Okay, I guess we could get started. How many more times do you want to hear I'm Joan Michaels? Maybe I'll change my name. I'm Topo Jijo. But I am happy to be here, and thanks for sticking with us for the afternoon program. Hope you enjoyed your lunch. One of the pain points I think I could honestly say for many sites, it's OK we know about quality of life and maintaining follow-up and getting follow-up, but it's ECHO, right? Everybody's ECHO report looks different. Perhaps from hospital to hospital, the abbreviations for a gradient look different. Where do I find this in the report? Give me something if most of you are nurses, and you're not going to walk out of here as an echocinographer. But our hope is that we could give you some tools to go back and at least know enough to question, really, you didn't get that? Or I don't think that's something. I mean, I think this is something that's standard. So Shabnab Pate from Baylor Scott White is the ECHO supervisor trainer. And if you know anything about the world of ECHO, I don't know if you know I know this, but Dr. Paul Grayburn, who's kind of a big deal in the world of ECHO, he actually wrote the MITREL module of all the ECHO variables when that was approved. So he's very knowledgeable. He handpicked her and said, come with me. So that's kind of cool. Nobody ever wanted me to go with them anywhere. That's cool. You should wear that on your tag. Anyway, it is my great pleasure to introduce Shabnab. And she will be allowing us into her mindset of ECHO geniosity to let us leave here and go back to have some, again, the toolkits to at least, I'm not going to say push back, but at least challenge or, in a nice way, start the conversation of, I think we should be able to get this. And there's the world of aortic. There's the scarier world of MITREL. And if you heard anything, the complete nightmare of tricuspid. I don't want to scare anybody, but how are we refining what we're looking for for both AS and AR? What should we be really looking for? MITREL and ECHO is so critical for MITREL and even more critical for tricuspid. So even if you're sitting there saying, yeah, well, my doc said they're not going to do tricuspid, they're lying to you. Yes, they will, right? So at least half listen, even if you're not doing tricuspids yet, and let's walk out of here being the best informed on all ECHO variables in the TVT registry. So with that, I will introduce Shavnaab, and thank you. All right, thank you so much. I appreciate your time. I know it's been a wonderful conference. The sessions that I've been able to attend have really taught me a lot. Because like she said, my focus is typically performing ECHO and getting a lot of the measurements that you guys need. And so when I created this presentation, it was a little challenging. Because I'm not used to teaching where to find elements and why they're important, more so how to get them to other sonographers and other cardiologists. So I do appreciate your time, and we'll go ahead and get started. Thank you so much. So one of the first things I'll go through is I do speaking events for Edwards. So I talk about TAVR a lot, aortic stenosis, and what sonographers need to do to get a high-quality study. And that's the focus of that. So this is kind of a nice world to be in in that regard, because we're going to kick off with the TAVR things. But really what you guys need to understand is why is ECHO important? Why are we using it? We'll talk about the ECHO elements for TAVR, TMBR. And then we're going to talk about the tricuspid valve interventions. Even though we don't have those forms yet, they're going to come. And what I do want to tell you guys is data is on repeat. I'm going to repeat different things throughout this entire thing, because LV function, it's going to be on every one of these forms. They want an EF. I'm not going to go into it on every single case, because you guys know it's there. But there are some examples of how we get those measurements and where you can find that information on the ECHO report. So we'll keep on going through that. So the reason why ECHO is important is because it gives you real time, very quick information. Appropriate use criteria, we talk about that a lot. ECHO is indicated in every one of these pathologies that we're going to talk about today. It's how we find out how severe things are. So the role of the sonographer in your facility is very important. Your physicians really only get the information that the sonographers give them. If they don't capture an image of it, it didn't happen. So just remember that. And then there's reasons why we use TTE versus TEE. TTE gives us a really good look at the ventricles, LV function, whereas we might not be able to see everything, because we're imaging through tissue, bone, lungs. Things scatter. It's a little bit difficult sometimes if you see something was not measurable on an ECHO report. That can affect you, right? Why wasn't it measurable? There are some patient reasons why, body habitus and whatnot, that can make it difficult. TEE is used really to look at the valves, because where it sits in the esophagus, it's very close to the heart. There's not bone and lungs in the way. And it's sitting right behind the upper chamber. So we get a great shot of the tricuspid valve, mitral valve, the left atrial appendage. They're having a conversation about that next door, all sorts of things. And then we also use the TTE to kind of follow the patient. How successful was our intervention, right? We're going to keep looking at the LV volumes. We're going to look at LV function, RV function. What are the other valves doing? How are they doing? Are they functioning normally? All of that is super important. So ECHO really is that cornerstone in the managing of cardiac patients. This is a great paper written by Zogby. And you'll notice a few authors down. Dr. Paul Graber, he was my mentor. He came to Baylor around the same time that I did. And he was our medical director. And I was the technical director of our ECHO lab. And he actually helped provide our team with all the skills needed to make sure that all of the data that is necessary for you guys and your practice is part of a normal ECHO protocol, right? So we'll reference a lot of things based on that paper. Just to show you guys, this is the first image that a sonographer sees every time we start an ECHO. This particular patient is being evaluated for aortic stenosis. I don't expect you guys to know this necessarily, but let me see. I don't know if my little pointer will work. I'm gonna try and make it work. All right, so there's your aortic valve. Usually it's opening and closing and you would see that, but right now you just kind of see that little bright dot right next to my pointer. It's not moving. The aortic valve isn't opening, but we're also looking at a lot of different things when we look right at this image. Off the bat, I can see the LV. I can see the thickness of the LV walls. These are the walls. This is the LV. This is the mitral valve, aortic valve, left atrium, right ventricle, aorta. I'm already getting an assessment. And in my head, I'm looking at this and I'm thinking, well, the aortic valve isn't opening, but the LV function looks normal. So I should expect to see some high gradients, peak velocity, mean gradient, things like that. So we're already trying to make sure that what we see in the image is gonna match those numbers that we report. We're gonna also, these are a list of the things that are in the TBT registry, very summarized, right? So LV function, that includes the diameters of the LV, the end-systolic and end-diastolic volumes. We're gonna look at the actual morphology of the aortic valve, what's causing the stenosis, right? And then we're gonna do all those Doppler measurements that you guys are gathering as well, peak gradient, peak velocity, mean gradient, aortic valve area, stroke volume. All of that information is gonna come from a lot of different things within the echo. So we'll keep rolling. A lot of people like to see these beautiful images. This is actually the aortic valve. On the left is your rheumatic aortic valve disease where the leaflets are thickened. And when I say leaflets, I'm talking about these parts. They're a lot more redundant. They should be very thin and pliable. This middle one is calcified aortic valve. This is a very severe valve. It's probably not opening or closing. It's just fixed. And then this is your bicuspid, and this is a true bicuspid where it only has two leaflets. A lot of valves will be called bicuspid, but it's really because the third leaflet is fused. This could be the case, but in this particular patient, it's a true bicuspid. And so these are things that we might not necessarily be able to see on an echo. The histology, we cannot make a diagnosis, but we can see if the valve is opening or closing and what those gradients and velocities and function of the valve is. And so we have these classes that we stage aortic stenosis. I'm not going to get into all of this necessarily, but what I want you to see is that hemodynamic consequences column. This is where we're talking about the LV function and how it plays a role in aortic stenosis. So the LV does start to fail over time with the aortic valve disease. We get a pressure overload on the LV, which then causes the muscles to first thicken. Basically, it's like working out at the gym. You got to work harder, you get bigger muscles while your heart does the same thing. But over time, as the progression of aortic stenosis happens, we get into the D categories, which is where we start seeing symptoms for the patients, right? And so we start seeing diastolic dysfunction, LV hypertrophy. In the D1 category, these are those straightforward high-velocity patients. They have a normal EF, they have some LV wall thickness that we're seeing, but then our velocities, which is in that valve hemodynamics column, that's where we start seeing those peak velocities above four meters per second, a mean gradient above 40, aortic valve area less than one, severe, right? These are the patients that we're qualifying for some kind of intervention for TAVR. And so we need to report all of these things. The one thing that we're not talking about here is what happens to a patient, or you're not seeing here, is what happens to a patient once they're symptomatic and have severe AS. Their two-year mortality is, what, 50%? And then five years, only 20%, right? So they don't sit well. And that takes us into the D2 and D3 categories. These are our low-flow, low-gradient patients. So D1, I'm sorry, D2 is your patient who has a reduced EF. So say that image that we saw in the beginning, what if the EF was not normal and the valve is not opening? Well, those gradients, the numbers will be lower. I need to assume that I'm gonna get a less than four. Doesn't mean it's not severe. It just means that LV is not producing enough stroke volume across that valve for me to get a high velocity. So we have questions, right? So then we do some illicit testing to see if we can get the gradient higher. And we call that a dopamine challenge, right? So we'll bring the patient back in, or maybe the patient gets referred to your facility and they have an echo report that says they only got 3.8 as the peak velocity and the mean gradient is in the 30s. And now they're at your facility, at your valve clinic, because they want to get the patient to see if they actually have severe AS. And I will tell you in our facility, we don't always trust what we get. We go ahead and take a look ourselves with the probe before we even spike a dibutamine bag and make them do the dibutamine. We see, can we get the velocity without it? Because echo is very operator dependent, right? So depending on their skill level, the type of equipment they're using. So you do want to kind of trust but verify everything for your patients. The other category is this D3, which I think is where we may actually be missing patients. And remember, they don't sit well. So this D3 category is where we have patients that are normally F, but maybe the ventricle is small. And so we have a small stroke volume index, less than 35. So index to their body surface area. These patients get called moderate a lot, but they actually have severe valve disease. But what do you do with them? Do you intervene? This is one of those that sits with the heart team and everybody goes back and forth and they look to see what's the best treatment for this patient. So when you scale back to the echo, the most important value that you're gonna look at for that particular patient is the stroke volume index and it should be on your echo reports, okay? So make sure if you're seeing those kind of numbers and the patient's coming through your office or their paperwork is coming through your office and you see that they have kind of, maybe that valve area is less than one, but the mean gradient and the peak velocity are not four and 40. There's something going on here and it could be that you need to just take a peek further down and see what that stroke volume index is because it might be appropriate for them to have some kind of intervention. And now we're talking about what are those velocities look like? So in our facility, when I first started working with our coordinators that were doing TBT registry data entry, I said, where can I find these numbers? Because I can't find them on the echo report. And so we literally went through step-by-step on an echo. I'm like, well, it is on the image, but depending on the facility, they may measure this three or four times. You need to know which one to pick. In our practice and when I train new hires, I ask them hold off on measuring everything until you know for sure you have your highest velocity. That's number one, it's very important. And so in this particular patient, you should find a V max of 7.2. I mean, this is legitimate high gradient, high velocity aortic stenosis with a mean of 121. I'm not making it up, it really is real. This patient is one that we use as a case study for our students and our people that are orienting to valve clinic. And it's an interesting case because the other views that we get actually got lower numbers. Some only like 4.2, another window gave us a five meter jet. So it's really important to make sure your echo lab is reporting the highest velocities because that's what you're gonna be looking for to match with your cath gradients. There is correlation that should happen as well. And so we also are looking at patients, this is a mitral valve, but sometimes they have other valve disease too and your forms are asking for that, right? They wanna know what's the MR, what's the TR. So a complete echo has to be done. There are a lot of facilities that will be doing all the same measurements that you'll see on the other registry forms like MR EROA, PISA EROA for TR. All of that should also be included on your echo reports. I'll show you some samples of echo reports at the end and kind of give you some best practice that you can do. But right now we'll just talk about these elements. So this particular patient also had mitral valve disease. Now we're going right into the follow-ups for TAVR. So they got their device. These are some examples of the different types of devices that are out there. That same paper that I referenced earlier is where this chart came from. And it lists basically what you guys are seeing in your TVT registry. So our guidelines as sonographers match what you guys are asked to be put in, right? So we should be seeing once a valve is placed, we need to have what size and type of valve was placed, right? I always encourage sonographers, put it on the screen. Make it right there on the image that you guys 23 millimeter sapien, 24 or 25 millimeter evolute, whatever it may be. Have it on the screen. Make sure the blood pressure is visible. There's a lot of things to reduce the hunting for all the people that have to look at this echo later, right? That we can do. And it also helps our docs know exactly what kind of gradients we should be expecting to see based on that size of the device. But you'll also see things about the Dopplers that we talked about. So peak velocity, mean pressure gradient, LV and RV size and function, right? These are all repetitive data points that you're going to see pre-procedurally, during the procedure, post-procedurally, one month follow-up, one year follow-up, all of that. So consistency is really key. And it's important to kind of buddy up with your echo lab. I think it's really important to have whoever your contact is to talk about the elements that you guys are looking at because it was a light bulb moment for me early in my career right after we started TAVRS and these registries became very important for public reporting. I didn't know that there was somebody else looking for this information. So there could be some knowledge gaps that you guys can fill in that partnering with that team to make sure everybody's getting what they need. So we'll dive right into TMVR. Again, notice we're looking for LV size and function. We want the left atrial volume. We want to know why the MR is happening. What's the etiology? And we're also going to be looking for the PISA EROA and also the 3dB in a contracted area. They're derived differently, but they kind of mean the same thing. And then is there any other valve disease? And this is actually a sample report. And so what I really, it may be difficult for you to see, so I'll just read the way they describe the mitral valve. This particular study was done for endocarditis of the patient and, you know, right off the bat we see normal LV function, EF 60-65. I don't know if the forms allow you to put ranges in. Usually they want like an actual value, right, but EF is usually, it can be given in a range or a specific number, just know 60 and 65 are not that different in meaning and outcome for the patient, just so you know. And then it goes into talking about how this patient actually has an LV aneurysm along the basal inferior wall that was pretty significant. It talks about the RV function, normal, and this is kind of like that high-level view of what's going on. It's not the actual values that you may be looking for. But in the description for the MR, it says that there's two jets originating from A3 and P3 commissures. The A3 scallop is thickened and it prolapses with a 1.1 centimeter vegetation. There is evidence of leaflet perforation. The bigger of the two main MR jets appear to be through the A3 pre-formation. And the systolic flow reversal in all four of the pulmonary veins is evident and basically saying hey, this is severe MR. So that's a very, very well-stated description of the MR. It doesn't give you all the numbers that you need necessarily. Those should be found in the body of the report under those sections with all the measurements. Just to give you an example of what a pretty thorough description of what's happening with that mitral valve looks like, a good case, right? Not necessarily, you know, they need to fix the endocarditis first, but a really good case as far as the description goes. So look for that kind of detail in your ECHO reports. Pre-procedurally, we're looking at EF. On the left is trans-thoracic, right? So we don't use TEE to measure an EF, okay? But 3D gives us a lot of information. It gives us, the TTE on the left is giving us the end-diastolic volumes. The 3DEF is a little more accurate than just a 2DEF, all right? And then it's also giving us that strain, which is an indicator of heart failure, early heart, it can detect heart failure early. The image on the right, same patient, is a TEE, and it's just showing you this really bad MR jet caused by this flail posterior leaflet of the MR. So we're using the TEE to basically give us valve anatomy. We're going to measure that 3D vena contracta area. We're going to perform PISA on it. Some sites may forget to shift the baseline. There's a lot of elements that happen with doing a TEE or TTE for regurgitation, whether it's tricuspid or mitral, that the sonographer has to do in order to get those calculations. So PISA is dependent on literally taking this base, this color map that you see here, and really shifting this baseline up and making it a measurable, like this is the PISA hemisphere right here. And so I don't want to get into the technical details of it, but if they don't do that, we won't get a PISA EROA because we can't measure it unless certain things are done. So it's very important to, again, make sure you have a contact within the echo lab, make sure they know exactly what you guys need too, and then it will kind of help solidify that protocol that's developed based on all these needs. So post-procedure follow-up. So just remember, so whether it is a valve-in-valve transmitral intervention valve replacement, or it's a CLIP, you need to understand the differences that come with that. So CLIP usually just reduces the MR, so there's still a lot of MR quantification that needs to happen, whereas usually replacing the valve gets rid of almost all of the MR, so it becomes a lot less MR at the end of those. But you can still actually still have some residual paravalvular leak. Some of the valves will have a small to trace central leak. So really the image here is just kind of showing, we're getting a Doppler, which are the top two images. The image on the bottom left is a mitral CLIP. Those are two CLIPs sitting in the mitral valve, and then that's the same patient on the bottom right, just a different view. And you can see there is a little, these little blue jets that are kind of going down. These are the residual MR jets, right? So not a bad result just by eyeballing it, but we have to give you guys numbers, right? So it becomes tricky because each of these jets have to be measured. So the PISA has to be done on both of those jets in order to give you like a cumulative MR grade. So just know those are kind of some of the things that the sonographers are going to be doing in order to help you out. And then we're going to get into, this is the same patient again. So now we have a TMVR though. So this patient, just so you guys know, is actually coming in for a tricuspid valve evaluation. So our site did not perform these echoes. These are just the images that we received in order to kind of see what we needed to do for their tricuspid valve. And so this is a valve-in-valve bioprosthetic mitral valve with a sapien placed to reduce MR that they had before. And what you'll see in some of the upcoming images is what happened to this patient. And again, we were just using these images to evaluate for TR, but we got some really great images. And so what I want to show you guys is this is the device right here. This is your sapien. And then you'll see this little flash of red coming. So that's a paravalvular leak, right? So we have to basically grade how bad is that paravalvular leak because this is information that everybody needs to have. This is a 3D picture. Basically if you were looking kind of on-faucet from the atria looking down into the mitral valve. Basically from here looking down through it. And so you're seeing it kind of in a short axis. So this is the TMBR here. And then they actually had to put a little plug in because that leak was a lot worse before. But we still have that little flash of red. That's a leak, right? So we're going to grade it and measure a 3D EROA on this so that you guys can report it on your TBT registries. This is a follow-up echo. So it's going to get captured. And then we actually went through and we did gradients through the valve and the mean gradient through this particular repair was actually an average of 16. So pretty high gradient still. Now these valves will have higher gradients than a native valve. So just remember all prosthetic valves do have higher gradients inherently than a native valve. But these are the things that we're looking for and we're going to report this. So this particular patient is an AFib, right? So another thing that you guys have to document is what's the heart rhythm, what the EKG looked like. I've seen the entire form. So I know that you guys have to look at a lot of different things. And so you'll see us measure multiple things. If you're actually looking at the echoes or seeing a display of the echo report that shows every discrete data point, in AFib we like to average everything because each bead is slightly different, right? So an average of 16 for the mean gradient on this. And we'll be able to actually calculate a valve area based on these gradients that we're seeing and those will be reported on your TBT registry forms as well. And so now because it's the same patient, I'm just rolling right into the tricuspid part of this, right? Because tricuspid is coming. There's a lot of really neat interventions that are coming out. There's clips obviously and then there's actually valves coming out, right? So you're going to see a lot of the same elements, LV function, RV function. They want the RV volumes. They want to see what the RA volume is. All of this is going to be part of those forms, right? So just like for mitral you had to look at the left atrial volume, for tricuspid you're going to be looking at right atrial volume as well. So and then we're going to measure those EROAs for the tricuspid valve as well, the 3DVCA for tricuspid regurgitation. Is there any other valve disease? Any other devices placed? We're going to have to talk about those things on those forms too. And then obviously LV function. So really the main part of what we're talking about right now is repeat, repeat, repeat LV function, RV function, LA size, RA size. What's the severity of the regurgitation, whether it's mitral, aortic, or tricuspid? So again and again and again, same data over and over. So just remember that our ECHO protocols typically encompass all of the things that you should be looking for, and that's based on the ASC guidelines, American Society of ECHO. So should be fairly similar, just so you guys know. That form will just be more right-sided as far as some of the things that may be on it. This particular patient had two different images here, two different patients. Image on the left is a transthoracic. And the reason why I include it is because this is a functional TR case. So both the atria and the ventricle are severely dilated, and what happens is the annulus expands, gets bigger, and so now the leaflets, they're not co-acting. There's a big gap. And so it's creating this TR that you're seeing. But on the image on the right, that's a TEE, and it's actually showing a pacemaker wire that is severely restricting this posterior leaflet. There's like a teeny little leaflet right there that you can maybe barely see, but what's happening is it's keeping it pinned against the wall, which we do see this a lot. So functional, and then pacemaker-related, we see TR a lot from these two causes, just so you know. And so this patient's getting evaluated for a tricuspid device, and—oops, sorry. There we go. And so it's all right there. That's the etiology. And then, again, for RV function, we're going to do a 3D analysis. So RV function is one of those twisty ones. I think this is where it's going to get a little more meaty on the form, because we use about five different things to grade RV function, because currently the guidelines only say normal, abnormal. I work with Dr. Graeburn currently in his research core lab, and one of our goals is to take all the data that we're getting for all these tricuspid and right ventricle cases and create guidelines for mild, moderate, severe, whether it's dilation, RV function, all of that. So hopefully in the next near future, we'll be able to give you that information. The reason why I threw up a 3D image is because it's really great when your lab can do that, because what you'll see is it gives us the volumes that you're going to have to report, those end-diastolic volumes, which then give us stroke volume and EF, right? And so EF is one of those things that we're going to use to grade the function of the right ventricle. The other thing it's going to give us with just one image, just this one image, is giving me all of this information. So the RV free wall strain, which is also something that we use, so that's the second parameter that we're using to grade RV function, it's also going to give us all of the sizes at three different levels, the base, which is closer to the valve, mid-ventricle, and then the length of the ventricle from apex to annulus. And so all of that is going to be important for sizing and things like that. What's the retention mechanism for these valves? So imagine if the annulus is big and the ventricle is big, what's going to keep this valve from popping out, right? So they need to know all of this information to see how much oversizing has to happen in order to keep that valve in place. The other thing that the 3D will give us is TAPSE and the fractional area change. So all five of those elements we can get off of one image. So a lot of what I was just saying is skill set for sonographers and the type of equipment that they have, right? So it's nice to be able to just get everything from one shot. It's less time on the table for your patient. It's a lot more information. It's a high yield from a very low amount of actual imaging. So hopefully most of your sites have that capability, and if they don't, they should in the near future because it's coming as, you know, one of the main things. And then grading the severity of tricuspids. So tricuspid has a five scale, right? Mild to torrential. So usually we're used to mild, moderate, severe. Well, they've added massive and torrential for tricuspid valve. And then what is the success in tricuspid intervention? Is it a reduction of two of those grades? What is it, right? So there is some information that should be coming out soon based on all the Triluminate study and Trisense studies that are slowly publishing all their data for everybody to get their hands on, but Becky Hahn helped write this paper back in 2019, and she kind of broke it down into three different things that you can measure because one of the other things that you see on these TBT registry forms is quantitative Doppler or volumetric Doppler, and that's the way that they're calculating the EROA or the effective regurgitant orifice area. And so it kind of puts everything together in one chart. So it helps us know once we measure on the bottom left is a 3D VCA, and then on the bottom right you're seeing a PISA calculation. We're going to do all of these measurements, 3D and PISA, all the 2D measurements, we're going to put it all together, and we're going to make sure everything is, it coordinates with each other. So I'm getting a PISA of 1.98, which is huge, right? That's going to be in that torrential range, and is it believable, right? So there's a lot of critical thinking that has to happen on your cardiologist's point too to be able to report these numbers accurately. But I just wanted to show you some of the different methods that we use and how we make it fit into this five-level grading system that they have for TR. TR is a much, the tricuspid valve is a bigger valve than the mitral valve. You're going to see a lot bigger numbers as far as these EROAs and vena contracta diameters and areas go. Okay. So a lot of that to get to the echo reports, right? So this is just an example of a standard echo report. One of the things that you'll find is, okay, cool, there's the LV diameters here, and okay, here's the left atrial volume. I can find it. It's small, but it's on there. I've got a good description of what's going on with the mitral valve. It says there's moderate mitral regurgitation. That's atrial functional and etiology, mild tethering of the posterior leaflet is noted, and the PISA EROA is 0.35. Great. That gives you a lot of the things that you need for your form. But there are some missing elements here, right? This is the whole report. There's nothing more. And that's because a lot of facilities will create pretty reports for your referring physicians and internal medicine doctors that are the ones that are actually usually reading the echo reports for your patients, not to be five pages long, because there's two pages of just numbers, which is kind of a clip of what you see on the right here. And so this is why I always say it's important to find a contact within the echo lab, because they'll show you how to find the data, the actual source data. It may be in the EHR, just on a different page where you find the echo report. It could say detailed report. They all say different things, but it's also within the echo PACS system that we are importing all of our studies to once we finish an echo. It gets uploaded into this echo PACS, and that's where the doctors and the sonographers are entering data. And so most facilities that I have visited across the U.S., the sonographers will pre-read the echo. So the sonographer will come in, put their interpretation, and then the physician will follow them, read what they put in, make changes where applicable, remeasure things if they need to, and then sign and finalize the report. So I wouldn't look at it until all that's done, but it's important because the sonographers all know that the numbers need to be as accurate as possible. But usually, especially if you're in an accredited lab, there's a technical director that's typically a sonographer, and then you have a medical director of your echo lab. And these two people, the sonographer will manage the sonographers in conjunction with the medical director, and then the medical director will go to the physicians peer to peer and talk about what needs to be on their echo reports. But these two individuals are very vested in the completeness of these reports because we also have an accrediting body that we have to answer to, right? So they would be the people I would talk to first if you're trying to make a connection with your echo lab. If they have a lead person, if it's an unaccredited lab, that's okay, it doesn't make a difference. You just need to find someone that understands all of these data elements and can show you guys where to find this long report instead of this short, truncated one that may be too brief for what you need. It might not have all those discrete data elements that you want, but they're there. You just have to ask for it and kind of hunt for it sometimes. So that would be my biggest takeaway to make sure that's happening. The other part of this is kind of what we said earlier. We're checking the same structures, data on repeat. so across all the forms, I literally pulled up every form for all of these valves that we've talked about and cross-referenced to see, okay, LVF, all of it, every one of them. EROAs for the regurgitation, every type, and then they want to know how it was calculated. So that's important. Most of the ECHO reports will say 3-DBCA this, PISA EROA that, quantitative Doppler was used, and this is the EROA. So make sure, if you guys can't find those things, you've got to talk to the ECHO lab and say, I need you to report it like this, because it will make your lives a lot easier in the future as you guys adopt new procedures like tricuspid valve. The other thing that I wanted to bring up that Joan was really kind enough to chit-chat about was AI and how it's working and integrating it into healthcare, right? So people are talking about it. Some healthcare systems are allowing certain types of AI to be used. In our core lab, we actually have started using US2AI, which is actually measuring images, the volumes. It can't calculate EROA, although it's trying. But it's not great at it yet. So there's opportunity with that. But there is other AI that's already being worked on, and some really, actually, at the ACC conference, that was a few months back, we had a visitor come to Plano, and he was talking about what they're doing out in Perth and Australia, because they have a database for every ECHO element. Every ECHO they do, every measurement goes into a countrywide database, and they have AI reading it. And what it's doing is predicting heart failure based on certain values on the ECHO report. So I think there's a lot of really cool things to come. I don't know what the space will be as far as, you know, TBT registries go and those elements of tracking. But I do think that there is a space for it when we're looking at outcomes for patients when we have multiple time points of data to say, wow, the EF improved or RV function improved when we fixed this valve and then you get a lot more information about that. But I would love to hear you guys, your thoughts on AI and if you guys are using it in your everyday work. And that's it. Thank you. Yeah, you're welcome. Thank you guys. Can you hear me? Okay. So a couple of questions. Sometimes we hear, well, we just couldn't get it or we couldn't get this value. So it's a two for. Is there one data element that you hate to get because it's difficult? And as the patient comes from the waiting room into the exam room, can you write then based on their height, weight, you know, boniness or whatever, I'm never going to be able to get. I mean, is there the nightmare scenario that we could be armed with to accept the response of, we couldn't get this, that, and the other? Or is that, should that be a hard stop, unacceptable when someone says they couldn't get the images? So I don't know that there should ever be a hard stop in a sense and it's very hard to predict who will make good images versus bad images. So, you know, in the echo world, we always look up our patients before we go see them. And when I see that they're 4'11 and 300 pounds, my head is already like, wow, how am I going to see this heart? Because, you know, body habitus is what it is. But I will tell you, some of my trickiest patients that I know are going to be the most challenging are my 6'5", 120-pound, real thin COPD or some kind of pulmonary problem patient where the heart has shifted down towards the stomach. I mean, it really is all about how the heart sits in the chest. And to answer you, there is no, you know, I can't eyeball a patient and say you're going to make good images or not. I can assume maybe they'll make better images when they're more petite and more fit and things like that. But really the main thing is knowing what kind of tools your sonographers have in their toolbox. So we use ultrasound enhancing agents to help us see that blood to muscle border in the heart. So when we're measuring volumes, it's accurate. Or we can see wall motion abnormalities. If I can't give you an EF, it's because I couldn't give that patient this image enhancer that we need to use. So a lot of times they call it echo contrast, even though it's not a real contrast. It doesn't go through the kidneys. It's not radioactive or anything like that. It's not like what they use in fluoro or nuclear cardiology. But we do use it to help us see the heart better and see the chambers better and be able to measure the RV diameters, LV diameters, LV volumes, get the EF. If they don't have that or they're not using it, that's a problem. And they should be using those things. Otherwise, there are patients where you just can't see anything. I've had many times I've gotten called into the ICU and, you know, the patient's not doing well and they just got there and they've gotten limited imaging and, you know, they had a pneumothorax and I couldn't see and they wanted to see if they, you know, they had blunt trauma to the chest. And they want to make sure the mitral valve is okay. And I can't see anything. And there are some cases where you can't. And I'm not saying you have to take it, but I would question it to see why and what was done and if a repeat echo can be performed maybe a few days later to maybe get the information that's needed. Mm-hmm. Yeah. I'll throw this in, but let me before I forget about AI. In your hospital right now, raise hands, who has like a department of echo, department of nuclear med? Who's a department or an office of AI that you know of? I think you're wrong. And I'm glad you're, I'm glad no hands, oh, there you go. Ruined the day. What's that? So hearing everything about AI and hearing Dr. Bott yesterday and we talked about an article that just came out about AI looking at CT, right? And so it's coming. And this is just a PSA kind of thing. Go back and question that. Because as I talk to sites, they're telling me, oh, we have a, we have like an office or somebody in their hospital working on that. So what that means is there's limited resources. And if they're looking for projects or whatever, keep an eye on the articles and the papers that are coming out and maybe, you know, pick me, pick me if there's one thing that could be a clear runway for helping either with echo or CT or something. I mean, I don't know anything about AI. I'm trying to read about it. But just it would be a curiosity thing to go back and say is your hospital looking? Because I bet more than, more than we know they are. Most of the newer ecosystem actually, they are already using AI in the automated measurements that the equipment is doing. So in some way, shape or form, at least in the echo lab, it's probably already happening how your institute is. I would, you know, say promoting it, right? So I think there's a lot of opportunity there with regard to saying, hey, we are using AI. Especially in cardiology, it seems like with the measurement. So this isn't for you to answer. It's just sort of an aha kind of thing. And with mitral tear, we have a question. Is it degenerative or functional etiology? And more than you know, folks will say neither. So then we'll say, well, then what is it? And why are we doing, why are you doing the mitral? This is in the early days. And I just point that out because I'm not sure why, is it a hand stroke? Is it a mistake of coding or you can't find anything? But when a site codes neither, is it that they can't find, do you know, or is there any guidance we could share of, that can't be, why are they there? It may even be just a knowledge. It could be a typo like you just spoke of. So just to make sure everybody's on the same page, primary is typically like a flail or prolapse or something, you know, is wrong with the valve itself. Maybe a ruptured chordae has caused one of the segments of the leaflet to be flail. So that would be your primary or degenerative. Whereas secondary would be your functional, right? And functional means enlarged, right? So maybe the LV, maybe they've had an ischemic event and the poster wall is now dilated and achinetic and it's tethering one of the leaflets from moving the way it should move. And now it's not closing the whole way, right? And so that becomes functional and it can be ventricular like we just described with an ischemic event or the atria could be huge for whatever reason. Why is it enlarged? That's a whole other topic to go into. Why are these atria getting bigger? But the annulus will then expand and then you have that poor coaptation like we showed you for that tricuspid valve. So I don't know why. And it's just sort of awareness that, you know, maybe you should say really, then why are they here? I'll just, and then I have some answers to some of the questions, but to reinforce what you're saying, now I'm missing my thought, let me go to the questions and I'll come back to that. There's a couple of questions here that I think we've confused you in the NCDR registries between TVT and LAO. So just to clear it up, TVT registry. Oh, I've checked some of them, yes. Well, a lot of them and, okay. Okay, a lot of them are asking about a 45-day follow-up, which we don't do in TVT. So just for the few questions that came up on that, TVT asks for the echo post-deployment. You want to know where it is. Then we ask for a pre-discharge echo. We ask for a 30-day echo. And we ask for a one-year echo. If anybody tells you anything different, you call me, right. That's where we are. Very, very, very important. Again, sick of hearing it, but with tricuspid, the TR at one year is the money shot. Okay, that along with the one-year KCCQ. So here's the catch. Many facilities are no longer doing the pre-discharge echo. That's okay. But if you do not do the pre-discharge echo, you have to be 100% double-dog sure you do that 30-day echo. The 30-day echo has always been the FDA gold standard of, especially with the self-expanding valve, right. So the 30-day echo is the important one. Now you have to decide do you trust the referring physician to do it if the patient doesn't come back to you? Or are you going to repeat it? So that's within your culture and your system and your relationships with your referring physicians. Some hospitals are still doing pre-discharge and 30-day. And that's fine. But if you have to pick one or the other, the goal would be to do 30-day if you can get it. Don't forget that's attached to the PVL and the composite which gives you your public reporting rating. Okay, so that's one thing about the echo. Now we also have the timeline. And again, you should know this, but I'll just say to make myself happy. There's the 23- to 75-day window of doing that 30-day echo. But somebody might be in the room who missed getting credit for that echo if they did it on day 22, right. And that again depends on the culture and the system of your hospital, because if you're run by a cardiologist, 23- to 75-days might be okay, except if you have a rhythm problem or something or you went home a little shaky and they want to see you sooner. But a lot of hospitals get into trouble with this if they're run by more a cardiac surgeon. That surgeon is not going to wait 23 days. They're used to cutting for cabbage and seeing them in 7- to 14-days, right. So they want the same thing with TAVR. Those folks are coming back for post-op visit, that's when they're getting the echo. And it's not counting. So we changed that. You should know this, but I feel the need to just mention. You could get the 30-day echo from day 7 to 75 only if you still get the KCCQ and the New York Heart Classification within the 23- to 75-days. If that's confusing, come find me later. But we wanted to open that window because a lot of the thought leaders and the steering members said, you know, I've never seen a change between 7 and 20. Why aren't we letting? So they allowed that window to expand to catch that 30-day echo. Okay, so I hope that helps. And again, I don't want to speak to LAO because LAO does have the 45, 60, 90 days in one year. They have the four follow-ups. I don't know if that's going to change. But with us, it's not changing for all four modules. TAVR, which will also include AR, we're not going to add a new module, M-tier, M-replacement, T-tier, I guess we're calling the clip for tricuspid, the terminology, and then the tricuspid replacement. Those four modules will all be at 30-day and one-year follow-up are required. Okay. So that kicks off all that. Here, for patients who have had a large parried device leak, I guess paravalvular leak requiring intervention, and I don't know if we could speak to this, but is there a preferred device? And this is just an opinion. Do you see any? So, yeah, the most common, I don't know that there is a preferred device, but they do have these plugs or implantsers that they're using and putting into kind of like the case that I showed you guys earlier. That was an implantser plug. That's the most common device that I'm seeing to close. A significant PBL, something that may be causing hemolysis, right? So when they have that significant PBL, those patients are having bleeding issues, right? So that's the one that I see most commonly. What if my site does CTs and they don't do ECHOs anymore? I mean, we've sort of changed that to say we're asking for the value but not necessarily the modality, dictating the modality. In your experience, I don't want to cross over into too much CT, but an opinion, not that will hold you to it. You know, there's a lot of literature out there about, how do I say it, like the reproducibility of ECHO-EF, right, so CT is better at doing LV function and RV function. So I'm not saying that ECHO is not good at it. It is still the gold standard, but at the same time we would, I don't think it would make a difference. It might even be more accurate. Okay. And that might help with your flow or, you know, who's fighting to get into the one department versus the other department. Again, it depends on how your hospitals are set up, but it might work. What I wanted to mention before is, and again, following up what you're saying, if a new program ever reaches out to say, how do I do this, I'll always say your smartest echocinographer may or may not be the cardiologist. You have to smoke out the smartest echocinographer or ECHO person. Make sure they're in the front row at your first heart team meeting. If you show an echocinographer, this is what I need, you'll get it, but don't let them guess and then say, why didn't you tell me that? So if you're looking at a lot of hospitals or growing other programs, new programs, so you're starting from over or perhaps you're out there and you're more on the starting end of it, I say the two smartest, the two most important people in your heart team meetings are your coder, so you get paid for these cases and they know what's coming down, and also the, and I'm not just saying that because you're here. Tell me more. Yes, they could make or break your program, and even more so when we're doing mitral and tricuspid, right? Here's an interesting one. Do you see any, again, opinion, do you see any difference in leaks, PVL leaks, I guess, between general anesthesia and ICE procedures? Ooh, okay. So ICE is very dependent on access and TE is kind of the one that's been the most studied, right, so there's been a lot of really great talks on ICE versus TEE, especially for like left atrial appendage closure, some of the other devices as well. I do think there's a space for combining the two as far as the views that they get, but it's all about your operator who's operating the ICE, right? So some hospitals are arguing that, you know, they don't need someone competent in TEE, they can just have the interventionalist do the ICE procedure and get everything that you need, but as far as visualization and being able to see things the way we consider standard for these different procedures, it's TEE all the way. That's my vote as well. A couple of the other questions I think are physician-specific or, you know, that the answer you all don't like when we say ask your physician, but about documentation. So I'll stop there and perhaps somebody will come up and ask you a question afterward, but I really thank you, and Echo, we value you, we thank you, and I always, and oh, here's the other thing, Echo, again, you don't have to listen to this, but really respect and appreciate your echo sonographers because they are at a real rare commodity, and that, again, it could shut down your program. It did during COVID, and then it was hard to rebuild those programs. So thank you very much. Thank you.

echocardiography

transcatheter aortic valve replacement

mitral valve interventions

tricuspid valve procedures

standardized tools

sonographers

artificial intelligence

imaging quality

clinical decision-making