Dr. Bob Underwood (Host): Today, we are talking to two esteemed physicians who joined the Children's Health Heart Center in 2023. These providers are bringing new innovations to the Heart Center. Let's learn more about their focuses and how they are contributing to cutting edge care for patients.

 This is Pediatric Insights, Advances, and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm Dr. Bob Underwood. Our guests today are Dr. Karl Reyes, a Board Certified Thoracic and Cardiovascular Surgeon who cares for adults and children at Children's Health.

He serves as the Surgical Director of the Adult Congenital Heart Disease Program, the Director of the Congenital Cardiac Surgery Education Program, and is an Associate Professor at UT Southwestern. Also joining us is Dr. Nicholas Anderson, who is the Director of the Complex Biventricular Repair Program and Surgical Director of the Cardiovascular Intensive Care Unit at Children's Health. He is also an Associate Professor of Pediatric Cardiothoracic Surgery at UT Southwestern.

Doctors, welcome.

Nicholas Andersen, MD: Awesome. Thanks for having us.

Karl Reyes, MD: Thank you. Thank you for having us.

Dr. Bob Underwood (Host): First I'd like to ask Dr. Reyes, can you share more about your role as the Surgical Director of the Adult Congenital Heart Disease Program at Children's Health? What does your expertise in this area mean to patients and patient populations that have grown up with CHD?

Karl Reyes, MD: With regards to adult congenital heart disease, what many people don't realize or what the population doesn't realize is that there is really a growing need for adult congenital heart disease care. As we take care of a lot of these patients who are younger who have congenital heart disease, as they grow older, a lot of them will just need more surgery, more care, whether it's medical management or surgical management down the road. And we, as a program, the Heart Center addressing that basically and organizing our efforts to grow this program.

Dr. Bob Underwood (Host): I think that's amazing. It's wonderful because that's exactly what we think, we often don't think of adults with congenital heart disease. Dr. Anderson, can you share more about your expertise with biventricular repair, and how is this specialty setting Children's Health apart?

Nicholas Andersen, MD: Yeah, I think by introduction, what I would say is that the biggest challenge that we face in our field, which is treating children with heart disease is, trying to design solutions for children who have what's called single ventricle heart disease.

And that means that they have a heart malformation where only, one of their two ventricles can be used in the circulation. The concept of biventricular repair is somewhat new in the sense that there have been recent advances in surgical techniques and also, cardiology where we're learning that we can take a large number of children who have single ventricle heart defects and find ways to use both ventricles and to create a normal two ventricle circulation. The benefit is really that, we're able to help children live longer normal lives with a normal circulation, and avoid long term single ventricle care, and also in some cases avoid things like heart transplants. So it's really, I think, an exciting area of congenital heart surgery and cardiology, with a lot of promise. In terms of my expertise, this is something that I was trained in specifically during my fellowship at Boston Children's Hospital, where a lot of this work has been pioneered. And then I also spent the last several years, at another institution putting these techniques into practice and I'm really excited to have the opportunity to come to Children's Health and to continue to work in this area and hopefully bring these innovations to our patient population here in the Dallas market.

Host: Yeah, absolutely. Those are really great advances and such a benefit to the patient population. So, Dr. Reyes, can you explain why it's important to have someone who is specialized in adult congenital heart disease on a pediatric cardiology team?

Karl Reyes, MD: Well, I think that adult congenital heart disease and adult congenital heart surgery in itself is a very special practice. You're combining adult care with patients who have complex congenital heart defects that are either repaired or unrepaired and, these are fraught with a lot of things that a lot of practitioners and laypeople do not have a good understanding of and I think that having somebody who specializes in this care, can really help in advancing that area of expertise. Many times, patients will have multiple problems that are not just related to their congenital heart defects; they're also related to having other end organ problems such as kidney problems and liver problems and somebody is dedicated to the care of the patient and all these other, comorbidities, so to speak, can help improve the results in when we take care of these patients.

 It's not uncommon for us to encounter patients who are in advanced heart failure or on the brink of heart failure. But what they really do need is a surgical repair instead of, for example, a heart transplant. And when that expertise is there and you put your efforts together, you can actually recover a lot of these patients and make them better without needing heart transplantation.

Host: That is absolutely fascinating. It really is. And Dr. Anderson, my understanding is that the team now has five surgeons, which means two surgeons can be assigned to every case. How does this really change the level of care?

Nicholas Andersen, MD: I think that's an important piece of our program, currently at Children's Health. Congenital heart surgery is arguably the most technically challenging, difficult surgery that's performed in all of medicine, and it's also a very small, rare, field, and so there's not a lot of people in the country who actually perform congenital heart surgery.

It's estimated that there's really only about 250 individuals who are full time congenital heart surgeons in America. And so what happens is, there's only a very small number of surgeons in each state who actually do this work and oftentimes, they can find themselves in situations where they're by themselves and they're taking on very challenging cases, all alone.

We are incredibly fortunate that we have the volume and the bandwidth to have five surgeons, and we've made a commitment to have two surgeons working together on all of our complex cases. And it's really been shown to make a tremendous difference in outcomes and in the results that we can deliver, just on a daily level in terms of safety and, the adequacy of the repair and really translates into patients doing very well, getting through surgeries quickly, efficiently, and having the best chance of not needing future surgeries or other interventions. To be able to do that and have two surgeons, is really a rare thing in our field, but it's a real blessing.

And it's something that we're able to do based on the size of our program.

Host: That's amazing that you have that capability and I can only imagine how much smoother even a procedure would go when you've got two surgeons there at the same time, eh? Just amazing. Well, do either of you have any case examples that you'd like to share? Dr. Reyes?

Karl Reyes, MD: I think that a lot of the cases that come to Children's are highly complex adult congenital heart patients who have multiple problems. They have problems with aortic root, multiple valve problems that need to be fixed. Sometimes they have valve problems, root problems and on top of that they have irregular heart beats that need to be fixed. And a lot of those patients are in this area and we are taking these patients on and repairing these hearts, despite having all these multiple problems at the same time.

 In other places, you'll see maybe one valve needing to be fixed or one other problem needing to be fixed. But here, we really encounter multiple problems and so every patient, really is challenging and everything is very special I think at this point. I think in terms of the kind of expertise that we're bringing over to take care of these patients; it's certainly an interesting time and a great time to be here in Dallas. And I think that this is something that can really help with the care of our patients and to extend this kind of expertise.

Host: Yeah, absolutely. Great to be on the cutting edge of that. And Dr. Anderson, do you have any case examples you'd like to share?

Nicholas Andersen, MD: So we've already been quite successful in a very short period of time doing a number of biventricular repair procedures. And there's really two major categories that children fall into. The first category is children who already have all the structural components necessary for a two ventricle circulation. And what's required is really having an understanding of both, when a small ventricle is usable and can actually be used in a normal circulation. And then also sometimes it's just a technical challenge of figuring out how to connect the dots and get all the different components of the heart working together, due to atypical rearrangements sometimes.

And so, I've already performed about four operations, to achieve a normal two ventral circulation in children who already had the necessary structural components of their heart, just needed a little bit of work to understand how to put it all together. And then there's another group of children who actually have small ventricles where you can perform surgical procedures to try to actually grow the ventricle and get it to get bigger so that you can use it in a normal circulation in the future.

And, these procedures are called ventricular recruitment procedures. And I've just started performing ventricular recruitment procedures as well. And have a couple children who have already undergone these types of operations to try to grow a small ventricle. And so those children, we will likely be bringing back in probably 9 to 12 months to undergo a second stage biventricular conversion where we can take the ventricle that we've grown, we've gotten it bigger and larger and stronger, and then when we're ready to use it, we'll, convert them to a two ventricle circulation. So the work's already been progressing quite well on both fronts, both in children who have the structural components and then in children where we're trying to prepare the heart for a future two ventricle circulation.

Host: Wow, that's amazing. Honestly. So, Dr. Anderson, what aspirations do you have for the Heart Center as you embark on your first full year at Children's Health? And what brought you to Children's Health?

Nicholas Andersen, MD: So, what brought me to Children's Health, is honestly the people. I had an existing relationship with the Chief of Pediatric Heart Surgery at Children's Health named Dr. Jaquiss. He's been a long term mentor and teacher of mine, and when he called me and let me know that there was an opening, it was a very easy decision for me to come and work with him and the amazing team of cardiologists and surgeons that has been assembled at Children's Health.

So it's really the people. Children's Health is a long standing, established, congenital heart program that is incredibly reputable within our field. They've been doing surgery here for decades, and have pioneered operations. And they're really one of the major children's hospitals in America, so it's a real privilege for me to be here.

In terms of aspirations, I think that Dallas is a growing city, and in a big population center like Dallas, I think it's important to have really a top five or a top ten congenital heart program that can tackle any problem, and children in the state of Texas, we want to build a program to where they don't need to go anywhere else to have their heart disease cared for.

And so, to me, that means being able to participate in a program that can take on any case of any level of complexity. And so I think the team that we have now that we're putting together is going to be able to deliver that for children in Texas.

Host: That's awesome. And Dr. Reyes, how about you? What aspirations do you have for the Heart Center?

Karl Reyes, MD: Well, I have very similar aspirations. I think that we certainly have the ability, the capability, the expertise, the knowledge, the willpower, the strength to become a top five program, and even better than that. I echo Dr. Anderson's thoughts about the growth of this program, everything is growing by leaps and bounds at this point and, the sky's the limit. In a few years I think that we're going to be able to service not just North Texas, but, the surrounding states and probably even international patients.

I think that there's a lot of expertise here and we've just been constantly growing. There are a lot of recruitment efforts to gain even more expertise in certain areas and growth begets growth. And so I think that's the main goal for us. I also came here for the same reason. The people, the culture, the potential, you know, there is so much potential here in this area, in the Dallas area, and just being a part of something that has so much growth and promise, I think is, something that I just can't help but want to be here for.

Host: Dr. Reyes, you mentioned dysrhythmia. Do you have electrophysiologists that are part of the team as well?

Karl Reyes, MD: Yes, we do. We do have a team of electrophysiologists here at Children's, with decades of experience.

Host: Yeah, it's one of the things that when you mention dysrhythmia, again, you think of dysrhythmia and electrophysiology being involved with adult cardiac disease, not really think about it in terms of pediatric patient populations.

Karl Reyes, MD: There are arrhythmias that are acquired as you grow older and there are arrhythmias that you are born with or they develop in childhood.

 And those are two very separate arrhythmias. And so, yes, it's not common for people to hear that there are dysrhythmias in kids, but they can be very fatal. They can be dangerous.

Host: Thank you so much for your time with us today and to our audience for listening to Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at Childrens.com. And if you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on your social channels.