortality and morbidity associated with that burden of condition, and the congenital heart disease spectrum, both from the cyanotic and potentially the acyanotic lesions, although their risk profiles are different.

There is limited data available using gestational age as a continuous rather than dichotomized variable. Most studies from single centers or registries don't have the luxury of size and volume. So it's easy to just split things below 37 weeks, or into large chunks of preemie groups. But that doesn't really give you granular answers. So the study used wonderful CDC data to get to that question. The authors used contemporary US national population-based data to look at these problems. As of the mid-2014’s, the CDC required a listing of congenital heart disease. They went back to the birth/death registry in this study from 2014-2019 of all live-born preterm infants between 21 to 36 weeks gestation. They clustered into five groupings of gestational age categories that you can read about in the paper. They only took cyanotic congenital heart disease, CCHD. A lot of studies you'll see CCHD referred to as critical congenital heart disease, as for a ductal-dependent or those who can't leave a hospital potentially. Here they're defining it as cyanotic, which is another proxy term, versus the acyanotic ones like ASD’s and VSD’s that may not need interventions prior to going home.

The primary outcome in this study was one year survival between those preterm infants with and without cyanotic heart disease as stratified by the gestational groupings. They also had secondary outcomes in early mortality. Early mortality is mortality before three days of age, where they tried to stratify babies who never even actually potentially made it to surgery for a variety of reasons, which they discuss in the paper, to avoid confounding with operative mortality. Lastly, they compare these trends over the five-year period to see if there's any trend over time in outcomes between the two groups.

They used proportions as a display data characteristic and calculated both crude and adjusted risk differences for survival and mortality between the two groups. They adjusted for basic covariates like gender/sex, multiple gestations, and IUGR. They produced risk differences for risk by year using a logistic model for mortality and the year of the data set as a predictor.

They found almost 2.7 million preterm infants born between 21 to 36 weeks in the US over that five year span, about 11.5% of all live births in that time period. They were able to whittle down to about 3619 subjects, which is 0.13 % of that population, that had a documented cyanotic congenital heart disease. The highest representation is between 25 and 28 weekers, and the lowest representation is actually in the late preemies, 35 to 36 weekers. Preterm infants with cyanotic congenital heart disease were less likely to be multiples, but more likely to be IUGR and SGA than those who did not have CHD. Additionally, the cyanotic congenital heart disease population had more representation from maternal problems such as gestational diabetes and diabetes mellitus, hypertension and maternal gestational hypertension, as well as being non-Hispanic white and having more private insurance, which I think is a fascinating mix of representations. 

Ultimately, in one year survival, the preterm infant population with no heart disease had survivals anywhere from 18% to >90 %, between gestational ages of 21 to 27 weeks. And that probably rings true for most of us in this field. By 27 weeks, we don't really talk to families about the significance of high mortality risks for the preterm infant without significant congenital anomalies, let alone congenital heart disease. But for the cyanotic heart disease population, survival went from 16.7% to only 54% between 21 and 31 weeks. It actually plateaued around this 54% mark, and only improved to about 76-77 % by 36 weeks gestation. This showed a statistically significant risk difference between basically the entire gestational age cohort between preterm infants with and without heart disease, between the 23 and 36 week marks. The greatest risk difference is actually in the 28 to 31 weekers, which was around a 37% risk difference between being born with and without heart disease. 

When it comes to early mortality in those without heart disease, the early mortality in the first few days decline rapidly, from >90 % in extreme prematurity, to about 46% by 25 weeks gestation. But with heart disease, early mortality accounted for half or nearly three-quarters of the deaths between 23 and 30 weeks, and only declined starting at around 31 weeks gestation. There’s like an entire 1.5-month gap between when early mortality stratifies itself out between those with and without heart disease. The largest difference was actually in the smaller babies, somewhere around 24 and 26 weeks.

Lastly, we're looking at the time trends. For the non-CHD population, there was a small but statistically significant decrease in one-year mortality, which was seen greatest in the smallest babies, less than 25 weeks. For the congenital heart disease population, there was not a statistically significant trend, but if anything, a trend for increased mortality in all the gestational ages between 2014 and 2019. The worst of it seemed to be in the 35 and 36 weeks gestation.

So just a fascinating population-based study, on where things are going in two similar-ish groups differentiated by a major congenital malformation. This clearly represents the trend that we see in most of our units and in the literature in general. We are doing better. We're getting to 22-weekers, we're getting to 21-weekers. I don't have to tell a program in Iowa about that! We're doing better and better in striving for the preterm infant and the ability to get them through survival and through the morbidities. Those gains are not being realized in the congenital heart population. And there's a lot of speculation about why, but Adrianne, I'd love to hear your thoughts on that on the paper and then what struck out to you as interesting or different, from what you already had been aware of.

Adrianne Bischoff

Thank you. That was great, Nim. I think we can do a discussion overall of what some of these articles are going to talk about in conjunction. So I'm just going to go right ahead into the next one, which is a similar topic. Does that seem reasonable?

Nim Goldshtrom

Yeah, it's not a bad idea actually to kind of just consolidate everything at the end. Because it's better message that way. 

Adrianne Bischoff

All right, so the next one we wanted to talk about is “Similarities and Differences in the Neurodevelopmental Outcome of Children with Congenital Heart Disease and Children Born Very Preterm at School Entry.” This is a study by Wehrle, et al. It came out in the Journal of Pediatrics in November of 2022. For this article, they were comparing cognitive, motor, and behavioral outcomes in patients with congenital heart disease and very preterm children. The main message is that it underscores the need for tailored follow-up programs that address unique challenges in each of these groups. This study examined the neurodevelopmental outcomes of 155 congenital heart disease children after cardiopulmonary bypass, and 251 very preterm children. They used, of course, standardized assessments. The results were analyzed through hypothesis and equivalence testing, which was new for me to read about, in order to identify differences and similarities.

Here's how I summarize the results that they had. In terms of cognitive and motor outcomes, both groups demonstrated normal IQ’s, with mild impairments being more prevalent in the very preterm children. But the motor deficits were more pronounced in the congenital heart disease children, especially when it comes to dynamic balance. So, Nim, let me ask you a question. How do you tailor developmental interventions in kind of the NICU-CVICU setting, which is where you work, in these groups specific for motor and cognitive challenges? Are there any interventions that you have found that are particularly effective for congenital heart disease-related motor deficits?

Nim Goldshtrom

Not that I'm aware of. We employ the same surveillance, evaluation, and interventions that we would do for any other neonate who's in the NICU, a former preemie who's getting to a mature age. We utilize speech, physical therapists, and occupational therapists. We try to, when possible and when safe, when the amount of intensive care or lines allow it, to do parental holding. Skin-to-skin, even for the more mature child, has benefits even outside the scope of preterm infants. We move them when they can be moved; these kids sitting in bed all day is not helping their development. Getting parents to come into unit, giving them 24-hour access to stay at the bedside, and engaging with them as much as possible is also important. I think our unit is unique where it's easy to apply that craft when you have a general NICU that you come from, nurses that come from there, and therapists that are straddling both units as one larger unit. We are part of a heart center, but the cardiac NICU also functions both as a CICU and a NICU until we get the benefit of both worlds.

Adrianne Bischoff

Yeah. Good opportunity here for us to give a shout-out to all these therapists that did not get as much recognition as they certainly deserve and the critical role that they play in our babies in the NICU and CVICU settings. Anyway, thank you. Back to my results. What else did this article look at? They also looked at behavioral challenges. Both of the groups experienced behavioral difficulties, both through peer problems, and therefore they have kind of like a shared vulnerability. In terms of therapy utilization, there were disparities. They were significantly underutilized for congenital heart disease children, which was about 23%, compared to the very preterm infants. Even though, as I just said, the congenital heart disease children are more likely to have motor impairments when compared to the very preterms.

I just wanted to highlight a little bit of the figures and tables that they have in this paper. I recommend that everyone opens these PDF’s at the end of listening to us, where they emphasize these unique motor deficits of the congenital heart disease children compared to the fine motor skills of the very preterms, and the lack of equivalent therapy access and the systemic gaps that we're seeing.

Another question that I wanted to ask you – sorry Nim, I'm going to put you on the spot here, but you're in a very unique place for today's discussion! – from your experience, how do you think follow-up programs for congenital heart disease children can mirror this structured support that is available for the very preterms that we have all over?

Nim Goldshtrom

Boy, we do not have enough time in one podcast to answer that question, but it is a great opportunity for a future case to look at the highlights of follow-up in the preterm infant who gets potential hemodynamic consultations versus the preterm infant who has CHD. I'll give you my personal experience at our center. It is challenging. It is challenging to get a congenital heart population to come back in. That is not a criticism or to imply that the challenge goes in one direction (it's just a family, it's a center, it's a cardiologist, etc). I think there is, again this is my just personal bias and experience, a subtle misconception that a term child with congenital heart disease who has bypass surgery and then comes out of a hospital with what you would call minimal residual lesions and no significant morbidities (didn't get a surgical site infection, didn't have chyle, has a functioning heart without a lot of stenosis, valves that work, etc.) is now at no risk. That is not to say that that's how they're being counseled or that's how they're being informed in their cardiology visits, hardly from it. But I think this data just shows so much that they are basically like our preterm infants. I just don't think we get that as a collective group, because it's just such a much bigger pool of people who are caring for them. And then they lean on their cardiologists so heavily and rightly so, because they're the ones following them up with serial echos and following up their progress and their growth and development. I think the cardiologists have such a large swath of things that they need to do, where for us once a baby leaves, it's a lot of things to do but our major focus is, are you meeting milestones? You need to come back in and we need to do those developmental assessments because, we'll talk about it at the end of all these papers, but the discrepancy here is not that they don't have the same problems. They're clearly not utilizing the same services, at least from this paper in this one center. And I worry that we, as a community in the CHD world, it's a bigger pool of people impacting the team of care and that the emphasis on neurodevelopment is potentially lost, because they’re term otherwise, and they're leaving the hospital. Maybe there's a subtle misconception that the risk is gone. It's wonderful to see this data, as troubling as it is, shine a light on the fact that they are functionally the same. A term child with CHD and a preterm infant literally need the same a degree of counseling and therapy to not miss those potential gains, windows of opportunities, and actually get to their full potential.

Adrianne Bischoff

Thank you. I think it summarizes that we do have a very pressing need to close these kind of therapy gaps and follow up. I think future research should continue to explore the systemic solutions that we can do to improve equity, access, and outcomes for both of these populations.

Nim Goldshtrom

It's an incredible point. To further move into the physiological stuff surrounding this area, the next article I wanted to highlight is, where could be the sources of these problems, right? Why is it that we're seeing survival mortality rates across preterm infants with or without CHD be so discrepant? And at the same time, a term baby with CHD appears to have functional impairments akin to a preterm infant, although having maturity that is far beyond it. Part of what we know from other studies, which we'll highlight with this next paper which also comes from a group of authors who have highlighted the problem of CHD babies having smaller brain volumes in fetal life and already being growth-limited as compared to term babies without CHD, is that they are always constantly being exposed to a degree of neurological impairment and injury. These changing practices that we have may be actually part of the solution. The next paper we have, entitled, “Declining Incidence of Postoperative Neural Brain Injury in Congenital Heart Disease,” comes from another UCSF group. First author is Shab Peyvandi, a great researcher in both cardiac neurodevelopmental outcomes and neuroimaging, and last author, Patrick McQuillan. Neurodevelopmental outcomes are really the most common morbidity in congenital heart disease population. Survival has been improving drastically for several decades due to improved surgical technique, physiological understanding of the post-operative state, treatment of low cardiac output, and early recognition of near-arrest and arrest physiologies. The risk of brain injury is anywhere from 10-35% preoperatively, but it doubles to about 33-75 % in the post-operative period. White matter injury, outside of our intraventricular hemorrhage, is the second most common injury in the preterm population. These data are account for the declines in rates in neonatal brain injury in preterm infants. With all the gains we see in survival and morbidity, we’re also doing better with neonatal brain injury in the preterm infant and especially white matter injury over time. So this study wanted to look at these trends in a cohort study of two centers over 20 year period, to evaluate trends in brain injury and neonates with complex CHD, similar to how their other colleagues looked at the trends between preterm infants with or without congenital heart disease.

This study was between 2001 and 2021, but in full term newborns with congenital heart disease having a neonatal operation. Within the first 30 days between two collaborating sites, the University of San Francisco and British Columbia's Children’s Hospital. It’s a prospective study designed with a preoperative MRI, postoperative MRI, and neurodevelopmental follow-up into childhood for several years. They excluded any preterm infants or anyone less than 37 weeks, those with known congenital infections, congenital malformations, and suspected or confirmed genetic anomalies. That's an important distinction because there's our mixed population – we know that the CHD population is also very highly represented by genetic conditions; anywhere from 15 to 30 % of CHD can have genetic conditions. We're also removing a much higher risk group here and talking about ones who we can affectionately call isolated congenital heart disease, without another associated malformation. The primary cohort here actually contained a tremendous amount of D-loop transposition of the great arteries and single ventricle physiologies, of which almost three quarters were hypoplastic left hearts. The majority of those single ventricles received the Norwood operation, which is performing an aortic arch reconstruction and their pulmonary flow was provided through a Sano, with only five patients receiving a modified right BTT shunt. There were a very small number of other diagnoses, which you guys can go into, such as a hyperplastic right heart and DORV’s and tet’s and things like that. MRIs were done preoperatively again at the earliest time available, when they were stable. Post-operatively, they were done outside of the perioperative care window. They quoted a mean of ~15 days between preoperative and post-operative MRIs. They were read by blinded neuroradiologists, blinded to the clinical care of the child.

They categorized brain injuries in a few ways. They did it by major conditions, stroke, white matter injury, IVH, global hypoxic ischemic injury. There was also a post-op read limited to newly acquired lesions that were not evident on the preoperative screen. Two trained raters and a neurologist read them. They also quantified something called white matter injury volume as another quantitative measure to figure out the burden of injury in these MRIs. They stratified the cohort into four epochs of about five years each, 2001-2005, 2006-2010, 20011-15, and so on.

The primary outcome here was the presence of white matter injury, both pre and post operatively, with the primary exposure being the epoch, the four or five year period of time in this 20 year study. Logistical regression was used for analysis. They had 270 participants and about 246 received a pre-op MRI, 220 with a post MRI. They had 258 (nearly 90% of the study) that either a pre- and/or post-op MRI (not all had both a preoperative and a postoperative MRI). In pre-op MRI findings, they noted that there was an increased rate of prenatal diagnosis rates in the preop population over time. There was less balloon atrial septostomies as the epochs went from earliest to most recent. There was no change in preoperative white matter injury on preoperative MRIs across a 20 year period, which hovered around 20%. And there was a trend, but not statistically significant, for less stroke.

Postoperatively though, there was a statistically significant decrease in white matter injury over time, both by site and by cardiac lesion type, primarily the DTGA and single ventricles. Postmenstrual age was also a significant predictor, so the later you had it, the less findings you found. This was also when controlling for a variety in the epoch as well. There was an 18% decrease from epoch one, so 2001 era, to the later 2016-2020 era. The odds of a new post-op white matter injury in Epoch 4 was actually the same as Epoch 1, even though there was a decreasing incidence of finding. Between the two ventricle DTGA and single ventricle physiology, both had longer bypass times over the 20-year period, longer cross-clamp times, and both showed higher blood pressure parameters over time as well, but no substantial change in the VIS (vasoinotropic score). VIS is an aggregate feature generated by all the different inotropes you used in different ratios to create the total burn or inotropy experienced in the post-operative period. So despite blood pressures going up, the VIS actually didn't change. It wasn't at a cost of more drugs. It was actually because of different drug choices. So they saw, over time, a real drop in the use of milrinone and a significant increase between those two centers in epinephrine and dopamine. Additionally, in that time, preoperatively white matter injury volumes were about the same, but post-operative injury volumes decreased over time with the largest difference between the third and the fourth epochs in the last 10 years. Cardiac lesions seem to have the biggest impact on the variants and single ventricles seem to have even more white matter injury than DTGA, which is also not surprising. 

So it's still happening. What's fascinating here is it's happening preoperatively. It seems like there are some gains postoperatively, which we can talk about in a bit and why that might be. But there is clearly a pathologic injury pattern here that sets these kids up, along with all the hemodynamic disturbances of bypass surgery and the recovery and low [cardiac] output states, for physical brain injury that leads to of the outcomes that you were describing in the last paper.

Adrianne Bischoff

Yeah, that's great. It's a great segue to the last article that we wanted to discuss, which is not the same format as the other ones. This is a letter to the editor. This article is “Integrated cardiac care models of neonates with congenital heart disease: the evolving role of the neonatologist.” This one, although not quite as brand new, from June of 2021, we thought it would fit well into this theme, especially having Nim right here, which I'm very proud of. They basically talk about how neonatologists can contribute to the perioperative management of babies with congenital heart disease and highlighting that these patients face care transitions – all the time between NICUs, CICUs, surgical teams, etc., and therefore there's a lot of complexity and the risk of some communication gaps. 

This study was actually a survey of 22 North American level four NICUs to examine the admission policies, the neonatologist's roles, and the care variability. Although it was comprehensive, the lack of correlation between practices and outcomes limits the findings. But it does provide some opportunities for future research, but mostly for me to gather Nim’s insights on this important population. Some of their key results were that, yes, neonatologists are involved in the prenatal counseling of babies with congenital heart disease in 86% of the centers. In terms of where these babies are admitted, the decision to admit in the CICU versus NICU is mostly based on factors like gestational age, birth weight, and cardiac lesion. In terms of post-operative care, it's not surprising, but most of the babies are taken care of in a CICU setting, even if they are preterm infants. That's probably just because they most often have to wait until they are bigger before their repair. But I guess Nim can give us some insights of what type of babies Columbia is operating on, even when they are little and could stay in a NICU setting in other places. Nim, before I move on, do you want to share a little bit of your experience in this combined unit? How can we optimize the transitions and what type of babies would be better served in one versus another setting, when we don't have the ability to have a unit like you guys have over there?

Nim Goldshtrom

Again, how much time are they going to let us have on this journal club? It's a complex answer. But I think what you're showing is, the practice around US-based institutions that are all CICUs have some consistency, or at least a rubric, for how they make decisions. This is care by committee, right? Like when you meet certain criteria, you go here. Then when you're in a different phase of care, you'll go there. And then when you're in a different phase of care, you go somewhere else. For a lot of populations, that'll probably work well. This is kind of going to bleed into the three papers that we just talked about, but let's look at the outcomes that the three papers we just described talked about. The preterm infant with and without congenital heart disease has a massive discrepancy in mortality over a very recent period of time, 2014 to 2019. Term babies with congenital heart disease have the same degree of neurological development at school age as preterm infants, and yet not do not engage in services as much. And despite that, it seems like in last 20 years, we're doing a better job in post-operative management because we're seeing white matter injury improve when we're adjusting the parameters. There are historical reasons why, from the last paper by Shab Peyvandi et al, that milrinone went out of favor and epinephrine use went up. Some of that is what we're understanding about the fears we used to have about single ventricle and SVR versus PVR versus the need to maintain normal parameters as a competing interest. Those are the outcomes, and our colleagues in CICU’s are describing these varied practices. Columbia’s vision and what our creators in Ganga Krishnamurthy and Emile Bacha thought was specialized high-risk patients probably deserve special teams, and consistency is going to help. I think that's the message. It’s not to poke holes in these practices that everyone's reflecting on, but what we are doing, and it seems like what UCSF is doing as well, is having more dedicated neonatologists directly involved and are unique things that are potentially hard to replicate. Rather replicating us as a model, think about the concept of employing specialized team. Take a look at what you do in Iowa, right? You don't rotate a whole bunch of floating nurses to your small baby units at 21, 22, 23, and 24 weeks to run your protocols of multiple echos over multiple days with concerted efforts about changing physiology. You put dedicated teams together, and you train people into those teams. You don't put less experienced people in situations where they're not going to have the opportunity to succeed.

Our view is very similar. The neonate, preterm or term, with congenital heart disease is a unique and special population, even among all congenital heart disease kids. The PICU scene, the older children, the redo operations, the kids with bad genetic conditions, poor lymphatics, chyle every time you open their chest and do anything, those are hard things that a CICU has to deal with for sure. And they deal with it at two or three times the volume that they deal with neonates. However, the neonate physiology is also unique. And so, I can see in the landscape that we're at, where you have intensivists who have to cover a myriad degree of physiologies – neonatal physiology of pre-op single ventricle and then shunted physiology. And then the next bed, it's a four op fast track conduit revision. And then the next bed, it's your heart failure kid on a Berlin heart waiting for their transplant for two months, and you're talking about anticoagulation and feeding and salt intake because they're in heart failure. Those are a lot of different high-functioning tasks to have to remember all the time. The most specialized populations, for example heart failure and transplant, they've had dedicated teams for years. You don't even have regular cardiologists in most hospitals – you bring in specialists just to deal with the mechanical hearts, and the mechanical support, and the artificial hearts, and the transplants. Neonates, in our opinion, need a specialized team. Our models are examples of what can be achieved, but they're definitely not the only thing. Our hope is to encourage the idea of specialists. These kids should have specialized teams, just like Iowa does for their most extreme premature infants. Your outcomes are fantastic compared to the nation. This is what I hope these articles can show. These are the problems for the congenital heart disease population. Look how similar, sadly, they are to the preterm infant population, even a term age. This is why neonatologists should get involved. Not to take away things from our other highly involved and highly important colleagues of cardiologists and intensivists and cardiac intensivists, but to find a way to marry that input and drive a specialized team for this population as well.

Adrianne Bischoff

Yeah, that's great. I will also highlight that you don't need only the neonatologist's expertise, but the neonatologists also need to be more prepared and better educated on how to manage these kids. I will say the reality is, even here where we have a hemodynamics program, our bread and butter is normal structural hearts. So when we do admit a preemie that has congenital heart defect, where the standard of care is for them to be in the NICU until they are ready for surgery before moving on to the PICU, we still have to manage those patients. I do feel like there's still a big gap in knowledge in how to manage these babies. The cardiology team does come and help, but they are also not intensivists. So it's just messy, right? And then we kind of have to rely on our colleagues from CICU and ask for their input as well. But then how do you merge that CICU knowledge with NICU preterm knowledge with cardiac lesion-specific knowledge? I think we all need to do a better job at that.

Nim Goldshtrom

Yeah. Look, the models are there. You did it yourself, right? You spent extra time just learning a brand new skill and the physiological underpinnings. Forget preterm cardiovascular physiology, shunting physiology, and the premature myocardium, but then also echo technique - what are the limitations of the tool? Cardiologists and intensivists in the pediatric field have been doing additional training for decades – heart failure, electrophysiology, dual boarding, etc. For the neonatal population, in our opinion, to gain more of this value, it's a little bit of competing interest. To say for neonatologists, you should go get extra training is great and it is what it takes, unfortunately. You have to be able to be the glue, which is again how we see ourselves in this model. I don't round alone. I have a cardiologist with me on every single patient all the time. I can't have the bandwidth to be looking at echo at such a high level that I can make perfect reads like an echocardiographer or cardiologist. I need someone to also spend the time with updating surgeons if we have to, there's too many things versus updating parents versus doing procedures, which is what we're good at. And that cardiologist is heavily dependent on [us doing that].

What we do with the extra training is that we are the glue. We spent more time doing an extra year of training. Neonatology trainees can consider doing, just like you guys have set up for, neonatologists who want to come in and like dedicate a year or those who want to come in for a couple of months, there's ways you can cut this by, but someone has to be the glue that can know the language of all the players in the room. That's what additional training can do. That's how you can build towards specialized processes is by these little extra training spots that show your ability to connect the things that you're not getting in your primary fellowship, which is okay. But that's the value of that extra training, you're going to add more value to these patients wherever they end up going to, and be a very important part of those dedicated teams wherever you go.

Adrianne Bischoff

Yeah. I think this is all part of a big cultural shift that is happening in neonatal intensive care over the last couple of years and will probably only continue. If you look back 10, 15 years ago, the neonatologist had to know everything and feel like they were the expert about every single aspect of a baby's care, whereas the knowledge is just so exponential that we cannot be experts on everything. That's why we're seeing models like here at the University of Iowa, we have neuro-critical care team, hemodynamics team, chronic lung team, or like you have in Columbia with your CICU combined with NICU team, because some people do have to take that extra mile and we have to work together. It does have to compartmentalize in some way, so that we can take the best out of the expertise of everyone, especially for the sickest patients. Of course, I still need to know about nutrition. I still need to know how to feed the baby. I still need to know how to use the ventilator, but I don't need to be the expert on how to use all the inotropes, vasoactive drugs, scanning, and know how to manage the most complex chronic lung disease patients that are now 60 weeks corrected. It's just not possible, right? So there is a cultural shift in how we move forward and this world of NICU-CICU is definitely part of that.

Nim Goldshtrom

I see so many parallels in you guys trying to push forward at the edge of viability. The resources and tools it takes to survive those kids, and what neonates across the country and across the world who have congenital heart disease could potentially be benefiting by just a little bit more specialty, just getting specialized people. We harp on it because we're talking to an neonatology audience. I highly encourage those who are interested in pursuing interest training because it is the only way to bridge the gap wherever you end up going. But this really could be for anyone, right? A PICU person who wants to spend more time in Neonatal Cardiac Intensive Care Unit can gain the same skills of cardiologists as well. You need glue people, who can talk to divisions and both sides and get them to trust in their management practices. They should be in a place where they can get training and just see things again and again and again, and just feed into those practices and understand them at a base level of like, here's the rationale, here's why we do what we do, here's our feeding/TPN strategy pre-op and post-op. All those nuances add together. We have PT/OT that comes in all the time. Whenever the second the baby is safe to do, I don't know if that happens in a lot of CICU’s, it may or may not, but that is a dedicated part of our process. We have donor milk now and we built it up alongside our NICU. That may or may not be available, but we've also had, thankfully, a slowly decreasing incidence of NEC pre- and post-operatively over time. There's the temporal correlation to donor milk, those slow processes are because we're trying to be the glue between cardiac ICU practices and neonatal practices. This may be where the gains are potentially coming from. It's just going to take more people to come in and replicate those things in other places through combined training.

Adrianne Bischoff

Thanks for your advocacy and for you and your team being that glue. The patients at Columbia are very lucky to have a team like you guys.

Nim Goldshtrom

Well, 21 and 22 weekers are lucky to have you guys, because I do not know what I would do if I needed to get an echo every 12 hours on an edge of viability patient. That is not a resource I have at my disposal.

Adrianne Bischoff

I think this was a great discussion, and I learned a lot. I am very thankful that I had you to share some of your insights with me, and hopefully our audience will enjoy it as well.

Nim Goldshtrom

We're going to keep finding those pearls in cardiovascular physiology, and hear what the audience wants to hear. Great talking to you again. See you next time.

Adrianne Bischoff

See you next time.