Congenital heart surgery continues to evolve and advance as the field’s leaders explore new frontiers on a quest to improve outcomes and the patient and family experience—regionally and around the world.

David Morales, MD, newly appointed executive co-director of the Heart Institute at Cincinnati Children’s and director of Cardiothoracic Surgery, shares his insights and vision for how congenital heart surgery is progressing with the next generation of clinicians—and how the Heart Institute is moving this forward.

Global and Virtual Collaborations will Improve Surgical Outcomes

As congenital heart surgery care evolves, the Heart Institute is expanding its national and international collaborations across numerous platforms to improve patient care globally, educate current and future physicians and surgeons, and foster the development of new innovations. This work continues to gain importance as it trains more surgeons and gives more children access to lifesaving care around the world. This can be seen in their cutting-edge work with virtual surgical planning for complex congenital heart defects and for the use of ventricular assist devices (VADs) to support those children with failing hearts. 

The Heart Institute has pioneered the use of VADs for children awaiting a heart transplant or other surgeries. The Heart Institute team is also highly skilled in implanting total artificial hearts.

The Heart Institute’s work with VADs has positioned Cincinnati Children’s as a national and international leader in pediatric VADs and enabled a national learning network. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) now includes more than 57 pediatric hospitals across North America. The Heart Institute houses the ACTION operations team and data coordinating center.

“We are fortunate to have been helping lead the development of the pediatric VAD field,” Morales says. “We train many clinicians as well as test and teach others about new VAD devices around the world.”

A similar community dedicated to virtual surgery for congenital heart surgery has been started, which Cincinnati Children’s is helping to lead and develop across the country. Collaboration improves care and quality of life for children with congenital heart conditions around the world.

“We’re creating a metauniverse where a surgeon in Japan who wants to talk to an expert in the USA or anywhere can connect through our platform to plan out a complex surgery using their patient’s actual CT [computed tomography] or MRI [magnetic resonance imaging] scan in the virtual space just like our kids play video games with people around the world—the whole point of this line of investigation is collaboration, research, education and innovation,” Morales says. “We want to impact how care is delivered in many different places.”

Opportunities include:

• Plan and simulate. Cincinnati Children’s has virtual platforms that allow surgeons to simulate and plan complex congenital heart procedures in advance. They also allow surgeons to experience or plan out rare surgeries as a community that they might not normally encounter. Technology allows surgeons across the nation and the globe to connect with each other through virtual reality goggles. “If I have a difficult case, I can call a colleague, and we can both explore the patient’s actual CT/MRI and try different surgical approaches until we find the best one,” Morales says. “We all learn together.”

• Teach and train. Virtual surgery opens avenues to educate and train residents, fellows and surgeons around the world. From straightforward heart procedures like atrial septal defect closures to more complex surgeries like complex biventricular repairs, virtual training is an effective tool, Morales says. This improves care in more remote places without access to heart experts. It also allows more clinicians to access training without the cost of travel. The Heart Institute already works with colleagues in Florida and Tel Aviv and has relationships with others in Europe and Japan. The in-house developed platform will be able to translate what is being said in over 10 languages to each surgeon’s native language.

• Educate patients and families. Virtual technology allows a surgeon to walk parents and older patients through an upcoming procedure so they can see what will take place. “For older children, it can ease their mind because they can actually see and experience what we are discussing; it is no longer a black box,” Morales says. Despite multiple explanations from a care team, several families say they didn’t fully understand their child’s heart defect until they put on the virtual goggles.

Robust Research will Advance Care

Just as collaborations around virtual surgery and VADs expand treatment options, research drives ongoing improvements in congenital heart surgery. Large-scale studies impact care for children on multiple levels, from diagnosis to transplant and everything in between and after surgery. The Heart Institute’s research lab publishes more than 250 papers a year, educates medical students and collaborates with eight other divisions at Cincinnati Children’s.

The Cardiothoracic Surgery Research Lab is active with multiple lines of research from large outcome studies using artificial intelligence, large animal studies, tissue engineering, co- development of devices with industry, and genetics.

The lab currently has two National Institutes of Health R01 grants for which Morales is a principal investigator. The grants are studying:

Using machine learning and artificial intelligence to distribute donor organs more efficiently. As an institution that specializes in heart and multiorgan transplants, Cincinnati Children’s focuses on improving how thoracic organs are distributed across the nation, so children attain better outcomes. Dr. Morales and the Heart Institute are using data to make the best match between a donor heart or lung and a patient.

• Using virtual heart transplantation (calculations of total cardiac volume) to determine organ sizing, instead of listing candidates with acceptable donor weight
• Creating a system focused on determining best matches to extend life for patients post- transplant
• Increasing overall survival for the transplant community by approximately 30%

New ways to anticoagulate children on devices without causing bleeding. Along with the division of hematology, the Cardiothoracic Surgery Lab is leading an R01 investigation that hopes to improve care for children placed on mechanical circulatory devices. These children need blood thinners to prevent clotting, yet have a high incidence of bleeding and thrombosis, especially in the brain. The difficulty comes in finding the right coagulation management for each child and each device.

Regionalization will Expand Access

As expert centers like the Heart Institute share their knowledge with congenital heart colleagues around the world, one take away is clear: Patients benefit from regionalized programs, Morales says.

“Every child should have access to the same level of care no matter where they are born or live. That shouldn’t change the care you receive,” Morales says.

Programs that perform limited number of surgeries a year have difficulties keeping their staff, surgeons and the team performing its best especially given the wide variety of operations performed by a congenital heart surgery team. Surgeons and surgical teams at high-volume centers have more experience, particularly with more rare and complex cases. By developing regional collaborations, hospitals can ensure the best access to the best care and outcomes for all children.

The Joint Pediatric and Congenital Heart Program between Cincinnati Children’s and Kentucky Children’s Hospital is a good example of regional collaboration. The program ensures the same quality of congenital heart care for everyone throughout a geographic region through a one-program, two-site model. The Joint Heart Program offers a full spectrum of pediatric and adult congenital heart care across both sites—including cardiac catheterization, electrophysiology, surgery and transplantation—from the world-class cardiology experts and heart surgeons at both Cincinnati Children’s and Kentucky Children’s.

Morales wants to expand to additional sites to cover a larger region in Ohio, Kentucky and Indiana. As more sites and surgeons join the program, he envisions a division where every surgeon performs all surgeries, but each surgeon is also an expert in a particular area of focus.

“You don’t need to be the division chief to be the expert,” Morales says. “I want to break that mold. Our program should be known for each of its surgeons and their area of expertise.”

Morales strongly feels that what the cardiothoracic surgery team has accomplished and plans to achieve is only possible because “we are surrounded by an outstanding interdisciplinary clinical and research team.”

Visiting Lectureship: Honoring Dr. Tweddell

A new visiting lectureship launches in Spring 2023 to honor James Scott Tweddell, MD, executive co-director of the Heart Institute.

The world-renowned cardiothoracic surgeon passed away in July 2022 from cancer. He was a leader, innovator and teacher in the field, and this lectureship commemorates his achievements.