Thank you, again, for everyone staying for the last session. My name is Joan Michaels. I'm the director of the STS-ACC TBT Registry. Show of hands, maybe, who's here for their first NCDR meeting? A couple, wow. Thank you, thank you. You know, the last in-person meeting we had was New Orleans, and I've talked to a few of you, and there were, like, 1,800 people in the room. I don't know where my head is, but I think this has been the best one. I don't know. It's smaller, it's probably never going to be 1,800 people again, but I've met a lot of you. Hopefully, if you haven't met us, we're the TAVR team, Kristen's up front, Karen's helping with questions, and Bea's back at the house taking questions, but we try to do our best to keep up with your questions, and please introduce yourself if you're new or if you haven't met us after this little session. So I'll introduce what we want to talk about today, sort of a rollover from Toolkit Number One, where Dr. Roberts spoke. This is Toolkit Number Two, and kind of best practice, what's important, and then it's intimate enough that we could take questions. Hopefully, we'll have time for some Q&A. We're about to go in, you know, we started 10 years ago. By the way, it's the 10th anniversary of the TVT Registry, it's the 20th anniversary of TAVR, but the 10th anniversary of the TVT Registry, and boy, have we come a long way from just doing TAVR, then Mitral, then Mitral replacement, Mitral repair, and, you know, tricuspids right around the corner. But we're now into Version 3 of the Registry, and it's very clear to us that we need to get into, I don't know what we'll call it, maybe 3.1, if not Version 4. We're kind of in this fight now with RT, oh gosh, this is being recorded. We're in this discussion with the IT people to say, is it a mini-upgrade or a full upgrade? So we're advocating perhaps for a full upgrade, because we know more now than we did even when we launched Version 3, and I'll tell you what kind of is on our punch list. We need to make sure we're doing the right thing with tricuspid. We thought we knew it, but now we'll know more. And also, you all have given us a curve ball by starting to do combination procedures. Physicians said that will never happen. It's happening, so we need to make sure that we're collecting it the right way. So we'll probably enter into an upgrade sometime quarter one or quarter two of next year. We already have the punch list of what you've all given us as ideas, so keep giving us those ideas because that's what we're going to go back after this meeting and start working on. Lots to do in 2022. Next year, 2023, is going to be a busy year, and of course, we launched public reporting. So it's never a dull moment with the TBT registry. So I want to introduce our speakers this morning or this afternoon. Sarah Babcock is from Spectrum Health, and I will let her tell you a little bit about herself. She has been with us for a while, not new to the rodeo, and she's the lead abstractor at Spectrum Health and has been on the curriculum committee and very helpful with planning the sessions that you heard yesterday and you'll be hearing today. And Dr. Liu, Hao is our chief echocinographer from CEDARS. I asked him, all the famous people, he probably did echoes on, and of course, with HIPAA, he can't tell us, but maybe he'll tell us some secrets today. But his expertise is in echo, and if you know CEDARS, you know they do quite a few mitrals, so not to say this is all about how to be better with public reporting or how to get three stars. I know reaching for the stars is sort of our kind of theme, and we're not going to be echocinographers. We're nurses. We're abstractors. We're valve coordinators. But I think it's important to kind of bridge that gap a little bit so we have an understanding of how important those valve echo measurements are when it comes to documenting and making sure that your team knows what's important. What I have learned is that if you ask an echocinographer, I need this, their response will be, why didn't you tell me? Of course, I can do that. So it's a communication between the echo team and the heart team and the abstractor. So Liu will be telling us a little bit of what's made CEDARS so successful in their echo department. So I'll let Sarah start, and then we'll have time for Q&A. So again, thanks for being here. Good afternoon, everyone. Thank you so much for hanging out till the end. I appreciate that. As Joan said, my name is Sarah Babcock. I'm with Spectrum Health in Garner, Michigan. And I have done primarily TVT focus now for about three years. Prior to that, though, I spent another three years doing the STS adult cardiac. So I've been doing HVI for quite a bit of time. Prior to that, a couple other registries, and then old hat before that, as I was a pediatric nephrology nurse. So babies and dialysis, two separate worlds. But I'm going to give you a little bit of a layout of how we handle TVT registry inequality within Spectrum Health, and just give you a snippet of what we do with our data. And hopefully, there will be some things that you all are already doing, and that's wonderful. And maybe there'll be some things that you're not doing that might pique your interest a little bit. First and foremost is, who is your team? Communication is going to be your biggest currency. You can never do it enough, and you can never do it loud enough. You are going to do a lot of repetition. You're going to hand out data definitions multiple times. You're going to hand out abstraction forms multiple times. But having that big, open communication avenue is vital for you to be successful, and for your team to be successful. And with our team is what a lot of you, I'm sure, have as well. We have the interventional cardiologists. We have the cardiothoracic surgeons, myself as the data manager. We then involve the operations manager and structural heart. We bring in the clinic nurses, the research nurses, our mid-levels. We bring in the EP docs when we can. You want to bring as many people to that table as possible, and try and get them invested, because that is going to be what puts your data to use. And for those who have physicians or staff who are maybe not on site. So, for example, in a perfect world, they're all in one building, on one office floor. They're in offices next door to each other, and you can just jog down and say, hi. Doesn't really work that way. So, for those who have folks that are outside of your facility, get your power contacts. Who is in that office that you can get a bridge of communication with, and have them be your go-to person? So, find that person that you can use as a liaison to close that gap. Another thing to think about, too, is as we start to come out of the virtual world, and coming back to in-person, for a lot of physicians, virtual is great. I have seen absolutely an increase in my physician involvement with having the virtual aspect. So, don't be so quick to take that part away, because you still may use that in the future. There we go. Next, we're going to talk about what we discussed and when we discussed it. Of course, when reports are released, that's always a great time to bring your team together. If your physicians are like mine, they will immediately send me an email and say, did you know the reports are out? Yep, I get those same emails. So, I will make sure and get those ready for you, and send them off to you. We do a monthly EIT, or a quality meeting, at Spectrum Health, where we discuss data. We do deep dives for data. I meet every other week with my operations manager and structural heart to discuss stuff that maybe is not quite physician-ready, such as, I can't see cardiac rehab referrals. We've discussed it numerous times. What can I do to help get them invested and see what I'm seeing or not seeing in that situation? In addition to that, what we also do, at least implemented by myself, was I give them a wrap-up of a month when I finish. So, we all know the reports are wonderful, but they're a little bit behind where your team is at. So, the hard part is, when they come out, the data is somewhat older, just a little bit, Joan, just a little bit older. They want to see something right now. So, I find, if I give them a snippet of what they're working on currently, those trends when they come out on the report, they're not so surprising. So, when I finish a month of extraction, for example, if I finish August, I provide them with a snapshot and say, here's what I saw for August. We had this many pacers, this many people didn't have their walks, this many people didn't complete a survey. And, it gives us a chance to hunt down where the fallouts happened and why, and the goal would be to fix them. And then, when the reports come out, they're not as surprising when they start to see, why do we have so many pacemakers in the first quarter? Well, remember when I showed you those first three months and I kept saying to you, pacers are ticking up? That would be why. And, of course, other data that you want to review, you want to do your quality improvement projects. You want to do deep dives. You want to try and get ahead of your trends as fast as you can and find out, is it simply a technique that you need to adjust? Is it a procedure or step that you need to adjust? Is it a documentation that you need to adjust? Or, put in, for example. You are going to be what tells them that ahead of time. They may be able to tell you a case they did last month, but they're not going to remember stuff from three months ago. So, you giving them the heads up is really helpful in attacking those trends before they become problematic. And probably the last thing, the fourth W, if you will, is the why. And, I think this is the most important. I can give you a printout with graphs and numbers and data, and that's wonderful, but if you browse it, as most physicians will do, and stick it on your desk, what did we gain from that? Then, the trend that you noticed, you didn't notice, we're still having adverse events that we don't want to see. So, you need to be a data manager or wrangler, if you will. You are not a creator. So, when they don't like their data, what you say to them is, these are hands. They're not magic wands. This is your data. I'm just spitting it back to you. So, we need to fix the data that you give to me, and then it'll look better when I hand it back. You want to utilize your DQRs. Of course, green status is important, but don't simply say, well, I got a yellow status. It will be okay. You got a green status. You want them all the time. But, more importantly, you want to look, does what you see come out of the registry match what you see on your site? If I knew I had five pacemakers, example, excuse me, for this first quarter, but my report shows me eight, somewhere there's a disconnect. So, you're going to want to hunt down, where are those three missing pacemakers? Was it a misclick, mistype? Was it someone that got discharged into the next month and that put them into the next quarter? So, you always want to utilize your DQR before your reports come out, because once they're out and the data call has been set, it's not going to adjust itself. We want to reengage people, bring them back to the table, get them discussing, bring yourself to the table. You are never, by any means, just someone who supplies number or graphs. You are vital to that team, and you need to make sure that you communicate so much so that they know it, and they ask you questions, and they want to say, hey, how does this look? Or, where were we at last report for this? Be an equal player at that table. As we reengage to come back and get more involved as a team, your patients are ready to reengage as well, and they expect the same, if not better, quality care than what they received before the world of COVID. So, it's important to start building those blocks now, as hopefully we come out of it, so that we are prepared when they come back to give them the utmost best care. And of course, as you've heard all week long, it takes a team to put this data together, but it's a team that needs to use it, so don't be afraid to bring the team to the table. I talk really fast. Sorry, that's it. Last but not least is just some contact information, so you're more than welcome to reach out to me after this today, or even a month from now if you have any questions or want to run any information by me, or clarify what I talked really fast through. Thank you, Sarah. Hi, good afternoon. My name is Lu, from Echolab Cardiology in the Seattle Sinai Medical Center. I'd like to spend a few minutes to go over some echo measurements in patients with aortic valve stenosis and mitral valve regurgitation. Okay. Now, let's talk about aortic valve stenosis. We started actually in 2007. At that time, we called it a clinical trial. It was called a partner trial 15 years ago. Our pioneer, Dr. Rajiv Makar, worked with cardiac surgeon, Dr. Alfredo Trento, and echo cardiologist, Robert Siegel, so worked together as a team. Before we performed the TAVR, echo was routinely performed. Now, I just let you guys know what kind of information echo can give to us. So, after we performed echocardiogram transthoracic, there's five informations I was, you know, at least you can get it. Number one, what is, if patient has aortic valve stenosis, so what's the etiology? I mean, so what's the cause? Okay, number two, if patient has aortic valve stenosis, how bad is aortic stenosis? We're talking about severity. Number three, okay, if patient has aortic valve stenosis, what is patient cardiac function? Means the systolic and diastolic function. Number four, what is patient pulmonary artery systolic blood pressure, PASP? Number five, what is other coexisting valvular lesions? Okay, now let's talk about etiology. Now, most common cause of aortic stenosis in the United States is age-related degenerative aortic valve stenosis. Now, the pathology is pretty clear by the echo. You see the three cusps, thickening, calcified, reduced orifice. All right, now this is most patients is like over 80 years old. All right, but 30% of patients, people, if older than 80 years old, has aortic stenosis. All right, so this is why I call grandma-grandpa disease. All right. The second common cause is congenital bicuspid aortic valve. Now, in the echo, the pathology also pretty clear. You can see the valve, only two leaflets. But one leaflet is thickening, calcified. The other leaflet could be normal. But a patient with a congenital bicuspid aortic valve, the age is relatively young, so younger than 65 years old. So every time you scan a patient that has aortic stenosis, younger than 65 years old, you be careful. That could be bicuspid aortic valve. Normally, you know, degenerative is older people. Number three is less common in the United States. It's rheumatic aortic valve stenosis. Now, rheumatic aortic valve stenosis, on the echo, also pretty clear. You can see not only leaflets thickening, calcified, but the leaflets commercial fused together. The other important echo finding is every time you have a rheumatic disease, first attack in the mitral valve. So you see the aortic valve has stenosis. Mitral valve has stenosis regurgitation. Then be careful. That could be a rheumatic disease. Most patients has a rheumatic aortic stenosis that was born in another country, most likely developed country, not in the United States. This is three common causes in aortic stenosis. So next is how do we assess the severity of the aortic valve stenosis? Okay. Now, based on the ACC and the AHA guideline, so to judge the stenosis severity, number one is the velocity crosses stenotic aortic valve. Now, if the velocity is more than four meters per second, that is considered severe aortic valve stenosis. All right. This is, remember, this number is a four. Okay. Now, another, also you can remember four is the mean pressure, sorry, mean pressure gradient crosses the stenotic aortic valve more than 40 millimeter mercury. That's considered severe aortic valve stenosis. This is another number for four meters per second, 40 millimeter mercury for mean pressure gradient. All right. Now, the aortic valve area, if measured less than one centimeter square, that we call severe aortic valve stenosis. So for these three measurements, they're all important, but the key measurement, please remember, is only one. The highest velocity crossed stenotic aortic valve. Now, why I say that? Because the mean pressure gradient and aortic valve area, those two numbers, it all came from the highest velocity across the aortic valve. So as a stenographer in echo lab, so we have to try our best to find the highest velocity across the aortic valve. So if you want to know if this patient is severe or not severe, most likely the doctor will ask you questions. Hey, echo man, what's the velocity across the aortic valve? If you say four meters per second, thank you. They knew that. It's a mean gradient more than 40, area less than one. So to me, for the stenographer, the key is find the highest velocity. I used to use different way. Sometimes we use contrast, optic sound, or definity. Sometimes we do the stress echo. What's the point? Point is we want to get four meters per second. So that's the reason we want to know the severity. So for us, to judge the severity of the aortic stenosis is not that difficult. All you want to do is get the highest velocity. So next information by the echo you can get is cardiac function. So doctor want to know this patient, what's the ejection fraction? They want to know if it's normal or abnormal. What's the pulmonary artery systolic blood pressure? Then what's the other coexisting valve disease? For example, the patient has combined aortic valve regurgitation, has mitral valve regurgitation. So this is five information. I will say each echo you're supposed to give to doctor. All right. Now I don't want to spend time talking about how do we get this area and the mean gradient, how to measure that. I think it's a little bit too much for you guys because Stanley, my manager, told me you guys are not working in the echo lab. He told me, don't worry, they won't give you a hard time. That's why I tried to skip that. All right. So echo, of course, before the TAVR, we do the echo cardiogram. Now in pseudoscience, I would say 40% of echo also perform in the cath lab. All right. In the cath lab. So basically every sonographer has a beeper of, you know, hospital phone. Every time they page you or call you, you just directly go to cath lab. We call standing by echo cardiogram. So in the cath lab, basically they want you to spend like one or two minutes, quickly look after deploy the stand of the valve. So they want to know, hey, any paravalveular leakage? Do you see any pericardial effusion? So this is the most common question that we're asking. So after the procedure, we perform follow-up echo. So the day patient discharged, most likely next day morning discharged. All right. One month, three months, six months, and a year, two, three, four, five years follow-up. The first five years in a clinical trial, partner trial, all this echo done in pseudoscience. But now, because so many patients, I think a lot of patients now are doing the follow-up echo in the local community hospital. Now this is, I would say, a little bit challenging for sonographer. Because I don't know, is all the sonographer in a different hospital, they perform similar quality of the echo cardiogram? so this is why I think it is a challenge for the sonographer. Okay, now let's talk about mitral valve regurgitation. So mitral valve regurgitation is a very common valvular disease in the United States. So first of all, we have to understand some terminology, okay. You got to understand what's the difference between degenerative or primary MR versus functional MR, okay. Now primary MR means this is a structural problem in the mitral valve, so either leaflets or caudate tendons. For example, mitral valve prolapse, mitral valve flail, mitral valve perforated. This is what we call structural MR. We also sometimes call organic MR, okay. Now what is called functional MR? That means patient has mitral valve leakage, it is due to the left ventricle dysfunction or enlargement. Now you will say, who cares? Now we do care, okay, because functional MR, surgery and the clips, sometimes the results not as good as structural MR, especially in the P1, P2 eccentric. So another medical term is what is called concentric MR and what is called eccentric MR. Now so-called concentric MR means central jet, the MR jet regurgitates to the left atrium in the central cavity. So now this is easy to assess the severity by the echo, but the most challenging is called eccentric MR. That means the MR jet flows back to the left atrium along either anterior wall or posterior wall of the left atrium. So this is the most common. We underestimate the MR severity, feel like only a little MR, but actually it is severe. Now next thing is the terminology, so what is called acute MR versus chronic MR. Now acute MR is patient suddenly has a severe mitral valve regurgitation. For example, mitral valve flare, caudate tendinitis ruptured, papillary muscle ruptured due to the gunshot, due to endocarditis, due to the car accident, those are called acute MR. So acute MR, nothing you can do except the surgery because the patient is going to quickly die of valvular congestive heart failure. That's a very quick patient that died of pulmonary edema. So when we're talking about mitral valve repair, it's talking about chronic MR. That means patients has this MR year by year, decade by decade. This is called chronic mitral valve regurgitation. So this is some etiology. We try to understand that. Okay, now mitral valve regurgitation is always challenging here is to assess the severity. Now it's way more difficult than the aortic valve stenosis. Why? Because so far there's no single measurement you can reliable to evaluate mitral valve severity. So what we do here is we need to take a group of measurements, right, based on the 2D, based on the color, and based on the continual wave Doppler and the pulse wave Doppler. So we're going to use all the different measurements and then get a conclusion this is mild, moderate or severe. Okay, so now you can see the left column here is we're going to measure the structure and measure the chamber size. And we have a semi-quantitative evaluation and a quantitative evaluation. All right, now, so when you do echo for the mitral patient mitral valve regurgitation, of course, you're going to measure the chamber size, all right. Now in your database, I thought that you have like a measure the LV and diastolic dimension, LV and the systolic dimension. Now for chronic severe mitral valve regurgitation, of course, because the volume overloaded. So left atrium, left ventricle got to be enlarged. So left ventricle enlargement is one of the measurements to suggest patient has severe mitral valve regurgitation or not. So if the left ventricle chamber size is normal, it's difficult to call them severe because it's chronic volume overloaded, all right. Now semi-quantitative measurement, we measure the vena contracta. We measure the pulmonary vein inflow. Now I just want to let you guys know, in your database, I didn't see you have any data talking about pulmonary vein inflow. Now this is a very, very important echo finding for mitral valve regurgitation severity, okay. Now what does that mean? If patient, I'm sorry, it's true, okay, I'm sorry. Now because why, if you ask a patient, what's going on when you come to the hospital? The patient say, well, I don't know. My doctor told me my blood flow back to lungs. So what does that mean? That means severe regurgitation because the blood in the left ventricle leaking back to left atrium and it continue leaking back to the pulmonary vein and the lungs. So if you can find pulmonary vein has a systolic flow reversal, that's pretty much done deal because you find the leakage in the lung tissues. So that's a severe, all right. But however, reality is sometimes to get a pulmonary vein systolic flow reversal is not that easy, all right, it's not easy. But once you get it, that's very, very important, very, very important. All right, so now you can see the yellow arrow, the point, there's a flow reversal. Okay, now in your database collect, I can see there's a measurement for EROA. Now EROA means effective regurgitant orifice area. Now this belong to quantitative measurement. If EROA more than 0.4 centimeter square, that indicate patient has a severe mitral valve regurgitation. Now EROA, it is quantitative measurement, but I have to say in patient with eccentric mitral valve regurgitation, so the PISA and the EROA sometimes could be underestimated. That's why we, I just said, okay, based on the ACCAHA guideline, we cannot only rely on the one single measurement, all right. Now this is how do we, how can we use the echo to assess the severity of the mitral valve regurgitation, okay. Now basically if patient has mitral valve clips in the cath lab, most likely the TE in the cath lab, they don't use the TTE, they don't use TTE. So follow-up echo is a trans-thoracic. We perform echo. We continue measure the mitral valve regurgitation is improved or not. And also we can evaluate mitral valve mean pressure gradient. Now because you put the one clip, two clips, sometimes three clips, so you may have the risk you can get a mitral valve stenosis. That's why to get a mean pressure gradient is very important for follow-up mitral valve repair and or replacement, okay. So this is the follow-up, we're going to check mitral valve regurg, check the mean pressure gradient, check the cardiac function, and also check the chamber size. We hope after mitral valve repair, if this is successful, the left ventricle chamber size could be shrink a little bit, right, PR pressure going to be dropped down. So a patient will feel, clinically will feel much, much better symptomatically, all right. So basically we start mitral valve clip since 2006. So at that time, Dr. Sybil Carr, he is a pioneer interventional cardiologist to start mitral valve repair with clips, okay. I don't want to go to all the detail measurement by color, okay. So I'm just spend a few minutes. I'd like to answer any questions you have, because otherwise, I don't know, I'm talking about too much, you might fall asleep, you know. Yeah, thank you very much. Is it on? Okay. So thank you, Sarah. No, Lou, Lou, Lou, Lou, Lou, Lou. Lou. Lou. Lou. Lou. Lou. Lou. Lou. Lou. Lou. Lou. Lou. All right, don't leave me. I don't know if Stanley's in the room, but I think we just got Lou a pay raise, because somebody here is going to try to hire him away. I have heard Echo talks a lot, and I understand so much more now. So thank you. John, I like talking, because I teach Echo in the school. You've made me as a nurse understand what you're talking about. So I'm going to start out. And Sarah, thank you. I think we want to hear about what else is going on at your hospital and the Michigan initiatives and stuff, but that's kind of cool that everybody works together. So Lou, here's what we hear. When we see, and you guys throw in your questions too, but we hear we can't get that Echo data element because it's too hard. Should we believe that, or is that something we should say? What we do say is, well, can you try again? Or at what point are some of these variables very difficult to get? I know you mentioned one, but we get that a lot, and that's why the data's blank. Thank you, Joan. Let me answer that question. Technically, about 17% of Echo, we call it a technically difficult study. That's true. You know, especially a patient has emphysema, COPD, or a patient has an overweight, obese, like a 300-pound, last Tuesday I scanned a patient, 474 pounds. Now, it is tough. Now, but if you say this patient had difficult to get the pictures, that is for screen Echo. It's not for follow-up. If the screen Echo is perfect Echo quality, there's no reason on the follow-up you say, no, I couldn't get the image. You understand what I'm saying? Okay. Yeah. Yeah, but if there's a screening Echo, you have difficult that possible. So one other question we get. Our doctors don't believe in that measurement. Our doctors don't do that. Did you give us any out there measurements, or is everything that you just said sort of standard guideline practice that we should say, no, I mean, we get that, right? Yeah. Actually, there's a question. Okay. Yeah. So we say follow the guidelines, but again, is there anything here that just because you're seeders and just because you have McCarran, you know, you were the first to do MitraClip, are you doing anything special, or is this a standard operating practice that people should be comfortable saying, this is what we expect our Echo team to provide for us? Yeah. I would say it's a standard protocol. Everybody used ACC, AHA guideline. Doesn't know any difference. It doesn't matter which hospital you work, you know, should be the same, should be the same. Okay. Thank you. I'll stop there and take some questions. Okay. Can you hear me? Okay. I'm usually something I'm accused of having a problem with. There's a question here is, is a post-procedure EROA imperative? It is not traditionally measured at my facility, and I cannot tell you how many times we've had this question come into the registry about my doctors don't do EROA. All right. He's talking about EROA, effective regurgitant orifice area. Okay. Now, before the procedure with mitral valve clips or mitral valve replacement, we has to measure the EROA. It's a very important measurement. I just said it's quantitative evaluation of severity. Now, after the patient had procedure, if I scan this patient follow-up, now if the mitral valve only trivial residual or mild to moderate, I do not measure EROA. But if patient has significant residual mitral valve regurgitation, yes, we do measure. But I tell you the truth, in Cedars-Sinai, we didn't see a lot of patient post-procedure has still significant. Because, you know, this procedure done in the cath lab, the TE cardiologist in the cath lab, you cannot let the patient go out of cath lab with a significant MR. Right? You got to do one more clips. Right? And the surgeon in the room go to the OR. But you cannot say this is severe. Go back home. It's impossible. Okay. Not everybody is Cedars, Lou. Wait, wait, John. You can't like severe MR and say we're done. You can't say that. I know. I know. We just want to know how angry we should get with our FDA. Oh, don't be angry. Please. Okay. The next one is a question pretty specific to your facility. It says, for mitral clips, do you see successful post-procedure outcomes on a regular basis? Oh, can I? Of the mitral valve clips? Do you see? In success. Are they successful? Mostly successful. Oh, okay. Well, put this way. We start mitral valve clips in 2005, 2006. Pretty much, I would say, I would not say 100% successful. We also had some mistake. Patient go to OR, okay, has a mitral valve replaced by the surgeon. But put this way. I tell you truth, okay? The first five years, some cases not that good. Okay, we can make some poop at the beginning. I'm sorry. But now, last 10 years, we are very good. Most cases doing very, very good, right? Now, it's based on the equipment improvement, based on experience, technology. We are getting better and better. Yesterday, I scanned a patient. Patient has mitral valve two clips. Only trivial mitral valve regurgitation. Very good. But, again, based on which hospital and which cardiologist. So I cannot cover the other hospital. I don't know. If you ask me to do, maybe all CV are left over. I'm not a cardiologist. If anybody has any other questions, please send them in, so we can get them answered before you leave. Maybe I'll ask one more to Sarah. You're a commanding personality, and you make your people all show up. Was that hard? It was. When I first started, there was an abstracture before me, and to say the relationship was contentious would be a gross understatement. So coming in, of course, the first knee-jerk is, I'm not abstracting it correctly. The definitions are wrong. I'm not reading the definitions correctly. So as I had said in the talk, you will give them data definitions, and you'll give them to them over and over and over, and that's okay. I'm happy to give them. In fact, when we do deep data dives, sometimes the first part of my response, if it's a slideshow or an email, is the definition at the top, and I highlight those key words to get their attention. And so knowing the data is going to go a really, really long way. You can show up to your quality meetings or to your interactions, and you can speak to the data, not just this is our rate for this month, but this is our rate for this month. These were the patients. They were this quarter. If you remember, it was this case that turned into a SAVR. Being able to give them that detail goes a long way to showing your credibility. It's a good check for yourself to make sure that you are giving quality data, and I think it bestows a little bit of faith and trust in you, and you just keep doing it over and over. And I have reached a point now where I'm excited and then I feel very proud. I can sit at the table and I have the physicians will say, Well, what do you think, Sarah? What are you seeing? What do you think we need to do better? And that's huge. But you have to keep at it and know that initially it's going to be your fault. You're not doing it correctly. It's going to be your fault. So you just have to keep at it, know your data so that you can confidently speak to it, and that will go a long way. Sorry. Thanks. I think successful programs have committed themselves to the HART team. You know, when I do a presentation, I always say, Your smartest echocinographer, find them, and obviously it's Lew at Cedars, should be in the front row, should be at the HART team meetings. Just because we're about to enter into TAVR and tricuspid where we know very little. We know a lot about TAVR but not tricuspid and mitral, I'm sorry. But don't give up on your HART team meetings. They're more important now than ever, and especially with the low risk, that shared decision making, that conversation needs to have happen. And if you're new out there and you want to know who's doing it well, obviously Sarah, but in your area, we always could connect you with someone who's kind of cracked that nut. Don't, it's at 6 o'clock in the morning if that's when you have your meetings. I mean, we've heard all kinds of stories of success. We're here to help you. But before you leave, I want to make sure everybody in this room realizes we are doing an upgrade. So if you have anything except for minor vascular complications, Karen may disappear before Monday, we know. We know. We hear you loud and clear. We tried very much to knock off the minor and just have the major, but that's on our list of physician questions. But if you have questions you want us to either ask our physicians or say, please consider this for the new upgrade. And Lou, anything, like I wrote down with the pulmonary vein, let us know what we should make it so it could be the best upgrade we have. Let us know. And also, one more thing. Please, I hope everybody understands that now we accept the 30-day echo between 7 and 75 days if, if, and only if there is also a complete or a completed assessment or follow-up or clinic visit or something with the physician in the 23 to 75-day timeframe. So, yes, we will accept an echo 7 to 75 days, but you still have to do that follow-up between 23 and 75 days. Because you can't, the reason behind that is, no way can the KCCQ be completely measured between 7 and 75 days, but we can, between 7 and 75 days, or I'm sorry, between 7 days and 23 days. So that has to be done between 23 and 75 days. The New York Heart and the KCCQ, which could be done over the phone, but the echo now will take between 7 and 75 days. And so that will hopefully help with data completion. We'll take questions after. I know people are gracious enough to be here late on Friday, and Lou gave up a family vacation to be here. So I want to thank him. I want to thank Sarah. And thank you all also. I know it's Friday in Los Angeles, and you want to go see some movie stars. But we'll be here for a minute. Thank you so much. Thank you for all you do.

Joan Michaels

TBT Registry

NCDR meeting

Toolkit Number Two

data accuracy

communication

valve diseases

severity assessment