Morning, everyone. Thank you so much for joining our session. I'm Kim Pfeiffer, along with my colleague Robert Bunney. We will be moderating this session today. I hope you all had a good time last night at our networking session. There will be a question and answer period after the presentation. Dr. Sandeep Krishna graduated from UMKC School of Medicine. He did his cardiology fellowship at the Cedars-Sinai Hospital, where he was selected for the ACC Merr Fellowship, which was awarded to only four fellows across the country. He did his Interventional Cardiology and Structural Disease Fellowship at the University of Washington in Seattle. He's had multiple leadership positions in medical education, including serving on the ACGME Board of Directors as a resident member. Currently, he is the Director of Structural Heart Diseases and Heart Failure Programs at King's Daughters Medical Center in Ashland, Kentucky. Under his leadership, he has increased TAVR volumes, in fact, increasing their volumes over the past 12 months by double, modernizing their program, and started the fastest growing watchman and mitral clip program on the East Coast. Please join me in welcoming Dr. Krishna. Thank you all so much for having me today to talk to you about building blocks for a successful structural heart program. I'm really looking forward to the opportunity, and I want to thank the ACC for giving me the chance to speak with you and share my experience, my own little experience over the past few years at King's Daughters Medical Center. And I get to talk on behalf of the entire team here at King's Daughters. Everything you see here has truly been a team effort from the ground up. So I just want to be remiss to not mention all my teammates that have made this a smashing success for us. So without further ado, I'm going to give you a little bit about me. You've heard from Tim about my background. I've traveled all over the place, starting in the Midwest. My family and my parents still live in Missouri. I've been over in Atlanta for residency and then out to the West Coast for more of my subspecialty training. So I've gotten to see a lot of different systems. And I have some recent publications which really go into detail a lot of the topics that I'm going to share with you today. So the four citations you see here are actually all from ACC's Cardiology magazine. I think the first one was in November, but if you just type in my name, follow my ACC Cardiology magazine, there's a four-part series that I've written and that's available to anyone free on Google. If you just go for the PDFs, you can kind of get more details if you want some more details as to how some of these things were done in our program and some of my tips and tricks for growing programs. So just to kind of paint a picture and give you some context of where I live. So I live in Appalachia, and that's a pretty big area. It's kind of this whole area here. You can see my pointer. But the specific area is called Ashland, Kentucky. So it's right on the border of Kentucky, West Virginia, and Ohio, as you can see. And so it's unfortunately a very poor part of the country. As you know, West Virginia is, I think, one of the poorest states in the entire country for habitat. And so this population is very similar to that of West Virginia, unfortunately. And so patients have very limited resources. There's not a lot of big cities close by. Just to give you a sense, Cincinnati and Lexington are about two, two and a half hours away. For patients, Louisville is three hours. Columbus is also two and a half hours. So it's really not easy to get anywhere. Queensland is way back here. So if you kind of zoom in, you can see that here are the big city centers, Lexington, Cincinnati, Charleston, Huntington. Charleston is the biggest town in this part of West Virginia, and also the capital of West Virginia. But they have a full-blown structural program, but it's difficult for patients to make it that hour. So my goal when I was referred here was to really create a full-blown, commercially available structural heart program. So that includes transcatheter edge-to-edge repair for the mitral valve, CABR, and blood-vascular appendage exclusion. So just actually earlier this year, I'm pleased to share that the team here has applied for, and the team, we already had the Chesapeake Center accreditation, as I'm sure many of your centers do, but we applied for the transcatheter valve accreditation, and we're accredited in the first quarter of this year, and for the heart failure both inpatient and outpatient. And I want us to be able to apply for the ACC's Heart Care Center of Excellence. And so we're proudly displaying that for our patients in our waiting room, and this is a flyer outside from the hospital on one of the lampposts. So, again, as I promised, a little bit more about me. My journey over the past two and a half years has really got me interested in how we can reduce disparities in delivering care to patients. And I'm running geographic and socioeconomic disparities every day, and that's really bothered me, and I've noticed that so many of my patients who are just as deserving as the next person are just automatically excluded from a lot of the higher levels of care just because they live in a very rural part of the country. And the difficulties my patients face are not so similar to the difficulties some of your patients face. They may have to drive a long way, gas isn't cheap, money doesn't grow on trees as my dad used to always remind me when I was growing up. So they really struggle to make ends meet sometimes. So I have, to that end, been very interested in looking at how we can improve our systems of care, and I'm actually in the middle of getting my MBA at Wharton, and so I put this slide up just to share that with you. And I actually have a separate talk that I give specifically on disparities in structural heart disease, because that is a new area. And we'll touch on that briefly, but I think a lot of these things, if you focus on a business case for growing a structural heart program, you're going to automatically deal with a lot of these disparities. So it's very important that these things go hand-in-hand. So here are the volumes that we've done, and this is actually the first one of our cardiology and everything I just articled out in public. I just pulled this right out of there. So I joined the program around fiscal year 2019-2020, and so we're not doing any MitraBud, we're not doing any Watchman procedures. And when I say MitraBud and Watchman, I mean CDER and the LAA, just to be clear. But the TAVR program stagnated around 20 to 30 procedures a year, so my goal was to expand the TAVR program number one and then start a successful and sustainable MitraBud and Watchman program. And so you can see, it really has tremendous exponential growth. We're now doing over 100 TAVRs a year up to 40. We're on track to do about 50 or 60 MitraBud procedures a year, and we're on track to do about 200 Watchman procedures for this fiscal year. So we actually only have one nurse practitioner for support, we just hired two LDMs. So you may wonder how we do this if we truly have a superwoman for our nurse practitioner. But we've run into a lot of challenges and roadblocks. When I talk to my colleagues and folks that talk to me about their programs, they have mentioned many of these things. Anesthesiology block time. Lack of capital and space and time to do cases. Unsupported colleagues. Lack of administrative support. Lack of referrals. Patients are referred but don't come to clinics or the patients don't follow up. Problems with echo reads or something else. I think there's a number of other issues that come up, but these are probably the most common. So if you find yourself in one of these positions, don't fret, we can deal with it. I think we're as well served in a way. And so some of the learning objectives for today, I call them the six steps for program building success. One, to focus on really developing a business plan. And then finally, how you can leverage the resources you have provided for you by the ACC for success of your program and for your institution and for your operators and yourselves. So the first building block of success is that you have to learn to be a copycat. There's nothing wrong with that. In fact, it's quite cute as you can see here. So when I say be a copycat, visit other centers. See what they're doing. There's a lot of small centers, sorry, centers maybe in smaller cities you may not have thought of that are potentially doing a lot of volume. And sometimes it's easier for them to do volume because they have kind of a closed system like me. But it wasn't always easy, right? So they had to build their own volume and they had their own journey and their own stories. And that's what I did. I got a lot of help from talking to colleagues and going around the country and visiting places. So I learned from different support structures, meaning some places have three MPs and no nurses. Some have only nurses and one nurse practitioner. And it's still dependent on whether it's a private practice or another reimbursement system is set up. So it's going to really vary depending on the nature of the system here. And to keep that in mind as well, so it's not that you can totally copy everything but you can at least get an idea. And so I've got two examples of AAHA, the Arkansas Heart Hospital, and hopefully somebody in the audience here has this meeting at the Arkansas Heart Hospital and they're really doing some phenomenal things. I got a chance to meet Drew Jackson, who is the president of the organization, and see exactly how they have tackled some of their challenges. And one innovative thing that they do is they actually have a stenographer running the transesophageal echocardiotary microblast. And so that eases a lot of the imaging difficulties that a lot of centers have, or at least the intra-imaging difficulties. And I visited Dr. Hashimi in Mobile, Alabama, who's really done some amazing work in a private practice model to grow his practice in his private practice group. And they do a lot of very high-quality microblast procedures there. And so I learned a lot from visiting them. So step number two, strategic alignment. And that means, and that's kind of a very business school type jargon, but basically what that means is, what is your vision? And I'll always say, what do you want? And what does your employer and health system want? And those two visions, ideally they should be one. In reality they won't be, but you need to get them as close as possible. And hopefully align in some ways to get to the point where you can share resources and you can get on the same page. So really be realistic with your administrative teams. If you're an administrator and you're trying to support your physicians to get them to do more cases or whatever the case may be, understand what their concerns are. Have an honest discussion. Sometimes it's going to be uncomfortable. Uncomfortable is good, because that's how we grow. Being part of conversations where it's, you know, everything is rushed under the rug and really the hard issues don't come up, don't help us grow and don't really bring the program forward. And the growth of our program, we continue to have conversations every day. So I had one this morning. So it's part of our program growth and we continue to get better as we challenge ourselves and we challenge each other. So look for that common ground and that's how you truly align. I know I've been really giving broad strokes here and so I'm happy to get more granular during question time and always happy to discuss offline as well. My contact information, the moderators can make that available to you. So feel free to reach out any time. But it's certainly of interest to me and this is a very important step. So learning your GR, you know, it's one thing that when I was interviewed for my position here, I got a map out and said, wow, this is in a very rural part of the country. So what does that look like? So I put this together and my wife deserves credit for putting this together. When I say I put it together, I mean I screenshot it and put it on the slide and she did the hard work. So she really did an amazing job of getting a county level map and superimposing the data from where our patients were coming from in 2019. So before I joined, our patients were just coming from these five counties around Nashville and we had no extension to West Virginia whatsoever. And this is just for our structural recovery. So at that time it was only a tavern. So after we started opening up to MyTripBuff and Watchmen, and I did a lot of outreach and not so much outreach in the traditional sense of going out and doing outreach and clinics and what not. I used a lot of telehealth but what I did do is I did a lot of educational outreach. So I went out and had dinner with a lot of doctors and their staff and talked to them about when to refer for MyTripBuff, when to refer for Watchmen, etc. And shook a lot of hands, shared a lot of cell phone numbers and made sure that they had an easy way to reach me and made it very easy to refer patients. And there's a bit more to it but for the most part this is what that looks like and this is kind of the success you can have. So now we have this hundred mile radius reach and we're doing an amazing thing for these geographically challenged patients. So just to give you a sense, Charleston is way over here so we haven't even reached kind of our nearest competitor on the West Virginia side. These magenta dots represent other global and structural centers. This is Lexington, that's Cincinnati, this is a very small town in southeastern Kentucky. So that's also about two and a half hours away. So really we're doing a great service for our patients and I don't see any of these dots as competition, I just see them as additional ways for patients to get access to life-saving therapies. So I'm really encouraging, in fact I'm working with one of the law schools here, it's called Marshall University in Huntington, as hopefully I think they're bringing their structural health program online and that's something I think that would be a great service to this community. I mean they certainly need, we need all those centers that we can get at full hands on deck, especially in this rural area. So you have to know where your patients, what their options are. Now if you live in the middle of an urban area, it's going to be different, right? You are competing with a hospital maybe down the street and that is kind of your application and that's okay too. I think there you have to get a little bit more business savvy but then understand well why should patients come to hospital A instead of hospital B? What can you offer from a service perspective that the other competitor cannot offer? And we'll get into that in a second. And they're the most important thing that I think that the law sometimes gets over, where are the other medical centers in your area without a structural health program? Because these are your referring hospitals and you can consider them as in network. So what that means is that if you can develop relationships with the physicians there, that's going to go a long way. And when I say relationships, I mean really focusing on ways you can leverage whatever they can do. So for instance, we have a hospital that's about an hour away from us that does not have a structural program but does have everything except for one. They can do pacemakers, they can do SENS, they do have open heart surgery but there's no Canberra or Microsoft or whatnot. So I've said to them, hey, I want you guys to have all the revenue you can. I want to keep it local. Rural hospitals need all the revenue they can get because they're at risk for closing. They're financially becoming harder and harder to keep open. And it's more convenient for patients to be able to have their heart cath and their echo and whatever other pre-op testing they need and putting their tests in done locally instead of having to come to us an hour away each time. So we've really done it for the patients, we've done it for the centers, and so we've formed this relationship where they do all the work up for us and they electronically send us all the amnesties. The Canberra CT, the pre-op blood heart cath, the mountain echoes, the TEEs, whatever we need, they get done. And the patients love it. We do a lot of telehealth with the patients to keep them updated and avoid them having to come and make trips. And then the patients will eventually meet both the surgeon and myself up in the case of the Canberra and they'll come on the day of the procedure and do the same thing for the follow-up. We don't need to do all the follow-up. We just need to keep that relationship going with our referring providers and they do all the work for us and they send us the 30-day echo images and then we get those reports and send them to our registry folks for the NCDR and we've got the full complete set of data. And that's without the patient having to drive the extra hour just to get an echo. So these things make a big difference, both to the patients and their front providers. The third ballpoint I have here is note your data. That basically means that you should understand who in your area is staying busy with ordering echos, putting patients on guideline-directed medical care to all of the above. Because those are all important points because those providers or physicians or whoever it is in your community are the ones that probably have a lot of patients who have severe aorist illnesses, who have atrial fibrillation, who have myocardial infarction and could potentially report it yourself. So you really have to understand your customers' needs. So whatever it is, you need to meet them where they are. And you should ideally do it when you're not busy or when it is hard and all the time, not the duller way. So who are your customers? So a lot of patients think, or sorry, a lot of providers think automatically it's the patient. So of course it's the patient. But who else are the customers? So to me, it's referring physicians, it's the other hospitals in the area, like I mentioned. It's the patients and their families. So I always try to put myself, just like I'm sure you do, in the shoes of the patient and think, well, yes, this would be ideal if we could get the patient to come in and see me for X, Y, Z, or if we could just all have some of your system. Well, what's ideal for the patient? I mean, with gas costing $5 a gallon a couple months ago and with an hour-long drive one way for a patient, is it feasible or is it reasonable for me to ask this patient to come in and get an echo done when there's somewhere else that can do it just as well with similar quality and they'll do, we just have to send over the order and they can automatically send us the images. I mean, in that case, I think it's worth the effort. One of the biggest things that we've done is really connect our CT programs. So what happens is at that other hospital, what we do is have the CTA done and interpreted by the radiologist there locally and we actually do our own internal sizing for the tower and we also send it to industry as well. So we have multiple measurements for our tower patient and we don't rely on the outside hospital and the radiologist to do that. So, but we get the data. The most important thing is we send them the protocols and kind of troubleshoot it with them to make sure that we have the exact protocols we need and we make sure that we record, right? You know, and that's been an iterative process as well. It hasn't always been the same way. So, I'm not gonna get super into it, but it's worth the effort because now we have a distinct system down and we've got it and I'm looking to replicate that in other hospitals because then it really helps incentivize the local physicians to refer to you instead of referring elsewhere because they feel that they're part of the process. So, a shared vision is equal to common goals. So, partner with non-structural hospitals, partner with other structural centers and when I say this, I say, well, you may be at a center that is just starting out. You may be at a center that's very advanced. Either way, you have something to benefit from partnering with other structural centers because if they're just starting out, they're not gonna be wanting to do the high risk, you know, high-tested, low-coronary-type cases, right? But maybe your center will be and vice versa. So, find areas of common ground, give a level, understand that you're not gonna get all the revenue for the workup and that's okay, you don't need it, but you can get some of the revenue from doing the actual procedure and you can more importantly build that relationship with your referring physicians. And another thing you can do is invite the referring physicians to be a part of the procedure. That's something that I've offered all my referring physicians to come and either walk or maintain credentials and even scrub in to the procedure and it's certainly very enlightening. They oftentimes will not take me up on it. I haven't had a referring physician take me up on it yet, but it's a saving invitation and I truly mean it because I want them to feel like it is their patient, right? They're allowing me to participate and to carry on. I'm grateful for that, but more importantly, I want them to feel included in the process. And that's how you, again, that's just to emphasize, that's how you get this, right? So, this is how you get this reach from a very small radius to a hundred mile radius. So, the next part is the key influencers. So, these are the people that are the keys to the program and the keys to your success. The folks who can make or break a program. So, if overnight you can convince this person, he or she will open the floodgates to referrals. So, really you have to kind of look at what that person or people are worried about. If it's administration, what are their concerns about the program? If it's a heart surgeon, what are his or her concerns about the program? How can you address those concerns? And oftentimes what I hear from a lot of folks that I talk to is that there's friction between cardiology, pretty impressive surgery. There really shouldn't be. Everyone's on the same page. We're all here to take care of patients and do the most good. Whether the patient gets a surgical valve or a transcatheter valve, at the end of the day, as long as the patient's doing well and has a great outcome, that's all that matters. That's what we care. And one way to foster that, and it's not an easy culture to cultivate, that takes a lot of humility and respect from those parts of everyone involved to be able to come to the table and have that culture, but it starts, it has to start somewhere. And it can always start with a single person. For instance, at Ascension Pain Promise in Nashville, they do a very good job. They've been with Rodriguez and many more leaders in the field especially for transcatheter, edge-to-edger here. They do all their cases together. If you talk to Rodriguez's heart surgeon, Dr. Morse is a cardiologist. And so they are strong partners in that. And so that's one. And so because of that, Dr. Morse knows that any referrals that Dr. Rodriguez gets for a mitral valve repair or replacement is gonna be considered for mitral valve, and vice versa. Anything that Dr. Morse gets is gonna be considered for mitral valve surgery, right? So that's how they've really partnered and built a name and a reputation in the community. Edgers are also very important. That's an area where I am truly blessed because when I first came to this community, I met my edger, who's a cardiac anesthesiologist that he's been a partner. I've worked in cases without them, and for mitral valve especially. And the patients get to meet him ahead of time. I introduce him as my co-surgeon, which really is a co-surgeon relationship when you get to the stage of mitral valve because these patients are so complex, and the imaging is such a vital part of the entire procedure. So finally, my last point is to partner with the ACC. So we oftentimes overlook so much of the great stuff that the ACC does, and I know a lot of you are already involved with several of the committees, and you may be responsible for some of the things that I'm gonna go through right now, but the ACC has many wonderful resources for both you, your program, your patients, your hospital. So one of those, and a lot of those actually can be brought up by getting accreditation. So we're talking about structural heart disease, get the ACC TransCatheter Valves Certification. You know, it's worth the cost because it really introduces your entire system to all that the ACC can offer your patients and the hospital. And it really helps kind of laser focus on a lot of the quality issues and quality misfits, and it really helps foster that team relationship. That's what I've noticed in my own institution. I've pulled out four of the decision guides and patient brochures from CardioSmart, which hopefully most of you already know about, but if not, it's worth checking out. I think it's CardioSmart.org, or just type in just Google CardioSmart ACC, and it'll come up. But they've got decision aids for patients deciding between SABR and TABR. They have decision aids for patients deciding between symptom management and TABR for patients who are high or at operable risk. And they also have this kind of basic what if they were a stenosis, what happens next. And a lot of things that you can give your patients or include in some estimate brochures. We have one that we give our patients in addition to giving them the standard vendor or industry sponsored ones. So, that's my concluding thoughts, and I'll just leave you with this quote. And I would be happy to answer any questions. Thank you so much, and for having me, thanks for your time. Thank you, Dr. Krishna. We do have a question in the queue here that I'll read it out to you. It's got about three parts, so I'll go through it. How did the physician send you follow-up testing and assessments? So, the follow-up testing and assessments would be done and coordinated through the adult clinic coordinator. So, she's really the person that gets all the credit for the success of our program, which is Christy Shirley. But she would do most of that coordination with either the nurses. A lot of these are just questionnaires or a six-minute walk test. So, she would just get one of the office nurses in the referring physician's office to do these. And after a while, they understand what it is. We just send them instructions like, this is how you do whatever the instruments are. This is how you measure. This is what we're looking for. And then she would just do it and get it back to us. So, it's fairly straightforward. And in terms of the echo and whatnot, we would get the report, but we also wanted to make sure we had the images, both for quality purposes, for legal purposes, and just to make sure we were doing a good job for our patients as well. So, we also would review the images at any time there was a question. We would review the images if there was any unexpected findings. For instance, a gradient 30, one post-tab, or we would probably want to repeat that either at the center locally or have the patient come back and see us. But, you know, 95 plus percent of the time, there are no questions. It's fairly straightforward. It's fairly relevant in terms of the follow-up. So, in those cases, it was just protocolized. And as volumes increase, any challenges with getting that? Certainly, right. It becomes a big organizational effort. So, we're currently hiring another RN to join the team, or a nurse practitioner, even. I think our volumes could certainly justify that, and possibly even more. So, keeping up with insulated support staff is probably one of the most important things. And it's a tough sell sometimes for administration to understand, because there's not a lot of RBU generation in what we're doing, but there's a lot of value in a lot of the work that has to be done that's just part of the structural program requirements that just needs to be done, that's unfortunately not recognized by CMS. And how do you ensure that the referring providers are following up in the appropriate timeframe? So, well, again, we touch base with the patients, and we really leverage a lot of phone help for that. So, we do a lot of direct contact with the patients. So, if our patients, whether they live down the street, or two and a half hours away, a lot of our follow-ups are gonna be in telehealth. And most of my patients don't have access to broadband, or have a speed meter, and access for FaceTime. So, these are telehealth as in telephone. We don't care about the billing. That's really not the intent here. We're just trying to make it easy for patients. And we care most about just the patient experience, right? So, if patients want to come in, we always offer that. That's, you know, our doors are always open. They can walk in pretty much any time. And we have flexibility for that. But if most patients are happy, more than happy to save the gas, and save the trip, and just talk to us on the phone, that's usually the intent of the tent that can solve all the issues. And then another question here is, being a smaller hospital, do you have a dedicated team or staff that are part of your structural heart team? Or are all of your staff in your department trained to do these high-risk procedures? Oh, in the capital? Sure. We actually are a small hospital, but we're almost 450 to 500 beds. So, we're actually a decent size. So, we have 80 cath labs, but it's shared between IR and vascular labs. And there's actually a lot of staff. Not enough, believe it or not, but we have a core set of structural, dedicated cath lab staff, and they're usually always present. That team's always kind of growing, but it's usually the same five or six people that are scrubbing these procedures, these procedures, et cetera. But they're all cath lab staff. As soon as you get a question, they'll work with cath lab staff. And then another question here is, what do you recommend to help inspire or grow team investment and involvement in the program? Yeah, I think you're treating everyone that you're, as equals, everyone. And that's something I try to do from day one, giving them opportunities to learn. I think especially when you're out in the community program like I am, and you're not in academics, you don't have a lot of opportunities to learn. But, and that goes with the physicians and the ancillary staff, the stenographers, the cath lab staff. And everyone is eager to learn. They like their, everyone loves learning. So I've had this, and all your first, I do, I have been doing a lot of education with them on a monthly basis to train them on how to do preoperative echoes and how to really assess the microvalve and transthoracic echo, what we're looking for in a transesophageal echo, and what these intraoperative, how these intraoperative echoes look. When I first came here, they were doing everything under general anesthesia with transesophageal echo support, so we switched that, and now the default is quantum sedation with transthoracic echo support. So we really look to make sure the sonographers are comfortable with doing transthoracic echoes in the cath lab. So we had a training made for that. And it takes a lot, it takes a champion, I think, and at least for the early parts of the program, I was that champion to make sure that I was available on board-certified echo, so I was comfortable to teach all the sonographers what to look for in terms of PISA, exactly what that math was. And same thing with the cath lab staff. We had industry-sponsored dinners for them, taught them exactly what we were doing, why we were doing it, what the purpose of the procedures are, the patients for them, et cetera. So they really felt invested from day one. And then same thing for our office staff. It's just the same pattern, really including everyone in the education, helping them understand what we're doing and why we're doing it, and why it's important, and why their goals are important. And then people are automatically invested. They want to see everything succeed. And it's the same attitude for the reporting positions as well, same deal, make sure they're involved in whatever way they can, and to whatever extent they want to be involved. What is your time frame from referral to procedure? That's a good question, too. So for instance, different for every procedure. So for Watchman, really any preoperative workup we need is a Watchman, I call it a Watchman CT, or basically a coronary CPI. I don't do a lot of preoperative training, that's not the deal I go to, is because I find a CT day for Watchman is so much more useful in terms of the amount of information we're getting, and then I just want to make sure the patient's have had an echo in the past year or so. So really it can be quick, within a week or two, just depending on when we can get that patient through the CT scanner. TAMU is a little bit more involved, because they have to see the heart surgeon. Oftentimes, the heart surgeon's contact with the patient is through a telehealth visit, and then we'll have the patient come in for the heart scan and the CAT scan, so those steps can be done. We try not to do those on the same day, just because of contrast issues, and somewhere in between the CT surgeon will be scheduled on one of those days, to avoid having excess trips to the hospital, et cetera. So we really try to make it easy for the patients, however we can, but that can take up to a month. And the microbook can also take two to three weeks, just because of the need for the extensive workup. And then of course, we have to discuss all these patients on our multidisciplinary team meeting on Fridays. One more question. You had mentioned being a copycat and visiting other facilities. What made you choose Arkansas Heart Hospital and the one in Mobile, Alabama? Sure, yeah, actually I was interviewed for a position there previously, and just learned a lot during the interview. So I kind of went there and stayed in touch as well, so it's kind of serendipity, but now that their secret is out, there's really nice people, and I'm sure they welcome a visit. And since that time, I've visited other centers. I went to Emory and the University of Pennsylvania in the past two years. So every year, I try to go out and see another structural heart center. A, so I can keep my skills fresh as an operator. B, so I can learn from other centers and see what they're doing. Obviously, we don't do anywhere near the kind of volume that Emory does in Atlanta, but they have a lot of best practices. They have built a very strong structural program, and they've got a great structure behind it, pun intended, but they do a really good job of making sure all the fallout is taken care of, and it's a very complex process. They've got referrals from all over the state and all over the country. They have a lot of them in their place, but they do a good job of seeing how they've coordinated that. It's really helped me understand well, these are some of the things that we can do locally and internationally. So I encourage you to please reach out. I'm available on LinkedIn at some of the freshmen. If you just type in my name and Kentucky, I think it shows up as well. And as I said, moderators can provide email address and whatever else you guys need. Always happy to be a resource and very honored that I could be a part of your day today. Thank you for sharing some of your day with me. And thank you, Dr. Krishnam, for a great presentation. Thank you. Thank you.

structural heart program

copycat

strategic alignment

geographical challenges

TAVR volumes

MitraClip program

ACC resources