I'm Steve Hollenberg from Emory. My co-chair is Chris Barnett from UCSF, and I'd like to welcome you to this session. We're really excited that CHEST has put on this program to, if you will, introduce you to a burgeoning field of critical care cardiology. So CHEST has always been intrinsically multidisciplinary and focused on critical care and also pulmonary. But now the ICUs are, at least in terms of advanced mechanical support ICUs, are requiring a set of skills that are also closer to cardiology. And there's a small but growing group of interested people dual-boarded in cardiology and critical care, and we're really pleased to have some of them here today. And we're hoping that you'll get a sense of what this field is about and help us shape where it's going, because we're really excited about the future, and we're really excited about the possibilities of collaborating with people at CHEST and other places. So to start, we have Carlos Alvear from NYU, and he's going to talk about the genesis and maturation of critical care cardiology as a subspecialty. Thank you, Steve, and thank you to Doreen and CHEST for the great opportunity to be here and continue expanding our horizons and friends. So it's actually very exciting for us to do this as a collaboration with the critical care cardiology section of the American College of Cardiology, which is relatively new in our field. I'm Carlos Alvear, I'm the director of ECMO and CICU programs at Bellevue Hospital, and I'm also part of the ACC committees for critical care cardiology. And I don't have any specific disclosure for this talk other than that I am, that we are specimen, like many of us here who decided to go into these two fields of critical care and cardiology. And it's actually great because sometimes we have to explain to many people what we are, but being here with you and having this welcoming atmosphere in CHEST with many colleagues, seeing us come in and seeing more of the dual-trained cardiologists feels really nice and happy. So today, these are some of the things I hope to achieve to discuss where is critical care cardiology coming from and where are we going, really, what are the staffing models and the current needs in the country, and the potential initiatives that we can use for collaboration. But a big thing that I hope to achieve today is that at the end of the session, you guys will know that not all cardiologists are arrogant narcissists, okay, so hopefully we'll make some more friends here. It's going to be my outline for today, so I'll start with a little bit of the history, but for that, let's start with a case. This is not a clinical lecture, but we heard about this patient who's 67, comes with chest pain. He's hypotensive, tachycardic, hypoxic. He has a still ovation. He goes for PCI or the proximal LED, but he continues with hypotension, gets a PA catheter and gets temporary MCS. Then he's intubated. He's desynchronized with the vent, but you give him more sedation and he's even more hypotensive. He's oliguric. Now his lefties are going up. This patient was admitted to the CCU. On the other hand, we have a young patient who comes to the MECU with negative sepsis, complicated with ARDS, sepsis-induced cardiomyopathy. Now mixing shot with septic cardiogenic components, worsening AKI, this x-ray, his lactate goes up, and now you get this echo, and he has bimetric disfunction, now the RB is really bad and you have a P. Should we swap this patient from units? What do we do, right? And I think that's one of the reasons why we want to highlight where we come from. This is like three studies, and I don't pretend for you to look at the very small front here, but just to highlight, from the first landmark paper by Jason Katz from the Duke CICU, where he demonstrated that most of the cardiac diagnoses are coming down while non-cardiac diagnoses are going up in that particular institution, to what we see in CR-Sinai and in the Mayo Clinic database as published by Jake Jenser, to a more robust data in networks and expanded databases from the Medicare study that Xiaoxin has published here, and more recently the C3TN. The C3TN is, for us, a very important network that we're going to be spending a little bit more time talking in a little bit, but with this we identified that most patients admitted to the cardiac intensive care units really have no cardiac conditions or they're coming down, like the rates of stents are coming down, while other non-cardiac conditions, critically correlated, are going up, particularly respiratory insufficiency. So what we've seen in this evolution is from the first creation of the CICU by Desmond Judah in 1961, where we were taking care of coronary care patients, right, coronary care unit, to a more complex spectrum of patients with valvular disease, cardiogenic shock, complicated arrhythmias, medical conditions in patients with basic cardiovascular disease, or the other way around. We started to understand the importance of enhancing this. And as we described in the first paper from C3TN, we found that respiratory failure was the most common cause of admission to the CICU, and it's estimated that between 20 to 40 percent of the patients admitted to a cardiac ICU need some degree of mechanical ventilation, either invasive or non-invasive. So we're really going beyond the heart. So now we have patients who have respiratory failure, renal failure, delirium, agitation, pain, neurological issues that we have to address, palliative care becoming another big one, end-of-life issues that not all our general cardiologists are comfortable discussing or not trained to discuss that. In addition to that, we also have more complex procedures that we're doing. MCS is going up. We have percutaneous procedures to take care of patients with valvular disease. Now in our institutions, we're doing a lot of extraction of vegetation of the tricuspid valve because the surgeons are not very happy to take those patients because of recurrence rates. And what do we do with those patients that come back to our unit, and now they have anaphylaxis in their lungs, and they have bullets, and they develop a pneumothorax? A critical care cardiologist should be able to take care of that, but maybe the collaboration with our colleagues from pulmonary is extremely important because we need to escalate and have a multidisciplinary discussion. So that's how we have evolved to where we are today, and the reason why critical care cardiology sits now as a specialty. But it's important to understand that we actually try to organize ourselves in this framework that was proposed by Dave Moore in 2012, and in a very important AHA statement that was published in Circulation, and that is again updated this year by Shashank Singham. And here basically we have three levels of CICUs in the yellow, brown, and red colors for the United States, and the other graph in circles describe the ones that are proposed in Canada. And as you can see, level one CICUs are more complex, advanced MCS, advanced pulmonary care with respiratory therapies that you can really take care of the patient with the most advanced conditions. Now are we really meeting the demands to stop these CICUs in the country? It's really not realistic to expect that every hospital is going to have one of these, but you have to have a network of care in order to be able to escalate. The same thing we do, for example, for advanced respiratory care for patients with ARDS, we have to go on ECMO. And what we have seen, and this is an interesting study published in 2012 where they surveyed around 178 CICU leaders in the country, and trying to understand the different models. And as you can see here, there is only about 37% of the CICUs in the country that are considered closed units. And there is a very small proportion of these managed by cardiac intensive care specialists. Now this was 2012, fast forward 11 years, we're probably in a different position now, we don't have as recent data as we would like to. But one of the things that we highlight here is that many of these cases are very important to have that in collaboration, and I think Anne Gage will be discussing a little bit more of the details of how we really come to there, because we don't have enough cardiologists in the country. As you can see here, we only have 177 dual-trained critical care cardiologists who have done cardiology in critical care. And from those, not all of them are active at the current stage. This is a more recent paper by John Van Deepen that he surveyed 614 members of the AHA registries, and what he described here is that most of the CICUs in a more contemporary data of 2012, 2017, although again some few years behind, are not staffed by critical care cardiologists, only about a small proportion of those, maybe less than 15% really have dual-trained or somebody who has really been doing critical care and cardiology with expertise that can provide to this patient. And more recent data, this is a small survey study that we presented this year at the ACVC, where we look at what is the staffing for ECMO patients in 39 critical care cardiology units in the country, and we're talking about advanced academic centers. As you can see here, most of them are staffed by cardiothoracic surgeons. And when we talk about VA ECMO patients, for the most part, they go to the cardiovascular ICU. So there's a significant need here, and it's very important to have Eric Osborne on our panel because Eric has been doing VA ECMO for a very long time, and he's a pulmonary critical care specialist, which he can bring a lot of very important components to the mix. Now, what is a critical care cardiologist? So, you know, if you have a fancy car, you call a very nice and elegant mechanic who's going to take care of that. If you're one of those fancy doctors who fly planes, you go for the right person. But here, you might need to have somebody who understands the two fields, really, but we also need to understand our limitations. Jim Horwitz is going to describe a little bit more of what the training and education is having at this point. And finally, we've seen many trainees getting excited as we were at the moment this became a specialty. But many of us have to struggle to find places to be able to be trained on critical care cardiologists. When you go to a training place, you really want to have the skills that allow you to work in a cardiac intensive care unit, take care of the cardiovascular conditions, the critical care aspects that are happening, be able to work with your colleagues from the medical ICU, call them when you need them, and assist them when they need you. I think that's a very important part of this Venn diagram, where we really try to see the overlap of the areas that we can collaborate together. Now, this is important because in the current state of the cardiac intensive care unit, when we surveyed, this is a study that we did last year, when we surveyed fellows in training and general cardiologists practicing in the cardiac intensive care unit. Out of these, only 4% were dual training critical care. And we asked them about the comfort level to manage mechanical ventilation from non-invasive invasive mechanical ventilation. As you can see, fellows are in orange and practicing cardiologists are in blue. Their comfort level is very limited. One of the most scary things that we found with this survey is that only 25% of the people surveyed were able to identify a curve without a PEEP in the ventilator. And out of PEEP for a cardiac patient can be a very detrimental and dangerous thing. So it really calls for the training to be tailored to those particular needs. And does it work? Yes. This is a study done by Sam Brusca, where he surveyed several critical care cardiologists that either had dual training or were grandfathered into critical care and cardiology. And one of the most important things that they described to be useful in the training as an intensivist, as a critical care specialist after doing cardiology, was the management of ventilation, second, multi-system organ failure, as well as end-of-life issues. Now I showed this graph before. We have things that are important to incorporate in the care of the cardiac patient with all these complications. But what else can we bring to the table with our cardiology training? One of them is that we can take care of advancing hemodynamics, talking about what's happening with the patient with obstructive physiology that were identified by echocardiography, for example. Some of us are trained in transesophageal echocardiography or advanced echocardiogram as well, CT, MRI, to identify patients who need different interventions. In terms of EP arrhythmias, I think many of us, and you don't have to be a cardiologist to take care of VT storm, but we get trained to kind of reprogram, interrogate, and adjust in a pacemaker, in ICDs, or sometimes to entrench an arrhythmia in the middle of a storm that is not responding. Similarly, we can collaborate closely, because I don't think that cardiogenic shock and MCS management is not a one-person game. You really have to have a team. But it's very important that we have that understanding going back and forth. And then there are parts that many intensivists don't like to do, but I think it's equally important is to really transition into the outpatient care, prevention, management of antiplatelets. We understand the nuances of the antiplatelet trials, what happened with prasugrel, ticagrel, or copitogrel, and the different interactions based on the multiple studies that have been done. But I think another important aspect here is that our training in cardiology allow us to really see what's happening at the level that we have the discussion with our colleagues from surgery, for example, over a structural team. We understand coronary anatomy. What is going to be the most important revascularization strategy here? Is it even worth opening that artery, because now we're seeing that there is no viability in that territory? Or are we dealing with a complex hemodynamic case that we're not really putting together, and we have to have all our heads discussing what's going to be next? Now does this work? Do we really improve? Are we just here trying to say that we're cool kids and everything is fine? Well, there's a very nice paper coming out of Samsung Medical Center in Korea with 2,100 patients, where they actually assess what were the outcomes before and after the implementation of our critical care cardiologists in their unit. And as you can see here, it's very interesting because they improved survival significantly by the addition of this specialty. And it wasn't necessarily a cardiologist. It might have been sometimes a cardiologist with an intensivist or an intensivist who has done a lot of cardiovascular care for a long period of time. Locally, we don't have a lot of data, but these are two papers. One is by Daniel Sims from Montefiore, and what they show is that when you go to a high-intensity staffing in a closed-unit model, similar to what we have learned from critical care, survival can also be better. Now, we also can play in the sandbox with a lot of people, which is very complex. Sometimes in the middle of the night at 2 AM, you have to call your friendly surgeon to tell them, hey, can you put an egg on this patient, take this patient to the OR? And I think it's very important to have that ability to work in a multidisciplinary fashion, and that we don't always have an agreement in a particular area, and that's why you have to really call for help and integrate those things. Now, to conclude, there are a few things where we can potentially collaborate, and I think the first one is research, and one of them is that because now we are starting to produce many of these publications. We wrote the paper, Mechanical Ventilation in the Cardiac ICU, a few years back, and it was a whole encyclopedia of how to do, what to do with the vent. We were very happy because the first time in life, we were able to put the equation of motion in a cardiovascular journal. It made us proud, of course, but many cardiologists said, what is this? Now, as we started to demonstrate that many of the literature that we need in critical care cardiology are based in a field that is completely empty and novice, we started to borrow some of the studies that came from general critical care. And this is the AHA, Prevention of Complications in the Cardiac Intensive Care Unit statement that was published by, led by Chris Fortis, and many of us participated. And when we wrote this manuscript, which is kind of like our only guidelines in critical care cardiology, we really went into all the literature in general critical care to borrow what we could do and apply it to the cardiovascular patient, and then to the few studies and papers on the cardiovascular patient. So this is an area that the sky is the limit, and the field is very fertile and open for those who want to explore collaboration. We're doing this through the C3TN network. It was founded by Dave Morrow and the team group. We are now up to 40,000 patients, and it's a retrospective, high-quality data registry that is managed by the Timi group. And we have published over 28 manuscripts and over 50 papers presented here, some of which have allowed us to understand what are the different etiologies and phenotypes for cardiogenic shock, for example. The other one that we want to highlight was education domain. This is our NYU Critical Care Cardiology Symposium, and I'm very happy to have my co-co-co-course funders and directors here, where we started this for the last three years and now became the largest critical care cardiology conference in North America. And it's an area that we would love to be able to create more networking and collaboration with our societies, particularly with CHEST. And this is the Minnesota Critical Care Cardiology Education Summit, which was also a very good meeting. It's smaller, more intimate, but with a lot of hands-on training as well, led by Andrea Elliott. And the professional domain, we finally, as we mentioned, after many years of waiting, we became a section of the ACC. We have launched ACC CardioCast. It's a podcast that was launched recently. We have, actually, as you can see in the picture here, this is Sam Bernard, one of our attendants, teaching cardiologists how to do lung ultrasound, and it was very exciting. We have started to establish collaboration across the Atlantic with the Acute Cardiovascular Care Association. They're coming to our NYU symposium. We're developing several manuscripts in collaboration with them. We also did this Women in Critical Care Cardiology webinar that has never been done between the ACC and the ACVC. So we can think about something like this between ACC and CHEST. And then also expanding our horizons to countries that need our help. We're trying to collaborate with countries in Latin America, inviting collaborators from our areas. We have now a contact in South Africa who is kind of leading the critical care cardiology over there. And what we really want to do is that all these many faces, and I borrowed this slide from our good friend Jason Katz, who put it at the end of our talk last year at NYU symposium. We really want to see more of your faces here. And be friends with you guys, because at the end of the day, as my mentor and friends say, we all live in the same thorax. Thank you. Thank you, Carlos. We're a little bit over time, so I do want to get to the other speakers. Hopefully we will have a little bit of time to take questions at the end. Hi, everybody. Thanks for having us. And to continue on from where Carlos started, we're going to talk a bit about critical care cardiology trained pathways, how to do it right. So here are, I refused to put a picture of my giant head in there, so I put a picture of my hospital instead. Here's the objectives of my talk, looking a little bit about the history of this field and the path, and then kind of some of the pathways that are out there, up and coming, and hybrid pathways that exist as well. So going back to the history, Carlos talked about, touched on this as well. The first CCU started in the late 60s, early 70s perhaps. And the benefit of them was that they provided monitors for patients who had arrhythmias and then in the picture in the bottom left, you can see how a shockal rhythm was noticed on an oscilloscope. And then a nurse could monitor that remotely. That was one of the big keys, was that they were watching the four screens of the four patients in the CICU at Cornell in 1968. And then someone could come in and defibrillate them, and that was the core of the first CCU. Very quickly, balloon pumps were first started in like the late 1968, and swan gans catheters in that same time as well. But then in that ensuing next 30 years, what happened? Not much. So when I came up in 2008, 9, 10, there wasn't a lot out there. So there weren't a lot of mentors who were doing this. If you listen to Carlos talking, a lot of those earliest articles were 2012, give or take. So when I was looking, there wasn't much out there. There was really no one to talk to. And I knew I had this. I had some skills from my fellowship. I had TE. I knew how to use a balloon pump. I knew how to troubleshoot. I knew how to fix it. And then the same thing goes for Impella. So when I started my practice back then, basically I took those skills, and then I started taking care of more and more patients with cardiac arrest. So you learn more and more devices. And the key is not to highlight the devices themselves. It's just that it's really easy to find good pictures of them on the internet. They don't have backgrounds, so they paste in nicely. So again, more devices. And then the next thing you know, you start sneaking into other people's specialties. Oh, what are the nephrologists doing? Maybe I do have an opinion about when to start CVH. Maybe I do have an opinion about what the bath should be. And maybe sometimes that does make a difference. So you sort of learn from the specialties and sort of start stealing the first three things that they say on every single consult. And then if you're smart, you start getting close to the MICU. So more advanced ventilator, waveforms, pathologies you learn about. I was saying earlier that my original bronchoscopies were a MICU fellow named Mae West came down and helped teach me how to do bronchoscopy when I was a fifth year attending. And so what happened was a lot of that ended up after five or six years with a similar skill set that Carla showed in the last set, in the last set of slides. So a lot of areas of overlap between critical care and cardiology. A lot of skill sets you've seen here. And that was great. I mean, I think patients got somewhat better care. The nurses seemed happy. Heart failure seemed happy. The MICU seemed happy. But I was only there half the year. So what happens the other half of the year? That's a problem. And number two, this kind of pathway of education isn't sustainable. You know, it's not reliable. It's just happenstance. What you see is what you learn. And so on and so forth. So you can't reproduce it as well. So what do we do about that? So now, thankfully, we're in a different era where we have some training pathways for critical care cardiologists. And as you heard, there's still only 177 of us in the country. So it's still kind of up for grabs how we're going to train them. On the right, you can see a recent article by some of our crew that came out a few months ago that talks about a bunch of different pathways to get to this specialty. But I'm going to do this and blur it out because this is still kind of up for debate. This is still open. And if you actually look back, a lot of those specialties or a lot of those options on the bottom still have asterisks that say, this path does not exist yet. So you know, there's still a lot of thought about this. We don't know what the best way to go is. So one of the most common methods is the traditional pathway, which I call 3 plus 1. This is called traditional because in cardiology, there's a long history of doing three years of cardiology plus one year of cath, one year of EP, one year of heart failure, or what have you. So there's a lot of familiarity with this structure. It's accepted. It's simpler to establish in a way because there's a clean bifurcation between the two programs. Your program directors for general cardiology are happy because all their stuff is fulfilled before they move on. The challenges, of course, are funding. How do you pay for that extra year? And then it does offer you some flexibility, which we'll talk about a little bit later, in maybe you start some of the procedural skills or some of the electives from crit care in the third year of cardiology because, you know, our little secret is that that's what the cath lab does. That's what EP does. They do maybe three, four months of that in their third year to get the ball rolling. So you know, how do they structure, how are we going to structure this? Well, I think there's three kind of separate paths in that three plus one. There's standalone programs and then independent CC programs and a nested approach. So what is the standalone program? This is basically a one to two year standalone program that mimics kind of the two year CC pathway. It's a classic critical care pathway, pure as a digget, because it is the standard fare of all of the different ICUs. But perhaps for cardiologists, it doesn't have a cardiac bent, so maybe that's not the best approach. And again, you know, no one knows the answer. I'm just positing, you know, kind of what's out there. So the other options are independent critical care, cardiology program. The only one that we know of so far is at Minnesota, which is the slide that Carla showed earlier. And you know, one of the benefits of these types of programs is that you can, as I said, have a cardiology bent to, you know, and you can go as extreme as you want with it and have, you know, one month of CCU, two months of CCU, three months of CCU, because as long as you get your six plus three with non-medical, you've achieved what the ACGME puts out in order to sit for the boards. But perhaps, you know, if you keep doing this, perhaps it's too much cardiology. And this is a cardiologist saying this. And so maybe you should focus on some of the non-cardiac attributes of your training because you're going to spend the rest of your career likely doing MCS and all these fun cardiac toys. So maybe you should focus more on the core tenets of your critical care training that you all are familiar with. So how do we structure our program, which I refer to as a, you know, nested or a track within the pulmonary critical care program? We have the core rotations you see here. We're very lucky to have the leadership of Doreen, of course. And we're very lucky to have multiple different ICUs for patients, for people to rotate in. So in the medical ICU, you get two different experiences and two different MICUs with different practice patterns, patient populations, and two different roles. When you rotate through the first time, you're functioning as a first-year fellow. And when you rotate through a second time, you're functioning as a senior fellow and hopefully leading a second, another junior fellow in that pathway. Same thing goes for the CCU, two different programs. And then in the SICU as well, we have two very different surgical ICUs. One that tends to be more trauma and neurosurgical and critical care. And one that is more lung transplant, liver transplant, things like that. And two different campuses. So it provides a very broad education. And then, of course, you have cardiac surgery ICU with transplants and whatnot in neuroICU. And then we kind of continue that cardiac bent with electives in cardiac anesthesia and pulmonary hypertension, along with including toxicology and some of our bronch and procedural stimulation programs. So your MCS, again, I said we're not going to do too much cardiology. But really, there's MCS scattered across most of these rotations, so people get quite a good experience. The reason I sort of put this this way is that we don't know, just like we don't know what the cardiology critical care training program is, we don't know what the CCC FTE is. What is a full-time job? We have no idea. Everyone's program is different. Are you going to just work in the CICU? Are you going to work in the CICU and the cardiac surgery ICU? Or are you going to work in the CCU and the medical ICU? I mean, the goal, at least from our perspective, is that you probably should be trained to work in the CCU and the medical ICU when you come out of our program. And hopefully, you get enough CVICU experience to kind of learn the job, the rest of it later. But again, as I said, you can see the smattering of other things that are around the outside, transplant, PERT, TE, what have you. There's a lot of skills to add. So we try to provide a setting for people to leave qualified to do these core things. Again, I just want to also add that we have a specific training simulation education program that's actually led by Deepak. And one of the issues here is that it can be a challenge to get three years of procedural experience into one year. Often cardiologists come with a bevy of central line swans, CBPs, and what have you from their fellowship in cardiology. But you have to get airways. You have to get bronchoscopy. You have to meet the same criteria as everyone else. And one of the ways we've been able to do that is that we have a specific focus on tracking people's procedural training. And also, we have this education simulation block that is specified, that is created directly to match what each person needs or lacks during their fellowship. And that has required a lot of time by Deepak and others to train folks in simulation and these procedures. An integrated pathway is also listed. The authors of this article talk more about combining critical care with heart failure or other specialties. I would take integrated to mean the way that pulmonary and critical care are integrated. Perhaps in the future there will be a way for people who are doing cardiology and critical care to intermix their critical care time with their three years of cardiology, much like you do in pulmonary and critical care. It doesn't exist yet, but I would love to see that one day. A mixed agenda is something that I've sort of discussed, I've sort of made up that wasn't in the article. The idea is that there are some training programs that really have an attached focus of additional imaging. So we're cardiologists, there's a lot of imaging going on. Some folks have an additional one or two years of echocardiography. And sometimes there's an additional one or two years of research, depending on which program you look at. And that may help those programs get established for critical care. And right now, if that gets the people in the seats to train more folks, that's fantastic. Again, as I said, these are all up and coming training programs and methodologies. Traditional plus is basically talking, is basically people who do cardiology, critical care, and then want to do something else, like cardiac catheterization or heart failure. This is exceedingly popular amongst our fellows. Not sure why. I think that when you're a trainee, you want to get a job, you want to be unique, you want to have a role, a career. And I was there one day, too. I remember doing a lot of extra training, like cardiac CT that I don't use now. But the issue is that maybe this is too much. Maybe more is not always better. Burnout, if you look at the list of the highest specialties with burnout, we already have internal medicine, cardiology, and critical care. Do you need more? And the issue is that you can do these things, but it becomes challenging. You have many bosses. You're doing call and multiple specialties, multiple holidays and weekends. That can get old very fast. A lot of the folks that I know that do critical care and cath or heart failure, basically when they're off service from ICU, they're just in that other specialty. And it never ends. And I think that's challenging for a long-term career without burnout. But there are others who can discuss that more. And finally, heart failure hybrid is one of the newer thoughts in the field. And the idea here is that maybe if you're doing heart failure already, you can get a special certification in critical care. I think it's important and useful, as you heard about the workforce needs additional help. But it really is critical care lite. It's not the same thing. I think it's helpful. I don't think it solves a problem. Maybe it buys us time. But the discussion is out there amongst a lot of people in the field. So finally, this is the overall image of all these pathways with some of the pros and cons that you can look at further at your leisure. And I think a lot of focus is on COCATs and procedures. And obviously, there is a lot to be done. But that's not really the crux of it. The crux of it is the global training, getting training in all the non-cardiac portions of critical care, and making sure that when you come out, you are qualified to move on forward as you can learn some of these procedural skills and cardiac-specific skills when you're in attending. So finally, just pitch again that the NYU Critical Cardiology Symposium is coming up next Friday and Saturday with a day and a half of didactics, debates, small group sessions, breakout sessions, two different plenary speakers, a global live stream. And for the first year, we have also abstracts and mentorship programs for FITs. Thank you very much. So next up, we have Anne Gage from Nashville. She's going to talk about the role of critical care cardiology in the workplace, a practical approach to a collaborative model. Good morning, everyone. While my slides load, I'd also just like to echo the sentiment of how grateful I am for the collaboration between CHEST and the American College of Cardiology. These are two places that I consider home as a dual-trained physician. So thank you for hosting this. So I'm going to spend about 10 minutes talking about the role of critical care cardiology in the workplace and what a practical approach to collaborative care between cardiac critical care physicians and intensivists looks like. So a little bit about me. My name is Anne Gage, as mentioned. I'm an interventional cardiologist and a critical care physician. So I'm one of these people who did a really long run of training that we can talk about whether I regret it or not at a later time. These are my disclosures. I currently work at Centennial Medical Center in Nashville, Tennessee. So I can speak to the necessity of collaboration in cardiac critical care from my personal experience. So my journey as a critical care cardiologist began in Cleveland, where I did my cardiology training, my critical care training, and then my interventional cardiology training. From there, I went on to be staff at the Cleveland Clinic. I was interventional cardiology staff as well as cardiac critical care staff. And then about three years ago, my electrophysiologist husband and myself decided to move to Nashville, Tennessee, where I joined Centennial Medical Center. It's a large tertiary quaternary care center that is one of the HCA flagship hospitals. I specifically moved there with the task of starting and leading a cardiac intensive care unit. At this hospital, the CICU was undergoing a change in leadership from critical care leadership to cardiology leadership. And so I thought, hey, maybe I can take this skill set that I have and actually start this in a new place and take those challenges head on. So I think that cardiac critical care is a collaborative subspecialty by its inception. So shown here are two of the many critical care physicians to whom I'm indebted for my education and my personal and professional development. Dr. Mireles and later Dr. Chason, the critical care medicine program directors at the Cleveland Clinic, partnered with Dr. Menon to develop a cardiac critical care training program. I was the first person internally to go through this fellowship training pathway, but I was beat a couple years in advance by Dr. Alvear here, who did this program, came in for cardiac critical care as a standalone training pathway. And I think that when I think about collaboration between critical care and cardiology, there are a couple of just general things that I keep coming back to. Critical care cardiology exists because of the willingness of our critical care colleagues to invest in the education and training of cardiologists. I've benefited from this, and I'm grateful for this. When I think about who I am and kind of this whole pathway, I also think that critical care cardiologists are board-certified critical care medicine physicians. And myself and my colleagues, when we approach these kind of conversations, we really truly see ourselves as both cardiologists as well as critical care physicians. So this is a talk about collaboration, and I think we have to talk about what the benefits of collaboration are. Why should we partner at a training level, and why should we continue to partner throughout our careers? The first thing that comes to mind is certainly deference to expertise. There's a recognition that both specialties as well as our patients benefit from collaborative training and practice. There are, I think, benefits of having cardiologists embedded in MICU teams. There is the ability potentially to increase procedural competency and confidence of critical care medicine trainees. Having cardiologists around increases exposure to echo, TEE, POCUS, and cardiac catheterization for critical care physicians, things that are becoming increasingly important in MICU populations. There's also the potential that you have invested in me, I am now going to continue throughout the rest of my career to invest in my critical care partners and the trainees that they have. And so I think that this comes to fruition as that there are more opportunities to train cardiac critical care, or sorry, critical care physicians and their fellows when they're interested in training in CICU and the CVICU. There's potential for additional training in advanced mechanical circulatory support. There certainly, as mentioned, is that now we have invested parties who really want to do multidisciplinary research. And I'm going to speak to this a little bit more, but we know that multidisciplinary team care is really becoming the name of the game in cardiology and many MICU pathologies. So I have just a little bit of data in my talk, but this was from a survey that was sent out by Terrence Hill, who was actually one of my general cardiology fellows in Cleveland. And he surveyed critical care physicians and trainees across the country. And what he found was that, kind of on the right side of the screen, that these physicians, as you would expect critical care medicine physicians, they feel quite competent, performing or confident, performing non-cardiovascular procedures, intubation, managing mechanical ventilation, bronchoscopy, thoracentesis. Where they felt less confident, and this is understandable, I think, by training, is that the cardiovascular procedures they're less comfortable with. But these are things that, again, are making their way more and more into our other ICUs. I think that one of the things that was interesting about this study is that they showed that when surveyed, 88% of critical care medicine trainees did not feel comfortable taking care of the sickest cardiac patients. And so here, I think this goes back to some of these benefits of collaboration. I think we can help with some of these issues that this survey identified. Multidisciplinary team-based care for specific disease states. This is a busy slide, but what I think it shows is that cardiogenic shock, cardiac arrest, PE response teams, and acute aortopathies, all of these are moving towards team-based approaches to their care. This kind of figure up on the top left for you. This is from my institution. Our shock team has at least these five members on the team, and you can see that there is a critical care physician. This is outside, actually, of my own presence or some of my partners who are cardiac critical care physicians, but we believe that critical care is invaluable for approaching our cardiogenic shock patients. But one of the things that I think is that we speak the same language. So actually, when we're on a team, the ability of myself and my critical care colleagues to trust one another, to approach things with a similar thought pattern, that this is a benefit to kind of how our teams function, and we're seeing this across the spectrum. In the PE realm, I do a lot of PE work, both as a critical care physician, as an interventional cardiologist also. I'll put you on ECMO. I'll suck out your clot. I can do all of those things, and I enjoy them, but the PE discussions are certainly facilitated by the understanding that when I'm on the team, that I think that I add benefit in understanding the respiratory failure of the patient in front of me. I'm concerned about whether we're intubating, whether we're going on ECMO first. These are things that not necessarily my cardiology colleagues are innately trained to think about when they approach a PE call. And then in total deference, I have such respect and need for my critical care medicine colleagues that as a critical care physician, I rely on my critical care colleagues for many, many things. But first, it was my foundational critical care training. You guys are the experts in training in critical care. But throughout my career currently, my past career, and where I continue to see myself, I will rely on my critical care colleagues for development of best ICU practices and quality metrics, development of ICU protocols. I think that the critical care world is who's going to continue to initiate and lead many of our critical care trials that will develop the evidence-based medicine that I will be practicing and applying to the care of my patients. And I think that certainly the critical care world has done a great job with lessons in ICU administration, and I can continue to learn from those. I won't spend much time on this, but we've highlighted that there are many workforce issues. There are not enough critical care physicians, period, let alone cardiac critical care physicians, less than 200 of us. So the number of ICUs that are going to be staffed by dedicated cardiac critical care cardiologists are minimal, and that we will, moving forward, the model of care that is most broadly achievable for most hospital systems will be a co-management strategy. And so I think inherently, in order to take care of CICU patients, this is going to require a lot of collaboration. So I have just two slides left, but this is a lot of words, but I wanted to kind of, these are just my thoughts here. So what does collaborative care look like in my day-to-day practice? So I'm the medical director of the CICU. Half of our staff are cardiac critical care physicians, but the other half are advanced heart failure physicians with no critical care training. This kind of means that there's a dichotomy of how our CICU operates from week to week. And when I'm in the CICU, I rely on my critical care colleagues for procedures I seldom perform. I don't do awake fibro-optic intubations, because there are many more people around who are better equipped to do that and do it more frequently. I defer to those. I'm standing there and learning from them every time, but that's how we collaborate. I also really rely on them for cognitive collaboration. When the CICU is staffed by my heart failure colleagues, we employ a co-management strategy, as I mentioned. And I think that, ultimately, the co-management strategy provides continued educational opportunities and continual revisiting of evidence-based medicine that's beneficial for my team and all of the ancillary staff on my team. Multidisciplinary care is also mandatory for our shock evaluations and our PERT teams. So I think, as I noted, similarity of background and training allows for an enhanced level of communication, and it really builds trust on our teams. I work closely with the medical director of critical care. So before this, I was on a one-hour call with our division intensivists. The topic today was our transfer center. These are not things that is a—so this is way more fun than that. So as a cardiac critical care provider, I operate in a much larger system. And so I worked so closely with these people to allow—to develop systems that are going to benefit my patient population in the CICU. This is operations. It's quality metrics. It's protocols. It's also things about supply chain, resource allocation. And then our CICU team is a familiar partner to both the medical and the surgical ICU. So what this means is actually that cardiology consults on critically ill patients but who are not located in the CICU are triaged by our CICU team. We may give these consults to EP. We may give them to our general cardiology colleagues. But we're the first point of contact so that we say, hey, in the same way that cardiac critical care is important, maybe, yes, you're concerned about AFib with RVR, but when we take a little bit deeper look, this patient needs—we would make some changes with the ventilator. We have other things to suggest because of their additional critical illness. And so we take a lot of these consults. And then ultimately, I think this minimizes barriers to interdisciplinary care. So while I have a very optimistic view towards the future of cardiac critical care, I think that it's important that it's a new subspecialty. There has been both positive and negative reactions to our presence. Not everyone asked for us to be here. And I think that we've met appropriate circumspection about who we are and what we do. And so collaboration, great. There are certainly potential barriers to this. I think the elephant in the room is that the adoption of a CICU staffed or led by critical care cardiologists has the risk of marginalizing or alienating our cardiology colleagues and our critical care colleagues and or our critical care colleagues. These people have a wealth of prior experience in our CICU and frequently have significant professional satisfaction from working with our patient population. How do we deal with this? I also think that collaboration must acknowledge your unique political considerations at your institution. I have learned much about this. So if you ever want to know about it, please ask me. I also know that collaboration is a great kind of buzzword, but it requires buy-in from all parties. And so you have to understand kind of the world that you're working in. I ultimately have found in my own hospital that defining a shared mission that clearly defines provider roles leads to enhanced collaboration. And I guess my takeaway from all of this is that the barriers, once we've recognized them and addressed them, that these are opportunities to grow our subspecialty to improve the care of our patients. And I think that today is a great first step for us as far as being able to do joint sessions like this where we can begin to talk about collaborating, acknowledge barriers, and then look forward to the opportunities ahead of us. Thank you. Good morning, everyone. It's an honor to be up here with five cardiologists. I'm used to hanging out with CT surgeons. Thank you to President Doreen Idrizo-Harris for setting this up and Rich Hughes from Live Learning, Amy Morris also, Kaja Horinowicz is in the audience. She's a heart failure cardiologist from Minnesota. Who else is here? Who's pulmonary critical care? Any other cardiologists? How about, yeah, thank you, Kaja. How about medical critical care, anesthesia critical care, surgery critical care, APPs, residents? Outstanding. Outstanding. I'm loading here. I will be very brief. I did a lot of sports growing up, so thank you guys for coming here early on the last day of a conference. We're getting ready for one of our championship events, and our coach said, do you guys want to win? We said, oh, yeah, absolutely. We all want to win. And he said, well, are you guys chickens or are you pigs? We're like, what do you mean chickens or pigs? We're looking at him. He said, well, the chicken just lays the eggs, walks around, lays the eggs. The pig becomes the ham. That's commitment. If you want to win, that's commitment. So you're here committed on a Wednesday morning, the last day of the conference. So thank you for being here. I don't know if my slides are going to load or not. My first slide is Carlos gave me the chance, the task of, thank you. I messed it up the other day, so. Oh, that's OK. I will be very brief. I want to have a chance for discussion. Can't tell you how important it is that we embrace cardiac critical care. We need more intensivists. What the critical care specialist needs to know about caring for a cardiac critically ill patient, everything, everything. That mean that's it, really? So real briefly, and then I'm not going to go through all my slides. These slides from my colleagues up here were outstanding. I got into this by accident, because we go into medicine to try and save lives. I'm in Germany at the end of my fellowship. And we have another level of lung injury. And our servicemen and women that were injured in Iraq, Afghanistan, Europe, they all came through us in launch stool. We would do all the normal things for respiratory failure. Back then, we were using the oscillator. Anybody use the oscillator here? We've got a few. The VDR, high frequency percussive ventilation. We do all that, and they were still dying. But it's young trauma. So you're not going to give up. You're going to keep going. Right down the road, we had the Germans, and they had something called the Nova Lung. So this is pumpless extracorporeal support. And then I still remember the day. It was in November of 2007. I saw a prototype of this device. So this is the CardioHelp. And I said, what is that? I asked Alois, the German perfusionist who would come over. We put the patients. So these are guys who are dying. We put them on the Nova Lung, and then the Germans would come over and take them back to Regensburg because they had the expertise. None of this was approved. And yes, I got into a lot of trouble because I said, you're experimenting on our servicemen and women, but they survived. So I'm here today. If those guys had died in the beginning, I wouldn't be here today. He had, in that November, he had a prototype of the CardioHelp there. And then he said, this is VVECMO for rescue therapy. That led to us going over to Regensburg, hanging out in their cardiac surgery ICU, their medical ICU, and then we stepped into VAECMO from there. I will tell one last story, and then I'll stop. My first day, this is in, it's in the fall of 2007. So that's 15 years ago, 16 years ago, if my math is correct. Maybe I'm a little bit off, but I'm in the ER with these guys, and the ambulance rolls in, and they're doing CPR on an 84-year-old. They're like, okay. The CPR wasn't very good, actually. So that was a problem. The guy was pretty healthy. He fell out on the golf course. They got him on VAECMO in 10 minutes. And I'm sitting there watching. I'm thinking, this is crazy. Why are they doing this? This 84-year-old then went on VAECMO, went to the cath lab, got opened up, three weeks later walked out of the hospital. Now, again, this is one of those experiences, okay, it's a one-off, but it gave me an impression of what can be done. This 84-year-old was alive for, made it until 90. We became friends. I know a little bit of German, so we were talking. It showed me what can be done, and it got me an early entry into mechanical circulatory support. I spent the rest of the next 15 years or so in cardiac surgery ICUs and cardiac ICUs. And this is really the basics of you need your ventilator. We talked about it. Here I'm thinking about what can we, as pulmonary critical care physicians, what do we need to learn so that we can augment our cardiac critical care colleagues? And we need to know the basics, obviously, your vent, your sepsis, your, that's a next day dialysis machine. Mechanical ventilation still defines the modern ICU. As you saw from previous papers, almost over 50% of all the admissions to your cardiac ICUs, cardiac surgery ICUs, they're all on the ventilator. And I will commend my colleague, Carlos, who gave one of the best lectures on ventilators when I was in Minnesota with him, and I was like, he missed his calling. He should have been a pulmonologist. He had his kids up there, said his kids love, he loves the blower, his kids love the blower. But extracorporeal support will define the future of the ICU. Critical care providers from all backgrounds, we need to know shock, need to know PA catheters, obviously echo. We need to be able to learn that. The cardiologists are going to be better at it than we are. That's fine. But we can at least learn how to look, and you'd be surprised. Even if you can't get great windows, you do it long enough, you can tell when something's wrong, when you need to call people. And from all backgrounds, we're going to need to know shock, how to manage brain injury, transplant, both heart and lungs, mechanical circulatory support and ECMO, if the heart is sick, whether it's acute or chronic heart failure, balloon pumps, Impella 5-5, or the CP, centromags, if you don't need an oxygenator, and then if your heart and lungs are sick, then you're going to go right to VA ECMO. This is just a partial list of things that we would need to know, that these are just skills. When I read Ann's paper, I was reading Ann's paper with my wife, that graphic, the Venn diagram where you had the overlaps. My wife is a geriatrician. I'm trying to turn her into a geriatric ECMO physician, but she doesn't like it. She said, that sounds like a nightmare. So you need to know palliative care. But we were looking at that Venn diagram from Ann Gage's paper, and she's like, wait a minute, this is your skill set, and this is just what I evolved into because of where I worked. And it was mostly on-the-job training for me. How many here are from community hospitals? Okay, a few, a few. This is a challenge for us. Real quick, 84% of the hospitals in this country are community hospitals. We don't have all the big cardiac ICUs. We don't have lung transplant. Don't necessarily all have all the mechanical circuitry support devices. Well, what's the problem? Our patients are not where they need to be. They're not in the centers that have your cardiac critical care doctors. We need to get them to places that have all the resources. There's an amazing amount of missed chances to intervene early. Cardiac critical care is going to help us educate out and around our bigger centers so we can recognize shock and ARDS early and get them to bigger places. More collaboration and cross-fertilization. And then this is the swan has returned. We all need to know the swan. I'm going to end here just because I know we want time for questions and discussion. Can't tell you how important I think this is. We need more intensivists. We need more cardiac critical care intensivists. And I'm glad that CHESS can partner with this elite group. These guys are some of the leaders in the field of cardiac critical care, have contributed a tremendous amount to the literature. So thank you.

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