Three UCSF specialists shine a light on the rapidly evolving world of minimally invasive heart surgery, giving the evidence on risks and outcomes. With video illustrations, they explain advantages of advanced techniques for valve repair, VAD and coronary artery bypass grafting; how these methods can serve high-risk patients; and why the need for them is growing. Bonus: Hear about current clinical trials for patients with heart disease.
mm, I want to thank everybody for joining us this afternoon. I know everybody is busy and uh we want to be respectful of your time, but we want to really talk about something that I think as a hospital system and as a division were very passionate about and that's really treating patients with heart and vascular disease. And the theme of our talk will be small decisions, big different difference here. My disclosures, it's really a pleasure today to be uh presenting and uh kind of being involved with this really all star cast of faculty here at UCSF. Olivia mentioned a little bit. But first we have dr Mohamed even he's really built our structural heart program here at UCSF. From the ground up to one of the preeminent programs, not only in the city in the region, but really in the nation. Uh, so we're really excited to have dr Mohamed even as a, as a Panelist here at the Dorsey is the director of Milly evasive valve surgery here and has really kind of helped put UCSF uh structural programmes, the surgical structure program on the map. The nice thing is that he's done so much, but it's only the tip of the iceberg and there's a lot in the future that's going to happen. And we're excited to talk about that as well. Dr Rodrigo Desouza. It's a recent recruit from brazil and he's uh a kind of a jack of all trades, but he does uh one thing particularly very well that's middle invasive coronary surgery. Uh he's able to do a little evasive cabbages toward arterial calves and patients go home in two or three days and we'll have him talk a little bit more about that in a little bit. The next part of my talk, I really want to kind of focus on different disease processes and how we approach them. The first one is valuable heart disease and this is how we do surgery curly presently via Sir Anatomy through big incisions, do kingdoms coming through the aorta and through the right atrium. And this have we do surgery potential in the future. And I would argue that if we're doing surgery in the future the same way we're doing surgery now we're not making progress as a specialty. And as a field this how I think we're going to surgery in the present and the future through smaller small incisions, the melon invasive approach as well as to a trans catheter approach. And what I think is really exciting is that we actually really don't know what the future's gonna bring is most likely to bring a technology or an approach that we haven't thought about before. So that's what I think is really exciting about our field and our push to really kind of pushed the envelope And uh and advance the field. Here's another way of looking at it in the spirit of less is more uh you know with the flu season? Um you know coming up in, you know, several months from now? If you need a vaccination, would you rather get a vaccination from this needle here that's kind of small or maybe this needle here, that's a little bit bigger. And let's say if I were to tell you that the bigger needle was with the smaller needle was just as good at delivering a vaccine. It's a bigger needle. Uh which would you choose? What's interesting about this decision is if you look at the size of the smaller needle versus the bigger needle, it's maybe a millimeter. So, I think most of you cringe a little bit with the the bigger needle similarly, you know, when you think about decision locations, I think there is a huge difference between whether we're making a three centimeter for centimeter decision versus a 12 centimeter decision via the traditional way that most folks do cardiothoracic surgery. I can tell you that. I've never had anybody come to my office and probably not to Dr doJ's office or Dr Seuss office beg your first anonymous. It just doesn't happen anymore. This is how we done surgery in the past. And that's how I think we're going to a surgeon in the present and the future through less and less uh smaller incisions via trans catheter approaches for taverns and through the mitral uh mitral approaches as well. In some ways, I really do believe that this really should be the standard of care, the clinical goals of mental invasive surgery. Are these three these three things uh one I want to make sure that we do the operation safely so that patients can go back to their family and their loved ones. I want to make sure that we have addressed the pathology. Without any compromise. We wanna make sure we have a durable solution. So whether be the mitral valve, the aortic valve, we want to make sure the patient leaves the operating room without aortic stenosis or without any ai or without a much regurgitation, but also want to make sure that whatever we do it's gonna last the longest a time possible to make sure that patients have a long and fulfilling life. And the last thing is the decision location and the size, I could say that I feel relatively confident that we can do this 95% of time via middle invasive approach through a thoracotomy incision. I want to change gears a little bit and talk about Tavern and dr Mohamed will expand a little bit about some of the trials in the trans catheter space here at UCSF. They kind of a landmark of the first partner trials back in 2007 and began the explosion of trans catheter technologies. For those of you who haven't seen this is a trans catheter aortic valve replacement. The first one, the first trial again started in 2007. That's a very severely calcified and sclerotic aortic valve via transfer Meral approach on a balloon expandable system. We have a position the valve inside the uh the sclerotic aortic valve and employee new valve. And I remember back in the beginning days of tavern, the patients in the hospital maybe 34 days Now, patients are going home the next day and there have been programs out there that are trying to send the patient home the same day. So again, this is one of those kind of rare transformative technologies out there. That that's changed the way we approach and treat patients with New York cyanosis. So I'm really excited to be involved with that. Back in 2011, towers were approved by the FDA for prohibitive and high risk patients. And now as many of you know, it's approved for patients who are low risk. These are the devices that are clinically approved in the United States for Taverns and the far right are devices that have been approved or used elsewhere in europe and across the globe. I want to show you some important numbers greater than 500. This is important because these are the number of Tavern implants that we've done here at U. C. S. F. One of the largest structural programmes in san Francisco 124. That's the number of towers that we've done last year. We've been involved with all the major trial involvement from the inception as well as uh in the future as well, not only in the Yorick space, the micro space, but also in the tri customized space. I also want to add that as many of you know, the valve has four, The heart has four valves and to date all for the valves have been uh fixed or address via trans catheter approach. That's actually pretty impressive. Including diplomatic valve 98 an important number because that's the oldest patient that we do here at UCSF. This figure here is actually, I think an important figure. The orange line is tavern growth as a function of time. The top blue line uh includes any aortic valve replacement and then the red line includes isolated aortic valve replacement, something very unique happened in 2015 in that tavern exceeded isolated york valve replacement. And later in 2019, Taverns exceeded all forms of york valve replacement. It's pretty clear that this will be a dominant technology for patients with the york cyanosis. So uh we're obviously very actively involved with that, that's only one valve as you know, the aortic valve. Uh There are other valves and technologies in the market as well uh in both in the repair and replacement for micro disease. And this is the current trans catheter micro landscape in 2009. And now in 24,021 there even more devices out there. So again, we're excited about it and we're involved with many of the new trials that are out there. I want to change gears a little bit and talk about the second passionate of myself as well as dr dicey and Dr D. Souza, which is mentally invasive surgery. Uh I want to focus on the aortic valve. Mhm. People often ask why a right through economy. I think for me it's pretty clear. I think you avoid astronomy and it gives you sternal stability anytime you violate the sternum, the patients have to go home with a lot of physical restrictions and sternal precautions and that that doesn't happen. And we have your economy actually did it a strong economy today for a patient with the post infarct VSD. And every time we do a tsunami there's always a lot more bleeding. But when we do a middle invasive approach, I always look to our fellow and always comment on how little bleeding there is. If not no bleeding at all. By the time we're going on cardiopulmonary bypass uh talk about bleeding. There's a lot of data, very compelling data to show that the middle invasive approaches less bleeding. There's a faster recovery. It's more ergonomic and some would argue that you should avoid uh kind of mentally evasive approach for high risk patients. But I actually would argue that for these high risk patients are the ones that you want to do, the less invasive approach to kind of get them to recover a lot faster and the least of the least important reason why I do million evasive you're right. The economy is Kaz Missus as you see there in very small fine. So I just want to kind of highlight that's not a typical patient has a mental evasive aortic valve replacement and dr Dorsey kind of test that he does many HIV Rsv oradour economy as well and the results are pretty impressive and here are the reasons why we do aortic valve replacement. That circle represents the aortic valve and be a standard approach. You have an entire stirred um exposed, You have a cross clamp, you have a heart exposed but your area of interest is that green circle when we do a middle invasive aortic valve replacement. That's where our focus on. And that's all we really, we really need to see is the aortic valve and we want to fix the aortic valve very quickly and officially. So the far left, the tsunami approaching far right via a middle evasive approach. As you can see here again, you can see that, that there another reason is ergonomically the next time you look at an X ray. This patient on the far left obviously had a tavern. But if you look at the kind of a corona view, you see that that you're actually points towards the right chest. So if you do astronomy, if we do astronomy, there's certainly an element of having to rotate the heart to bring it into view. But if you make a decision, the right chest, you can often get a very uh direct view uh, that of the aortic valve. That's really uncompromised. And I want to show a video here of a traditional or typical view we have of the aortic valve. Uh, this is obviously a right to our economy decision. This patient has a Type zero by customer aortic valve. That is a true by custom work valve. And you can see you have a very direct view of the aortic valve where essentially anyone can really kind of respect that valve and replace that valve. Many would argue that increases operative time, but actually, you know, would suggest that it does not, and many of you, I would encourage you to come visit our operating room. You'll find that our operations do not necessarily take longer than its own only approach. And I think one of the reasons why is that we're working in parallel. So as we're operating, I'll have our fellow, uh, kind of work on the groin and we'll make a decision in the chest and we're working simultaneously, both opening and closing. Uh, and it does not necessarily take longer for a middle invasive approach. I want to show some videos of, of the valve deployment for those who have not had a chance to be in the operating room here. The valve has been debris did. And now we're sizing the valve. Uh, we will then put searchers, uh, circumferential e around the, uh, the annual list of the valve here. I'm putting surgeries along the kama. Sure. Uh that was the left and the non commercial. You're seeing me put soldiers in the left and the right. Commerce. Sure. And then now you're seeing me put searchers along the left and the and the and the right. Common. Sure. Then we start differentially put pledge of the future's all around uh the aortic analysts. And now you see uh futures around the analysts. Our next step is to put those futures into the bio prosthetic valve. The cuff of the bio prosthetic valve. Uh We do this very systematically and um we try to make sure that the spacing is perfect. We then parachute the valve into the aortic annual lists. And as you see here sometimes, you know, with the decisions so small that you can barely really squeeze the aortic valve through that decision. So you really can't make that decision that much smaller to get that aortic valve in here. You'll see me seating the aortic valve. I like to kind of see saw it down to the organic is to make sure it's nice and tight. Really try to minimize any risk of para vascular leak. And I always try to visualize the coronary ostia. As many of you know, one of the risk of a standard aortic valve replacement as well as whatever is obstructing the cornea, Austria. So I always try to visualize that changing gears a little bit. I want to talk about the mitral valve. I think there's an important anatomy lesson that many of you know, but just to remind all of us is a mitral valve is a very posterior structure. It's a very vertical structure. So this X ray here, just the patient had a previous mitral valve repair and look how posterior that mitral valve is is very close to the spinal column. As you can see here. I do think that a million basic mitral valve can uh surgery can be very straightforward with a stepwise approach. Again, uh This patient had a P. Two prolapse. We're making decision, we're working in parallel. I'll making the incision in the chest. Our fellows working and they're growing, exposing the federal vessels are typical. Decision size is 3.5, sometimes four centimeters or so. Uh We're exposing starting guards groove, we're entering the left atrium and we're testing the valve. As you see here, we have a P. Two prolapse with ruptured chords. My preference is uh kind of a respect approach. We put Neil chords in. So as you see here we're putting new chords in the area of prolapse, we adjust the height accordingly and um and that's all it takes essentially, the valve is now competent. Uh most of us will put a stabilizing angioplasty ring as we uh we just did and then finally we'll set the final height of the cord and we'll test as you see here, essentially. No residual mitral regurgitation. Um There's a lot of long term good data for patients who have the agenda of em are uh to get a mitral valve repair. And I actually wanted to just remind everyone that it is an A C C. H. A guideline in patient with severe m are even if they are asymptomatic uh to have mitral valve repair if it can be done at a high volume center with a greater than 90% 90% chance to repair, which we feel very confident that we can do here with Dr Toby Dorsey is as well as myself. I think another complicating issue our patients with severe michael annular calcification. I think most surgeons when they see this they cringe a little bit because there's a lot of uh kind of bad things that can happen including annular rupture uh and maybe putting a valve that's not appropriately sized. I think some would say that patients who are obese are contra indications for mental invasive approach. I would actually argue the other way about sometimes it's actually easier to do it mentally, basically this patient here has severe MAC as you can see here and we were able to uh to replace the valve mentally basically by putting a trans catheter valve in MAC and that's something that that I've written on and published on as well as our team here at UCSF. So here this place has severe MAC. We put circumferential structures around the micro annual calcification. We're deploying the trans catheter heart valve in the severe MAC. Uh and these are for high risk patients who are not necessarily candidates for the traditional approach we're deploying um In this picture here is being deployed 5050. But increasingly I found myself deploying probably a little bit more april than ventricular recognizing and trying to minimize the risk of left ventricular outflow tract obstruction but also recognizing that via this approach I can really securely anchor the valve and minimize the risk of P. V. L. Or any embolization. So I've been doing more of a atrial deployment as opposed to uh ventricular deployment. The picture to the left shows a severe mitral annular calcification. In the picture on the right shows that same Orpheus area area after a Tavern and Mac was deployed. And as you can see there's a huge increase in the micro annular orifice area after you deploy the trans catheter heart valve. Again, very uh excellent human dynamics um with the Tavern in my acquisition. So again, that's not necessarily a typical postoperative course for our pages of middle invasive mitral valve surgery. So again, the far left, the typical decisions that we might see for a middle invasive mitral valve surgery. Again it's 3.5, 4 centimeters or so. Uh So I do think that small incisions can make a big difference. Uh increasingly we're trying to push the envelope for women, we always try to um try to make the decision along their breast fold for Kaz Missus. And we have even done some kind of peru Arriola incisions to really try to minimize the scar. But again, the most important thing is to make sure we do the operation safely and address the pathology. But what the data show that the paper that we published in annals of thoracic surgery last year, looking at the S. S. National database in about 41,000 patients comparing minimally invasive surgery versus strong economy. And one of the arguments is that if you do it minimally invasively there are lower pair rates. One of the arguments is that if you do it mentally, basically the patients are a lower risk cohort. What this pastry this paper showed uh using the S. S. National data data set is that if experienced surgeons do it minimally invasively, their period is actually higher than v astronomy. So again that's an important point. And I actually think the reason why is you get a direct view of the mitral valve that's really unparalleled. Uh We also found which other studies have found that the middle invasive approach was associate with less a fib, less blood transfusion, shorter length of stay, which we've all seen before. So that's not necessarily new at all. So in many ways I really do think mainly base of Mitchell as well as aortic valve for the surgical approach really should be the standard of care. Again, I would argue that none of our audience would probably want a strong economy if they can help it, assuming that the therapy is as good, if not better than the status quo. I want to change gears a little bit and talk about heart failure. Um uh, and what we're doing here at UCSF, uh, this is a population projection by million. The millions stratified by age of patients, less than 65 patients greater than 65. Uh and the projection is into 2035 And the patients greater than 65, there is an expected 93% increase in this patient population. Here's another way of looking at this from the census, the United States census In 2035. There should be something very unique that's going to happen for the first time in us history, we're going to have older patients older than 65 outnumber younger patients. That's never happen ever in the United States history. I've always had Children under 18 outnumber people older than 65. But after 2035 we're going to see something that's gonna be a little bit different. And the reason why that's important is because heart failure is an element that affects the older generation and affects roughly 6.2 million americans it costs the nation $13.7 billion each year. Uh 655,000 americans die from heart disease each year and this represents one in four deaths. Heart disease costs United States 219 billion each year, the province of heart failure continues to rise over time with the aging population. The prevalence of heart failure is rejected increased by 46 From 2012 to 2030, affecting greater than eight million people greater than 18 years of age. The total percentage of the population with heart failure is rejected to rise from 2.4% in 2012 to 3% in 2030. Uh It does require a team approach. This is a heart lung procurement again involving uh many members of the team with our theme of small incisions and less is more. Uh We do have a robust uh middle invasive bad program here at UCSF. And here's some of the decisions that you can see here. So again, I think there's a lot of potential benefits of a million basic approach when you are uh implanting a bad device. As you can see here here here are some of the decisions that that we've done here at UCSF. Again, we're trying to push the envelope and really kind of set the patient up for when they get the heart transplant to have a fast recovery. Again, a million base of hardware uh that implantation in 2013. Lastly, I kind of want to talk, I know that we've talked a lot about less invasive approaches but I want to focus that we do also focus on high risk complex adult cardiac surgery and something that we take a lot of pride. Uh And we really welcome doing uh this is a patient that had a post infarct LV aneurysm. Um That that we fix. So we're open up the aneurysm sac. As you see here there's a large clot that we're moving. Yeah. Sorry the musical allowed. And you see a healthy rim of tissue there were putting kind of circumferential structures around the rim and then we parachute a piece of bovine pericardium to kind of close the defect. Yeah we read it of course the D. Site as you can see here. Yeah we close the left atrium. So again patient to uh that's obviously a very sick patient E. F maybe 15 20%. He eventually went home within 5 to 6 days or so after. Uh after that reception of the lb aneurysm. This right here if you look carefully you may not recognize. But that big thing on the patient's left is that patients right atrium. And this an operation that we did recently the patient needed uh There try customers valve replaces for the third time. Redo and we replaced the patients try customer value. But the patient had a very extremely large right atrium. This patient here had two prior trans catheter valve implanted. And again a redo operation where we explain the tire valve. Um This is a uh sorry so loud again. That's a picture of a tavern valve. That's been explaining this is a case that I do dr teng lei recently there's a patient that had aortic valve repair using the heart device. Um That's a picture of the device. We're actually the actual device itself so nicely about the Reagan because of the co optation. How did you go again? I apologize I didn't realize so loud. Um This is a facial that dilated a sending an aortic aneurysm that we've suddenly replaced the ascending aorta. Again these are not easy cases in many cases that we typically do here at UCSF and this is somewhat kind of fresh off the process. A patient had a post infarct VSD. Um that that we repaired actually earlier this morning. So uh this kind of patrick pair of the aneurysm on the L. B. And we patrick here the S. D. This is the A. S. D. Had multiple jets. Um And then this is the post repair of the the echo images essentially VSD. Is gone. The patient's doing well and hopefully estimated by this time. I want to talk about some research trials in the surgical space. Uh This is a trans a pickle solution to patients with degenerative mitral regurgitation. Uh that that I'm particularly involved with them on the national screening committee and the local P. I. Of this child. A harpoon trial. Dr Mahadevan is our co investigator with this trial and essentially it's a way to address patients with degenerative M. R. With flail or prolapse um leaflets without having to put the patient on carter pointed bypass via transit vehicle approach. Um I want lastly when I talk a little bit about ischemic heart disease um I'm gonna change actually. I'll go ahead and talk about trans catheter program and hand the microphone over to dr Mohamed. Even after that we'll talk about ischemic heart disease and Dr Rodrigo talk about some of the things that he's passionate about and we'll wrap up with a panel discussion. So what I'm gonna do is for for the next five minutes or so give you an overview of the various structural heart trials and things we do here so that you can get an idea of some of the exciting things we do and um so uh we have a number of structural heart trials. I'll give you a little intro through them if I may. So when they already can we have protected Taber we just a stroke protection with the sentinel to anabolic device. M bolic protection device during transkaryotic Well replacement we routinely used a lot of central devices for this and we just recently looked at our stroke rates and our sentinel use patients a stroke it was actually zero over the past year which is kind of you know another new kind of thing in the horizon where you can offer Tavern now with almost no stroke risk. Tavern load is a trial in which patients with moderate aortic stenosis. LV systolic dysfunction are randomized. Either Taber or for medical therapy on the mitral front. You know we have a three interesting trials. Rester is the trial tom just spoke to you about the harpoon trial and um and it's great to work with him on that. We also have the summit tendon full trans catheter mitral valve replacement trial which is a transit vehicle system. Some of you probably know attendant has been licensed already in europe but here in the U. S. We have three arms, the micro regurgitation, the the the mac arm. And so if you have any patients who are not great surgical candidates and of course will be very happy to assess them for that. And then we have the carillon which is reduced the device for functional M. R. In patients. Which is uh which is also uh you know for heart failure patients. This is the tendon transit vehicle device. As you can see, you know it's held by a tether sort of small incision, the apex by our cardiac surgical colleagues at UCSF. And then we go and deploy the bell with the tether anchor to into the apex. So this is the trial that'll have more than nearly 400 patients randomized 1 to 1. And there's also a non randomised arms. So that patients who we think may not get into the trial but still are you know good candidates can be uh recruited into it. The randomized arm is against micro clips. So again, you know patient gets a minimally invasive option either arm And then there are about 100 patients who can get into the Mac. Um so they have severe mac which is not suitable for surgery. Then of course it's an option. The caribbean devices, analysts inching devices have shown. This is for ischemic and an ischemic cardiomyopathy. More than two plus. M. R. N. H. A. Class 23 or four with the six minute walk distance about 1 50 to 4 50. You know these patients can get into this trial, you don't lose much because it's a coronary sinus device. So you still have the option of putting a clip or about later. I mean this is how it looks. You do as a cornerstone of venogram and you deployed approximately Salonica and then approximately anchor. These are the other structural trials, ongoing track aspect. We have the gator trial which is soon to start which essentially is for a geometric level stand for track replacement and track aspect. There are three approaches to a transfer Meral transit real. Uh So I think depending on patient anatomy we can decide which is the best one. Were also part of the Harvard trial which is the FBI DEA study for a SAPIEN and ibc position for patients severe functional tr we're not good candidates for replacement. We have two ongoing polyphonic trials compassion has three which is already recruited and is in a follow up phase altera's for the large our bot study. We are one of the 12 U. S. Sites and finish your initial recruitment and now we have a continued access recruitment for these complex congenital patients. We are part of all these P. Fo trials. You know, the amplats appear for US registry were one of the top five recruits in the US as we have for their gore registry. I mean we have a we just submitted a are abstract A. C. C. Which has presented same. The additional for P. F. O. S. With no complication rates. I mean, you know, almost 100% of our patients now go home within 4 to 5 hours of foreclosure. No overnight states. Yeah. Then we have the relief cardio farm secular polluter for migraine, you know, which is again a pivotal trial which were part of. So I'm working with a neurology colleagues. Then we have a number of heart failure trials. You know, relief HF is one where we use the intra atrial that divides the V. Wave device for reducing lung congestion, patients of advanced heart failure, resistant to other therapies. And then we just started their live trial which is a biometric system for patients with atypical or uh you know anti wall aneurysms which which caused heart failure as a cinching mechanism which essentially the picketing is repaired for lb aneurysms. Then we're just starting the policy renovation trials a trophy to for patients using intravascular ultrasound for pulmonary artery renovations and patients severe PhD to left heart disease. I mean we will be in fact our first patients scheduled very soon for that. So this is the wave device which we use for the intra atrial shunt The one other quick thing I want to show you which we made good progress and one of the largest, you know centers in the bay area's doing track a spit valve interventions for patients who are not good surgical candidates with severe functional tr as you can see this is a 88 year old patient. We had aortic paralytic following a tavern and then done an outside hospital. We treated the paralytic and then patient had ongoing heart failure. As you can see severe tr in multiple views here and we we put an initial clip in the intro septal still has residue tr so we go and put further clip in the post receptacle and as you can see patient left a trace to multi are this is a three D. Glass view showing two clips. So this is another option we're offering for patients with severe regurgitation, inoperable. So there's a number of uh you know options we can give to our patients and uh you know, delighted to share these with you and please let us know if you have any questions? Thank you. Dr Mohamed even uh dR Rodrigo, do you mind giving your slides? Okay so I'm going to talk about very briefly about many many of the basic coronary bypass as my passion. Um As you know uh coronary artery bypass best uh the best treatment option for patients with uh I mean multi vessel and complex coronary artery disease, particularly those with diabetes. Uh There's a lot of data about it uh And cabbage is uh that uh it's proved to be have a lot of long term benefits but also has a significant invasiveness. Uh And the problems with this kind of investments are a fool's anatomy. Uh exposed the patient to infections, low slow recovery. Uh paying triggers inflammation and bleeding possibilities, cardiopulmonary bypass that is used during the coronary. The traditional coronary artery bypass. Grafting also triggers inflammation, uh triggers acute kidney failure, triggers bleeding. Uh And also arrhythmias like atrial fibrillation. One of the biggest problem that we have is the arctic cross clamping and the arctic manipulation. That is uh I mean it's achilles heel of this this method of treatment that uh predispose the patient to a high index of stroke. Uh open graph harvesting also um expose the patient to uh you know incision operative incision infection. Uh And uh when uh we use the traditional coronary artery bypass graft technique. The hybrid coronary revascularization is difficult because we're unable to suspend or initiate uh that do interrogate plate. It's because uh probably the patient's going to have some serious bleeding problems. Uh The captain's alluded to off pump cabbage. But it's only uh it is only done in 10 to 15 at most centers in the U. S. And it evolves to mix cabbage. Any votes to uh totally material, minimally invasive coronary surgery cabbage. I mean and what are the characteristics of total material? Mix cabbage is first of all, there's no tsunami. We don't touch the students so it is not going to become a problem in the post op recovery period. Uh Most of the times don't use gonna cardiopulmonary bypass or if it is needed for a few high risk patients, we can do the it uh pump assisted using beating heart techniques. And when you do pump assisted, we we have some uh To us to avoid my uh email delusion and to enhance the removal of cytokines. Uh we're practically in 100% of the case use both Emma's. Uh we can complete the full treatment using radios or even gastric tube like arteries. There's no uh aortic manipulation. So it's neurotic story is a no arctic. Uh We harvest the graphs using endoscopic techniques. So there's just a few a few portals to certain endoscopes and harvest the whole the graft in its whole extension. And we should and we and we must adopt the arrest protocol adopted adapted to cardiff patients. That this is a proposition of the years cardiac uh enhance the recovery after surgery protocol that passes through basic constipation selection. Education where we have uh a few multi model uh drugs to to minimize the anesthesia effects. A few uh pre operative nist in care measures like fasting, no sedatives, no inside politics interpretive. We can use as less opioid or opioid free techniques. Use peripheral nerve blocks like director spinal block reduction of him. A dilution. Carpenter bypass. Keeping ventilation during the cartoon are bypassed uh infiltration of the institutions to uh even the drains institutions to uh blocked the pain in a patient uh and use normal hermia. Uh And in the ICU care. I mean for 2024 hours only we can use multi modal honest Rhodesia, prevention of knowledge and drama to rapidly excavated possibly the exhibition should be done at the r uh an early order intake. Quick dream removal after my prediction of waiting, documented quick emulation and screening for the leader in pain. I mean just 1.5 days the patient can go to the war where he's going to be treated by a multidisciplinary team. Um And uh mostly ate more than 90% of the patients can go home uh in 48 72 hours after approval in a six minute walking test with monitoring by phone or telemedicine right after discharge. This is this is as examples of patients that we do multiple graphs bypasses using minimally invasive technique and only arterial grafts. This is a. C. C. T. A. Of a case that we've done using uh double memory arteries so we can see the patient has a stand in the right. Um This is most hybrid the stains in the right coronary artery. And you can see that both I. M. Is the right. I'm A. To L. A. D. And the left. I am a two lateral wall vessel. Uh One of the other very interesting thing that data shows us that it's good for. Uh But it's hard but it's good if he is well established is to use the hybrid coronary revascularization is really important because um it has to to achieve a great collaboration environment between interventional cardiologists and cardiac surgeons. And it can be done even for elective patients output out clinic patients uh And we can do that even with acute patients regarding that. We can offer both of the best of both worlds. I mean best of the intervention in generational cardiology and humanitarian and the thing that we do using surgery. So it's a great opportunity for ISIS AND CTS work together to offer the best of two worlds hybrid strives to combine advantage. To avoid limitation of both techniques. Uh No need to stop uh and no delay starting adapt. Uh No standardizing matter. We can use P. T. I. First cabbage first are both at the same moment. We do have hybrid rooms in U. C. S. F. So it's possible to do that surgeon needs to adopt and commit to mixed cabbages. And we have a few data about that like uh trial that uh randomized for 4260 patients for cash 1350 patients for hybrid technique. And hybrid showed that it has a low rate of blood transfusions uh and shorter ventilation times and sharp length of stay in the hospital. So uh for elective patients you can you can do limit really deep plus Pc. I know nell ideal asians and the advantage the limit patton see that can be confirmed and geographically uh for selected patients with acute corners syndromes and not as a great opportunity to offer both the best of two worlds. Uh stenting uh non non allergy corporate relations and then staging for the same day or for the for the 1st 24 hours. Uh limit reality uh to complete the treatment so we can uh we can use hybrid to as a low procedure morbidity, minimally invasive. But LG is still treated with lima. Non only the vest is comparable treated with pc. I. And it is an alternative to patients with an atom suitable for for coronary bypass graft. But that has commodities that could be prevented. A good result in a traditional cabbage. A few numbers about nick's cabbages. Uh Mcginn was one of the first to report um uh study with more than 400 patients using mixed cabbages. And they did he did using uh single I. T. A. With a mortality uh comparable to the STS scores uh LaPierre uh showed uh published that paper with 0% mortality with 0% of the external wound infection and early return to physical full activities for two 12 days compared with five weeks for a patient with traditional cabbage. Even during the up cab without cardiopulmonary bypass option Mark rule. Um did also report about mix cabbage, showing that the latency of the lima uh in six months are 100% and 92% for autographs. And Rabindra showed that the exhibition rate using mix cabbage is much bigger. Almost Approximately 100 uh compared even with off pump techniques using conventional cabbage. Another numbers in elderly. So it's better for uh regarding the five years. All cause mortality. I mean uh 19% compared to 40 47 Zao showed a 78% reduction of stroke using an Arctic strategy. And this this great paper paper published by by Asia showed less operative blood loss, less mechanical ventilation, less I see you head of state less hostile and of state less opioid requirements and less pain. So what we know about using data about miscarriage, less pain, less stroke, fasters excavation shorter land of state. Both I see you in a hostile, better and faster recovery. Excellent patterns using total arterial strategy last but lost. So less transfusion and hence the opportunity of hybrid with a hard teamwork and collaborative environment and better aesthetics. I think that's it. Mhm. Yeah. Thank you Rodrigo. Um and I want to wrap up with probably two or minutes of slides here so we really do believe, I think the theme that you've seen here is that less is more, can be more assuming that it can be done as good if not better than the status quo. We really do believe in the value of teamwork and and we really believe that teamwork can make the dream work. We believe in partnerships and we believe that we can't do it alone and and we rely on all our partners from the surrounding area. Um uh and we we are are available but also relying on partners to help us as well around around the country. Um Last I want to I started with this painting here, which is really important. Where do we come from? Where do we come from? Our mission is pretty simple. We're dedicated to advancing health worldwide through research, education and and patient care. Who are We were a diverse group of physicians committed to collaboration, Innovation, clinical excellence and partnership with our community and then where we going? I think the theme again, the smallest regions can make a big difference. Teamwork and partnerships are key