Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Allison Williams: Hi, I'm Alli Williams, one of the pediatric hospitalists here at UPMC Children's Hospital of Pittsburgh.
Dr. Sameer Agnihotri: I'm Sameer Agnihotri. I'm an assistant professor in Department in Neurosurgery at Children's Hospital.
Dr. Williams: And welcome to "That's Pediatrics." Today we are talking with Dr. Bryan Goldstein. He is one of our pediatric interventional cardiologists and the director of the Cardiac Catheterization Laboratory and Interventional Cardiology Services, as well as an active researcher. Thanks for being here today.
Dr. Bryan Goldstein: Thank you so much for having me. I really look forward to the conversation today.
Dr. Agnihotri: We're very excited to have you.
Dr. Williams: Absolutely. Can you tell us a little bit about your journey to your career path working here at UPMC Children's Hospital of Pittsburgh?
Dr. Goldstein: Yeah, that's a big question. So, the pathway is interesting, of course, undergraduate and medical school and then, sorry, undergraduate medical school and then training in pediatrics.
So I trained in Boston Children's. I grew up in Boston and trained for my pediatrics at Boston Children's, and then my wife and I and our young 10-month-old moved out to the Midwest. We moved to Ann Arbor, Michigan, and I did my pediatric cardiology as well as interventional cardiology training at University of Michigan in Ann Arbor. And then my first faculty position was at Cincinnati Children's where I was for almost a decade and moved here just before the pandemic started at the end of 2019 to join the Heart Institute and Cardiology Group at UPMC Children's where I've been thrilled to be a part of for the last two and a half years.
Dr. Williams: Sounds like you've progressively made your way back to Boston. We hope that we've captivated you here in Pittsburgh for quite some time 'cause you've done some great work here. Tell us a little bit about the interventional cardiology services here.
Dr. Goldstein: Great, so the “cath lab,” as it's colloquially termed, we have two cardiac cath labs and we have a group that provides interventional diagnostic services or invasive procedures as well as electrophysiology, which is a separate service line using the same physical space, and we're in the process of upgrading.
As we've grown, our needs have grown as well, and so we're in the process of developing actually a new physical space that'll be an exciting expansion for the Heart Institute at UPMC Children's where we'll have three cath labs. We'll have cardiac MRI, and then a separate cardiac focused prep and recovery unit called the CPRU, or Cardiac Prep and Recovery Unit for patients. And that will be an exciting new feature for the interventional cardiology service line but in addition for cardiac MRI EP as well as other service lines that touch our space. We have three interventional cardiologists, including Dr. Sara Trucco and Dr. Jackie Kreutzer, who's our boss, chief of cardiology, as well as a couple of diagnostic cardiologists perform work in patients who have had heart transplantation.
Dr. Agnihotri: That's fantastic. Bryan, can you tell us what your long-term vision or what you foresee the future to be in cardiac intervention over the next, say, five years, 10 years?
Dr. Goldstein: Yeah. That seems like a one liner.
Dr. Agnihotri: Or if you had a magic wand, infinite budget, infinite staff, where's the future going?
Dr. Goldstein: Yeah, so I think there's a couple of ways to answer this question, and we can touch on a little bit of each of them. First is what's clearly happening in both adult and pediatric cardiac spaces, as well as I think probably the rest of medicine, is we're moving towards increasing utilization of more minimally invasive procedures to accomplish similar tasks. So whether that be neonates who need a surgical procedure to accomplish a source of lung blood flow that's safe to get them through until their next palliative procedure, we can now do that using the placement of corona artery stents in the patent ductus arteriosus, or PDA, in order to avoid a first aid surgery and deliver a patient who's three, four, five months old to the OR for the first time for their gland procedure. Or it's a patient who had tetralogy of Fallot repair as an infant and at age 15 or 20 or 25 or sometimes earlier or later than those years needs a pulmonary valve replacement because of the injury to the pulmonary valve at the first surgery. We can now do that in almost all patients in the catheter laboratory.
So there's clearly a move towards being able to treat patients with less open surgical procedures and more highly advanced new technology-driven, catheter-based, minimally invasive procedures.
But more than that, it still remains a physiologic laboratory, hence the name of Cardiac Catheterization Laboratory. And so we learn a lot about patients each time we treat them in the cath lab and can utilize studies to better understand what we're seeing and how to treat patients.
And so the relationship of cath and MRI in the new space, which will be physically adjacent with a door between them that allows patients to move from one space to the other or even have a catheter procedure driven exclusively by MRI and avoid use of radiation is really another place that we're going that's really important for families and patients because we know that radiation causes cancer. And so avoiding or reducing radiation will cause less cancer, and that has to be a good thing in patients who already are burdened with congenital heart disease.
So I think those are probably two really important places that the space is going. I'm sure there will be other and new avenues we explore, though, over the coming years, too.
Dr. Agnihotri: Right, and towards that, are there things that the listeners today could do both in the scientific community, medical community, and just patient families to help support you and grow your program and other things that you would want?
Dr. Goldstein: Yeah, that's great. Well, we're making a new space here, and it costs a lot of money. So there is a big capital key campaign going on through the Heart Institute to try and raise funds both for capital spaces for the physical plant but really more importantly for all of the things that we need to be successful in the new space and in our current space. That's resources, staff, infrastructure for the research we do for some of the clinical care we deliver. It is helping to who fund the vision that we have to try and reduce the use of radiation and cardiac catheterization.
So I'll give you a complex answer, but currently, the MRI systems that we use for diagnostic cardiac MRI, they're interfered with. They actually are affected by or affect the devices and systems we use in the cath lab. All the stuff we have is metallic, and the MRI is impacted, and the MRI impacts the metallic stuff. So we can't use MRI for guidance of this. Companies who make all of these products right now are not particularly incentivized to generate new low-metallic or non-ferromagnetic metal-based products, and so there's a lot of work being done to understand if industry's gonna move towards where we are as a space or if the space is gonna move, and we're gonna use a lower Tesla MRI that doesn't have as much challenge with the standard metallic devices.
But really, what I think we really wanna focus on in a lot of ways is understanding the impact of what we do. So it's one thing to miniaturize the technology to reduce an operation. For example, we're doing a lot of closure of the patent ductus arteriosus in preemies. So you're born in 24 weeks, you have a PDA, and it can really adversely impact your cardiac circulation as well as invoke a lot of lung disease. So we think it's the right thing to do to close the PDA, but historically, research has shown that the surgical closure of PDA creates a lot of new disease from the operation, and so kids don't necessarily do better after having had their PDA closed. We can now do this in a 15-minute procedure in the catheter laboratory without invoking all of the challenges induced by doing a thoracotomy, and studying that's complicated. The companies only wanna pay to make sure the device is safe and not really test whether the therapy is the right answer.
And so we, as a community, want to study this. We wanna understand the outcomes of what we do. And so we're very focused as a community, but we have a research collaborative that's really focused on really studying the outcomes of congenital heart interventions, whether they be surgical, medical, or catheter based.
Dr. Williams: That's what I was just gonna ask you 'cause I know that you do a lot of research. So you're using the we term, and I don't think for you, it's the “royal we.” You are actually included in this, which is amazing. Can you tell us a little bit more about the research collaborative that you're working on? I know it's multicenter, but that's about the extent of my knowledge.
Dr. Goldstein: That's great. Yeah. This is a huge passion of mine that has maybe become evident to the way I speak about it, but a colleague of mine and I developed this back in 2014. It's called the Congenital Cardiac Research Collaborative, or CCRC, and we now have about 15 or 16 centers that partake in the multicenter research that we do.
Historically, we have done what we term retrospective research, focused on collecting data from patients who have undergone a particular procedure or, more importantly, have a particular diagnosis and need a potential group of different procedures. And we collect data to try and understand what pathway's best for these patients.
We've done this with neonates who require a stable source of pulmonary blood flow, which is typically carried out with a BTT, or Blalock-Thomas-Taussig shunt. But more, recently we've used the PDA stent concept. So we've studied that to understand the implications for patients with this.
More recently, we've studied in patients who have tetralogy of Fallot and are symptomatic. They're blue, cyanotic, as neonates and need a procedure. There's eight different procedures that this group can have. And there may be anatomic differences that drive that decision. There may be center or practitioner differences that drive that decision. There may be family interests that drive that decision, but we don't know which decision is right in which patients.
And so we put together a group of 600 plus patients from nine centers to answer that question. Now moving forwards, we've recognized that there are challenges or limitations to retrospective research, and so we're starting now to do prospective research. So our group is leading through the NHLBI and the Pediatric Heart Network a project looking at patients who need a stable source of pulmonary blood flow as neonates, and they could either be randomized to the first ever congenital heart disease trial of a surgical and intervention, which is BTT shunt, or a catheter intervention, which is PDA stent. First time that that's ever been done, and we're really enthusiastic about being a part of it in UPMC Children's Hospital of Pittsburgh, but really also as the CCRC collaborative driving this effort to better understand how to treat patients best, recognizing that there probably won't be one answer for all patients but understanding in whom which therapy is better is really exciting to embark on that journey.
Dr. Agnihotri: Can you elaborate a bit more on this personalized medicine and also your journey through NIH funding and other funds through the American Heart Association? You've established such great research program. And can you let us know a bit of your exciting projects that you're willing to share with us?
Dr. Goldstein: Yeah, yeah. There's-
Dr. Agnihotri: Behind the scenes.
Dr. Goldstein: Yeah, absolutely. I appreciate it. I think funding in cardiology, as in probably many pediatric subspecialties, can often be a challenge, and I think recent funding cuts to NIH and the pressures from COVID have not made that easier for those of us outside of the COVID research space, if you will.
The Pediatric Heart Network is an existing now, I think it's in its 20th year, existing multicenter research network in pediatric cardiology focusing on either congenital or acquired heart diseases that has a stable source of funding from NHLBI and NIH and, in turn, funds projects that deems relevant to fund. And I have been a part of that organization for a long time when I was in Cincinnati Children's, and we remain a part of it now working on a number of the individual trials that are being executed through the Pediatric Heart Network, which is a great organization because it allows us with an established infrastructure to gain on a lot of efficiencies.
There's established data according, et cetera, et cetera, to be able to execute these complex trials for relatively modest cost. But one of the things we learned is that it's expensive to go collect data elements at every patient level. And our research group, the CCRC, has really worked hard to develop not just retrospective studies but a process to collect data from patients.
So we actually launched an advance of the clinical trial. We launched what's called the CCRC Registry, which is this large multicenter registry collecting data on discrete patient populations of interest to us and the folks who work with us, and that is other researchers, investigators, folks focused on quality, as well as patients and families. We have a family advisory board who gives us their advice as to what diseases may be most interesting to study and what outcomes are most important to them to assess. So the CCRC Registry, turns out, will be a major data source for the upcoming trial called the COMPASS Trial. So we've integrated a quality registry with a new prospective clinical trial.
In terms of the precision medicine question, that's a hot topic, of course, and we will have our toes in the water probably related to the genomics part of this because there will be blood samples drawn to a biobank for these patients. But I think really by having a prospective trial, we'll be able to understand what sort of patient level characteristics and factors are associated with better or worse outcomes of a particular therapy and be able to suggest which pathways may be best for which patients at a modest level. I think that's really important.
There's clearly no one size fits all strategy in pediatrics, and the challenge, of course, is compared to our adult colleagues who maybe, in a month and a half, do a 10,000-patient stent trial, it'll take us two years to enroll a couple hundred patients in this trial. And so we will get into the details of, I think, strategy and therapy in patients, but there's no way we'll know everything in any individual trial, no matter how adventurous and enthusiastic we are about it.
Dr. Williams: The work that you've been doing is just amazing between the multicenter collaborative, and there's just so many positive outcomes for patients with all the work that you've been doing. And you've talked so far about the new center that y'all are building here, and I assume that's in the Lawrenceville area. Is that correct, or is that center elsewhere?
Dr. Goldstein: No, it'll be at Children's. It'll be at Children's [in Lawrenceville]. It's gonna end up being a new physical space that doesn't yet exist at Children's, but it'll be integrated right into the hospital and the rest of the campus and in a way that makes sense for our patients who move back and forth between the different places.
Dr. Williams: That's amazing. So not only are you touching the lives of those outside and the nation but you're also directly gonna impact our community here in Pittsburgh, which is one of the things that I know UPMC Children's Hospital of Pittsburgh really thrives on, especially being a top 10 pediatric hospital, which is in large part due to the cardiology department here, which is also a part of that amazing rating that we have here.
The question that I have for you, too, is just related to the UPMC Children's growth that we've been seeing. We're starting to have more pediatric opportunities up in Hamot and over in UPMC Northwest. Is there any thought with the interventional cardiology department moving into more of our community centers, or are we mostly gonna focus on bringing our patients still here to the Pittsburgh area?
Dr. Goldstein: Yeah. Great question. Clearly, I've even, in only a couple of years, witnessed the growth of UPMC Children's in the region, which is terrific, and I was lucky enough to be recruited to join a program that was and is ranked the number two pediatric cardiac and heart center in the country, which is incredible. And so our reach, I think, has been in some ways at the tip of the spear for the reach and growth of UPMC Children's has been seen in the cardiac program now for some time.
We have patients who come to us from Philadelphia, from Boston, from Florida, from Texas, from West Virginia, and locally. One of the things we've tried to do to scale the growth within pediatric cardiology is develop relationships with the centers that either have or don't have association with UPMC Children's directly but are in the region, specifically the neonatal groups, in order to create a conduit or an opportunity for a safe, minimally invasive closure of the PDA in premature infants, and so we have that network pretty well established.
Unfortunately for us, our care is highly expertise and requires a high investment in both people and technology, and so that infrastructure is and will only exist at UPMC Children's, I'm sure, for a long time. But the ease of getting patients and families to us both virtually and to meet with us understand that this is a decision they wanna make to come here, and then getting them here and providing supports around their visit and stay are all actually quite mature at this time and work really well.
Dr. Williams: That's awesome. Well, thank you so much for coming today. Thank you for explaining to us and to all of our listeners the growth and development that we're having here at UPMC Children's Hospital of Pittsburgh. It's really exciting, both clinical and research.
Dr. Agnihotri: Truly an honor to have you here, and as long as you're not a Boston sports fan.
Dr. Goldstein: Go Sox.
Dr. Agnihotri: There it is.
Dr. Williams: Oh!
Dr. Goldstein: But I appreciate that. No, it's been quite an honor for me to be here and be a part of this today, and I wish you much luck with all of the growth at UPMC Children's. It's exciting to be a part of it.
Dr. Agnihotri: Thank you much.
Dr. Williams: Thank you. We hope everyone out there has a great day, and thanks for listening to "That's Pediatrics."
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