Hi everyone, my name is Joan Michaels, I'm the director of the STS ACC TVT registry at the Hart House and it is my pleasure this morning to be introducing you to Dr. David Roberts. Before I do, I just want to show a couple of slides of who helps you with your answers to your questions that you call in or send in. So kind of a nice picture of LA, I tried to do a better one, but I tried to get that photo that they showed during COVID with no one in the streets, but I couldn't find it. So welcome, hashtag Tavernation. So some of the folks that help answer your questions, you see them, you hear them on screen. Karen and Kristen are here, so please seek them out. Karen's in the front row there and she'll be moderating for this session. And Bea is back at the Hart House answering questions as well as Christina. Christina is our lead science person. And this is the curriculum committee that put the program both today and tomorrow on for you. A real, you could see they're from East Coast, West Coast, all over. And I want to point out Evelyn Wilder who is with Sutter Health. She's been, I would say I would give her status as a founding member of the TBT Nation in that she's been with the registry since the beginning. Evelyn is a great partner and helps us with our questions and has been supportive of the registry through the past 10 years. So a quick note is obviously working with Evelyn introduced me to Dr. Roberts and he'll be our speaker today. So Dr. Roberts, a couple fun facts about him, nothing embarrassing maybe. He was raised in Portugal, Lisbon, Portugal, which is interesting. Went to medical school on a Navy scholarship and then did a residency in Columbia, St. Luke's. We've already discussed my dislike for the Yankees. And then went to Oakland, which I love, to work at a Navy hospital and then did a fellowship at the Washington Hospital Center where I also worked. So this is a real connection beyond my wildest dreams. And his lovely wife Patty is an ER nurse, perhaps two children, but I'll get to the important part. He also has a dog named Bailey. But at Sutter he has been there since the early 90s in charge of running the cardiac service line. And I'll let him tell you a little bit more about the specifics. We thought today, since our program is centering around reaching for the stars, since we're public reporting ready and reports are out, and a lot of the folks on the curriculum committee wanted to know, how do you get there? So there are 87 programs in the state of California alone. There are 813 sites throughout the country, as you probably know. But there are only three three-star hospitals in the state of California. So how did Sutter do that? And without any other further delay, I'll let Dr. Roberts give us some background on how did he get to Sutter, how did he get Sutter to be three stars, and what work did that take to do? So interested in hearing his talk. Welcome, Dr. Roberts. Good afternoon. This is really a great meeting. So thanks for having me here. And I've got to thank Joan, and a shout out to Evelyn, who I think, she literally was working on slides with me yesterday evening, last minute as always. So I've been asked, how did we do three stars? So Sutter Medical Center, yeah, we're proud of that, three three-star programs in the state of California. And I have to say, it's a team sport above all, through and through. So I hope I get to impart that. Hey, let's stay on the health beat. As Santa knows, it is not Christmas without Mrs. Claus. Eighty-seven-year-old Marjorie Malaspino has been one of Santa's helpers for two decades. But when she suffered a heart failure, it was up to a team at Sutter Health to save Christmas. Fox 40's Jessica Mensch has her story. Oh, I've got to give you a cute one. It's Mrs. Claus' job to spread holiday cheer. Well, that's what makes Christmas come alive. Peasants are one thing, but when you actually take time out to spend with a person, I think that's more important. But for the first time in 20 years, Marjorie Malaspino couldn't play Mrs. Claus for a women's group last year. As much as I would have liked to, I couldn't. I didn't have the endurance. I couldn't hardly walk across a room. I didn't miss you. I'll get you next. The 87-year-old was in heart failure. Her aortic valve closed. It's a fatal condition. Once symptomatic, your life expectancy is about two years. In the old days, you had to open someone up. And for an 87-year-old, it was almost prohibitive. Determined to save Christmas this year, interventional cardiologist David Roberts at the Sutter Heart Institute found another way. It's called a transcatheter aortic valve replacement, where doctors thread a catheter containing a new heart valve through a vein and expand it inside of Malaspino. No cutting necessary. After the procedure, shoot, I can walk through the whole house now and take nothing of it. This Christmas, she's back to her duties as Mrs. Claus, passing out candy canes to the doctors and nurses who saved her. She wants this successful surgery to inspire other seniors to put their health first, too. I have a couple of friends that, when they lost a mate, they just stay at home, have given up. And I don't want them to. A Christmas wish that won't be her last, thanks to these doctors. Might as well live while you get a chance. Do everything. Thank you so much. And thank you. Merry Christmas. Jessica Mench, Fox 40 News. Do you play bingo? Yeah, the wink gets us every single time. Mrs. Claus tells us that she is. So that's what it's all about, right? It's the patients and how'd you like that wink, right? She's in her late 80s, and it was fun to have her come back. And that was in our valve clinic that she came back and handed everyone out candy. But let me back it up a little bit. Disclosures. So I'm equally convicted. I do valve proctoring, consulting, research, and I'm Speaker's Bureau for Edwards Abbott Medtronic. So I got a foot in all of the camps. So why are we discussing TAVR? I want to do this really quick, because you guys are all TAVR people. But we started back in 2012, right at the beginning of that graft. And it's really been explosive, the growth. And it continues to grow. And today, more valves are implanted using TAVR than SAVR. But the total volume has also gone up. So it's not a sum-neutral game. The total volume of aortic valve replacements has increased. And it really does speak to the fact that there was a big unmet need prior to TAVR. A lot of octogenarians weren't getting what they needed. And we're talking about a disease that, once you have symptoms of heart failure, has a life expectancy of only two or three years. So this is a really big deal. So this work is really, again, I'm talking to a TAVR crowd. You guys all know this. It's been grounded in good clinical science, New England Journal of Medicine articles. And it started off with extreme risk patients, went on to high risk, intermediate risk. And then finally, what I like to call standard risk. There's nothing low risk, right? It's standard risk. And the partner three trials showed that there was actually a slight advantage to TAVR versus SAVR. If you looked at the composite endpoint of death or disabling stroke, which are really the two things that we fear the most. This was our very first TAVR. And you can see me right in the middle. I'm scared to death. I really was. It's like, oh my goodness. I hope this goes well. And you couldn't have fit any more people in this room. I think everyone was there in one form or another. A lot of these folks are still working with the nurse to my right, Brenda, behind her, Daryl. They're still at my side today. The anesthesiologist, Brooksby, Ingram, the team is very much still there. This was done in a regular cath lab, not a hybrid, just a regular cath lab. And this is that same regular cath lab about three years later. It got very routine. All the people left. By the way, there's a joke there, those Starbucks mugs at the bottom. I showed this at a med staff talk, and the chief of staff freaked. She thought that we were actually there, behind the red line. I said, no, no, no. It's really okay. We pasted that on. But you get the picture. This has become a much more routine thing. And this is our 1,000th case in 2019. Pei-Ju Wong subsequently joined our team. He's third over on the left. And we've done over 1,700. We'll cross that 2,000th mark next year. So this just keeps accelerating. And it really is a story of progress. If you look at the median procedure time, it's gone from 150 to 49 minutes. The median length of stay used to be seven days. It's now one day. Despite the seven days, 10.7% still got readmitted. And now we're down to 8.9. Stroke rate, 4 to 2.9. And PVL, or perivalveular leak, from 14.3 to 0.8. We used to cut down on the femoral, or more critically, one-third of our cases used to be transaperal. And now over 95% are femoral percutaneous. And if we have to use an alternative access, we typically go to the carotid. And we used to use general anesthesia, now just conscious sedation. Patient goes to the PACU for a couple hours, and then up to their regular telemetry floor and home the next day. So it really is a tale of collaboration. We have a fantastic cath lab staff and team. There's some valve nurses in there too. But we've been pushing them slowly. You say three by three, then four by four. Now we do five by five, and we've been there for a while. I keep threatening them with six by six, but they give me the eyes. So I think we'll hold it at five by five. So how did we end up with three stars? So let's start off with case selection. Case selection is a really critical part of this story. In 2012, we were doing the sickest of the sick, the prohibitive risk. And we are blessed with a just fantastic surgical team. So they didn't turn down much. So we really were with very sick people. And at the time, no emergent TAVR was the word. Don't do your inpatients. They got tuned them up. They can't walk back in. You shouldn't be doing them. They're not going to do well. Just how this has evolved, and how do we fit this? How do we capture this data? Last year, no, it was this past February, President's Day. I was supposed to be in San Francisco with my wife for a birthday party at 6. And I said, honey, I'm going to the hospital for a couple hours to clean up some paperwork. Patient arrived from another hospital with a valve and had a bioprosthetic aortic insufficiency in the ICU. I'm just going to swing by and say hi to her on my way out. About 2 o'clock, I found her on wide open Lebofed with a pressure of 60, guppy breathing. She was going to code in front of my eyes. The cath lab was there with the STEMI team. They came up and got her. We brought her down and literally slammed a valve into her. Emergent TAVR, that was, but you know, this is where we're going to go. Remember when we used to angioplasty, and now we're doing STEMIs with PCI. So eventually, you know, this kind of care is going to have to become routine at some point. And for that lady, it made all the difference in the world. But for most patients, the big issue now is a strategy. If you are putting in a tissue valve in anyone under the age of 70, and even 75 if they look like they're going to go to 90 and they're healthy, you've got to assume you're going to have to do it again. They're going to outlive their bioprosthetic valve. So what are you going to do the second time? And that's really what drives our decision. TAVR, SAVR, SAVR, TAVR, TAVR, TAVR. I mean, if the annulus is small, if you can TAVR them once, it's a one and done. You really need to think of SAVR first. This would be typically truer for women. The smaller annuluses and healthy, they have longer life expectancies, under 75, especially if they don't have coronary disease. So we still do a lot of SAVR. So I think that's really what drives case selection. And it's got to be a team sport. We've got a great relationship with our surgeons. We're friends. We really are. I hear about hospitals where there's acrimony I can't imagine. So the interventional cardiologists, we're great friends with a dedicated cardiac anesthesiology team. Same thing with our echo specialists. They do TEs if we need to. They're fantastic echocardiographers. And then, of course, the cath lab staff and the operating room staff. It really has got to be a story of collaboration. And we get together on a weekly basis and have a multidisciplinary valve conference, and everybody's there, including the valve clinic nurses, the CV administrative leadership, or the old cath lab manager. Everyone pipes in, and we get shared decision making with every patient, and with every visit, and we document it in almost every note. We didn't on that case I just described to you. That was just right. But really for the routine work, we really try to make sure we have a consensus. And then some of these decisions are difficult. You've got that 73-year-old woman with a small annulus that's a one and done, and she really doesn't want SAVR. But if you present the story and you tell her why, so you can get a TAVR when you're 83, we rarely get pushback, as long as you really present it as a team decision. Couldn't be here without the valve nurses. This is not all of them, but the valve clinic is a critical part of the program. And they collect this data, which is so important, especially for frailty determination, the quality of life questionnaire. They're almost at 100% every quarter. I mean, they just do an outstanding, it puts us at 99% across the board. But this is a critical part of figuring out how sick your patients are. And if you can't determine that, you're never gonna get three stars, cuz that data gets fed into that number, and it's really important. Collaboration, I'd have to mention the administrative staff. We've had fantastic collaboration. There's a line of sight, it's integrated. Tom Rhodes is our administrator, and he's over the cath lab, he's over the valve clinic, he's also over the research nurses. So, and he has a direct line of sight to Rick Correll, who's our chief administrator for surgery, who sits on the main administrative team. So it's a very short line to the senior leadership, and they really pull everything together. So that's also a very important part of the puzzle. The picture to your right, I've gotta tell you this story. So this was about 2015, when we were in the older hospital. And when we started TAVR, where do you put the valve clinic? We were looking for some space. And it turns out, it went to an old part, an old wing of the hospital, which used to be where they delivered babies in the 60s, early 60s. And this was a retired obstetrician that everyone knew in town. And so he came over, he had severe aortic stenosis, and he was in his 80s. And so I'm looking at him and go, hey, Bob, did you deliver babies here? And he said, yes, I did, this is exactly where I used to deliver babies. So down the hall comes Bob Kincaid, one of our cardiac surgeons who is one of our TAVR surgeons. And Bob, look, we've got our old OB who used to deliver here. And he said, I was born here. So he goes home that night and finds his birth certificate. Guess who had signed it? He delivered him. So guess who ended up TAVRing him with me, of course. And by the way, about three months afterwards, Bob called me and said, please, I can't do any more interviews. This got out online. He was interviewed on one of the New York national shows, virtually. I mean, it's just crazy, he was just exhausted. Got TAVRed by the kid he delivered, good story. So Sacramento, let me just tell you all a little bit. How much time do I have? I've got about ten minutes. Good, perfect. So the Sacramento is a dollop of the Midwest in California, Central Valley. We don't have our backs up against the water. We pull it in from 360 degrees and from certainly north-south axis. And before the program started in Reno, we'd pull stuff in from there as well. And there are three very good, high quality programs. Mercy Davis, Mercy Dignity, which has the Kaiser contract, and Sutter. And they're all excellent, high volume programs. Fun fact, when Edwards released TAVR, they released at three sites simultaneously in two cities. New York City and Sacramento. How do you pick between these three? You don't. So we all launched simultaneously. Margaret Maddy, I have to acknowledge her. In the 90s, when I was in private practice, I used to go to Mercy and Sutter. At Mercy, they always got three stars for their surgical work. But I knew the work was comparable to Sutter, they were comparable. But they always got three stars. And I noticed there was always an army of nurses with clipboards, data nurses. And they were concurrently collecting data through those paper charts. And they'd approach me now and then, hey, this person had acute kidney injury, can you document that? I said, of course, and I'd make sure it got documented. But they were doing this work concurrently. It was critical to their success. And Margaret came over to Sutter about the time I became Cal Lab Director in 02. I said, Margaret, we've gotta do that here. So she really began a process where we hired a really robust team of data nurses to do this exactly. And this was pre-TAVR, we were doing NCDR, PCI, Cath PCI, but this is true across our entire service line. We've got a CV data team, they're only RNs. They've all had a minimum of five years of acute care hospital experience. So they're on the ball, they know what they're doing, they understand our work. In terms of TVT with Evelyn, the data is all abstracted concurrently, conjunctly with the weekly procedures. And then very importantly, every quarter, the multidisciplinary team gets together. And we review her data, review all the numbers, and then we look at all the fallouts, and we adjudicate them. Is this real? Yeah, sometimes it's real, gotta take the hit. Sometimes it's real, but we didn't document something. Or sometimes it isn't real, but that data gets adjudicated before it gets submitted. I can't emphasize how important this process is. If you look at our national benchmarks versus our stats, mortality, this was 2021, 0.4 versus 1.7. Stroke is 2.9 versus 1.8. PVL, we have 0.8 versus zero. And vascular complications, two versus 3.7. By the way, I've got to beef with your definition, the definition with vascular complications because a stent in an iliac is not a complication for me, but, or the patient for that matter. But we'll discuss that one another day. So if you look at our patient population, I told you we have a really good surgical team. We do a lot of SAVRTAVR. And so we have an older population. If you look at the surrounding hospitals, most of them, if you look at the octogenarian population, they're all in the 30% range. Ours is 54%. So we're doing an older patient population. And then if you break it down by, again, low slash standard versus intermediate versus high, we're the second guy from the bottom. You see that little nubbin of red. Almost no patients would be considered really standard risk. UC Davis just below us. I mean, everyone else is in the 20 to 30% range. So this is really important because if you don't capture this properly, your data is not gonna look favorable. So again, without that work of the data nurses, our numbers wouldn't look like this. So our death rate is 1.2%, but our expected is 2.2. So the O over E is 0.5. Death or stroke, 2.6 versus four. It's actually 0.6. Death, stroke, or bleeding, 5.3 versus 8.7. O over E is 0.6. It's 0.6 for everything else. Death or stroke, bleeding, or AKI. Death, stroke, bleeding, AKI, or PBL, six versus 9.9% expected. So again, without that robust data team collecting the data and collaborating, and collaboration and engagement from the clinicians to review that data, we wouldn't have this information. And so really, that was the other key cornerstone of how you get to 0.03 or three stars. I'm gonna just leave you with a teaser. We've worked in every valve. There's four in the heart. None of them are immune. So Pascal got just approved. You guys all heard that? The aortic valve is simple. It's very simple. The mitral, not so much. Tricuspid, even less so. There's three versus two leaflets. So, you know, TAVR, get ready. All you data TVT people, get ready for the slide on the right, because the left one's where we've been. Because we're gonna have to collect this data and figure it out. So how do you get to four stars? I mean, it starts with vision, both at a clinical and an administrative level. Collaboration, again, at every level. The administrators and the clinicians, all the way through to the data nurses, which, honestly, that drives clinical excellence. And without the data nurses, you don't have any dashboards at all. You're off the road very quickly. So you have to have information to know where you are and where you're going. So, thank you. Any questions? Yeah. Yes. Yes. Okay, can you hear me now? Okay. A couple different questions came in for, do you need open heart backup to support within the facility to do TAVR? So in other words, do you have to have an open heart program to be able to do TAVR in any facility? You know, I think there's an echo. Okay, is that any better? Ask me again. Okay. Do you need open heart backup support within the facility to do a TAVR? Yes, right now the answer is yes. Will that be true in the future? Maybe not. You know, PCI initially required backup support. We've had about three or four patients that, and none in the last four or five years, I'd say they all predate 2015, that we had to convert to surgery. And three or four, and none of them survived to leave the hospital. So, you know, I tell, and patients used to spend a lot of time, and we used to spend a lot of time discussing this, and I tell patients when they were sort of sitting on the fence wrestling with it, I say, hey, this is a little bit like you're going on southwest of Phoenix, you want a parachute? And I guess you're giving me one, I'll take it, but is it gonna do you any good? I'm not so sure, right? So this is a great question, and I suspect down the road, I wouldn't be surprised to see this without surgical backup. Okay. Selectively, I should say. Question number, okay. What advice do you have for a facility starting TAVR at the base level? Starting off day one. Make sure you've got enough volume. Volume, I didn't mention that in slides, but volume has been a critical driver of quality for us, I'm convinced. And when you do something routinely, five times every Wednesday, and then a couple of times on Tuesday, and a day on Thursday when we spill over, everyone gets really good at it. Nurses, techs, everybody. I think you have to realistically ask, if you're doing it once a week, is that really appropriate? Especially if you get into standard risk, where there really is no margin for error. If you're doing a standard risk patient, your risk of dying or having a stroke should be under 2%, and you should go home the next day. So you need to be able to deliver that. What is your facility's permanent pacemaker rate? Great question. So, what is our rate? It's typically under 5%. It gets driven more than anything today by, and this has to be captured at some point, by the way. We're not capturing it right now. A right bundle or bifacicula block, that rate's gonna be 20, 30%. So, but if you have a straight forward EKG without any conduction delay, it should be under 5%. We're not capturing that as a risk right now. That needs to be done. If you're implanting current valves properly, which includes Medtronic now, which used to, previously had a higher pace rate, these valves should not go less than two, more than two to three millimeters below the annulus, and you really shouldn't be, you shouldn't have a pacemaker rate over 5%. I don't think it's on. I can hear you though. Yeah. You did talk a little bit about this earlier, but are the SAVR volumes decreasing due to the increase in TAVR cases? There has been a drop in SAVR volume, no question. Okay. What are your facility's secrets to success? It just, where'd the question go? For the KCCQ. Do you have a TAVR coordinator to do follow-up as well? Yes, they're embedded in the valve clinic. So the valve clinic nurses are also, they're our coordination. They're the people, I always joke, they're the people that run my life. At the very least. Okay. This is one about capturing minor vascular complications. So how does your team avoid capturing minor vascular complications at access site for TAVR? The NCDR data definition for minor vascular complications is inclusive of the smallest of hematomas. A small hematoma, did I get the question right, is considered a complication? Right, yeah. Yeah, I mean, you know, for me a vascular complication is when you cannot bail yourself out of an endovascular problem, right? When you're doing endovascular work, think about peripheral work. How does a vascular surgeon define, and you're going contralaterally, opening up a superficial femoral artery. You put in a periclose, you get a small hematoma, is that considered a complication for that procedure? No, it goes with the territory. However, if you close the femoral artery, that you need to do an open cut down and a surgical repair, that's most definitely a complication. And that gets back to stenting. If you have a small intimal tear and you decide, sometimes you leave it alone, but if you decide to put a self-expanding stent just to make sure it's stable and doesn't expand down to the femoral artery, is that a complication? I mean, that wouldn't happen if you didn't have peripheral vascular disease to start with, and that's a group of patients that very often end up getting stinted anyway. So this one I struggle with. I mean, we all know what a vascular complication looks like. It's when the surgeon has to get his team out and fix a leg. That, to me, sets the patient back. That's gonna extend the hospital stay for two or three days. There's no question. The patient's been hurt by that event. Whereas just a small hematoma or any of the other things. One of the things, for instance, that will happen, sometimes the femoral artery will close. You do an angiogram and it's closed. You run a wire down, you do a soft, low-pressure balloon angioplasty, the femoral artery looks beautiful, and you're done. Does that get coded? That's definitely a problem with the registry because of the VARC guidelines that say a mention of bleeding, such as a hematoma, is considered a minor bleed. And that's, I think, where that question came from. And the next one is, how do you get your doctors to care about the data? You know, that's another, these are all great questions. Thankfully, I've been blessed not to have that problem. That team has been on board. It's built into our culture and DNA, going back to when we brought, where I described what happened in the early 2000s. And it really, it predates TAVR. So that whole process, that culture, was there before TAVR. So when TAVR came along, it just slipped right in. So I think if you have a physician that's not engaged I think, over the years, occasionally I've run into them, and here's how I approach it. This is their data. No, we're talking about, this is your data. And you look bad. And if you don't wanna look bad, you've gotta capture how sick your patients are. And then you won't look bad. So you wanna get engaged and make sure you are part of that process. And I've never not gotten engagement that way. Okay, the next one. Is your facility a verified stroke center? And do you find that those centers with stroke programs identify post-op strokes more often? We are a stroke center. So perhaps that does pick up some numbers. So we are a certified stroke center. I have to tell you that, if anything, we've gotta wave them off now and then. Patients unpack you, and they maybe have a little bit of a facial droop or something. And the next thing you know, that whole stroke team's there. Go, whoa. Let the patient wake up. And even if they have a very small event, managing them conservatively, rushing someone to the IR suite who's just had thermal access, you better make sure you're going after something significant. So to your question, the answer's probably yes. Probably does drive our limbers up. It's been, again, collaborative. And if anything, we tend to try to, a lot of times we find we need to wave them off. Okay, was the STS risk score documented for all of the structural cases at your facility? What was it? I'm sorry? Did everybody get an STS risk score prior to the procedure? Did everyone get an STS score? Yes. Yeah, that's actually, I think, captured in the valve clinic. Does your facility use the sentinel protection device during TAVR? Selectively. Selectively. Bicuspids, I mean, selectively, not everyone. I am not sure that I'm gonna get this question verbatim, but it was, oh, here we go. How did your team get such high five-meter walk numbers during the pandemic? Those nurses are awesome. You know, we did not really slow down much. And when we were asked to cancel elective cases, mitral regurge with some heart failure, you can sit on for a bit, but critical AS, you cannot. There is a death rate to every month you delay. And administration with support. And administration with support. So our valve clinic did not, it never closed. And we kept going. So they kept doing their work and collecting the data. This is a more general question. What criteria and who decides exactly if SAVR versus TAVR should be done initially? You know, again, that's a collaboration between us and the surgeons. We have a really good relationship. And initially, you know, we were part of S3. We were terrible enrollers. Because the surgeon said, I can operate on this. And my numbers are better than national numbers. And so initially, the standard risk patients got surgery at our institution for a long time. And then with the data, and I think there's now an acceptance that TAVR is at least an equal option. And it's interesting that we will, some of the people that I want them to operate on are not the ones they want to operate on. I'll give you a specific. So a 240 pound, five foot woman who has a 20 millimeter annulus. And they will sometimes send it back. Can you TAVR this lady? And I go, yes I could, but it's a one and done. I think you need to operate on this one. Okay. And then there's that robust, skinny, big 78 year old guy who's still running a mile, or was running a mile still a year ago. And they could SAVR him with an eye shut, but that's a good TAVR candidate. So we work well together. And at the end of the day, the patient makes a decision. Let's be very clear. Because we can present the recommendations and I'll tell them why I think they should have what they need, or what I think they need. But at the end of the day, it's the patient's decision. And I always emphasize that. You don't ever want, they can't, it's really important they don't perceive that something's getting shoved down their throat or they were getting railroaded, especially something at risk. It's gotta be the patient's call. Okay, next question. What about same day discharges for TAVR? What is your take on it? And have you done that at your facility? No, we haven't. We've thought about it. I'm not sure what I think about it. So I know there's a push for that. There's a push to do everything outpatient. I, and the data right now suggests you can do it safely. Now I do same day PCI now and send them home and that would have been inconceivable 20 years ago. But I'm using the radial artery. You're not gonna bleed to death from the radial artery. You put two fingers over it, worst case scenario. I'm not sure if I'm entirely comfortable yet. I need to, I'm not gonna be a trailblazer on this one. You've got a 14 French sheath that, or maybe 16 in the right femoral artery. That thing opens up. That patient's gonna bleed to death in 10 minutes. And if that happens at home, now mind you, it hasn't happened and I can't remember the last time it happened. So maybe it would be fine, but I'm not quite comfortable with it yet. Okay, I think we have time for at least one more. During the height of the pandemic, did you do telehealth visits? And if so, how did you take on the challenge of the five meter walk? I got that echo again. Sure, during the height of the pandemic, did you do telehealth visits? And if so, how did you take on the challenge of the five meter walk test pre-procedure? During the pandemic, did we do valve clinic visits? Telehealth visits. No, we will do that, and we still do that, for maybe the surgeon's visit. I'll see the patient in valve clinic and it's a clear TAVR patient, 85 year old. Then we'll set up a video visit with the surgeon. But if the patient can't come to clinic, why are we thinking about TAVR, is my opinion. You really gotta lay eyes on the patient to know what the right thing to do for them is. Thank you very much, we're at time, so we appreciate you taking all the questions. Thank you. All right, great, thanks. Let me say this about the five meter walk. Five meter walk at a lot of hospitals, some hospitals pivot it really well during COVID, but remember you could do that the morning of the procedure. So that's your fail safe to get it in before the patient goes in the room. So whoever's asking that, if you wanna talk to Karen or myself, we could talk to you about what we know some other hospitals are doing. But doing the KCCQ on the five meter could certainly be on your checklist before the patient leaves for the table. And that's a great way to make sure you get it done, even if it's the day of surgery or the day of the procedure. Thank you so much.

Joan Michaels

Dr. David Roberts

TAVR procedures

collaboration

data nurses

mortality rates

patient engagement

valve diseases