320. TAVR and Stroke with Dr. Samir Kapadia

Worldwide, cardiovascular disease affects the lives of hundreds of millions. Dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Cardi Nerds, I'm Dan Amador and boy do we have a very special episode for you today.

In this episode, we tackle the critical topic of stroke as a TAVR complication. We are going to glean insights on device innovation and the importance of randomized control trials in ensuring safety and efficacy in TAVR with Dr. Samir Kapadia. So stay with us. Audio editing for this episode was performed by me, Chelsea Amel-Tunabal. I am an intern in the Cardio Nerds Academy representing the House of Tossing. I am also a PGY1 internal medicine resident.

at the Sturdy Brook University Hospital. I'm so glad you were able to tune in and I hope you have a wonderful time. Thanks, Chelsea. Team, if you're enjoying the show, please take a minute to rate us on your favorite podcast app or do us one better and leave a review. This really goes a long way in spreading the Cardi Nerds word and growing our family. And with that, let's get to the show and get nerdy.

Hey CardioNerds, this is Amit Goyal and I am so excited for this very special discussion. Today, we get to learn all about TAVR-related stroke and periprocedural cerebral embolic protection from a world-renowned expert. and personal mentor and role model, Dr. Samir Kapadia. And we get to do all of this with an all-star crew of Cardi Nerds, including Drs. Chelsea Amatwineboa and Ahmed Ghanim, as well as for the very first time on Cardi Nerds, my good friend.

Dr. Nikolaus Spilius, or Nico, as his friends call him. Nico has been my co-fellow for cardiology and now interventional cardiology here at the Cleveland Clinic. And, you know, whether it's in the CCU or the cath lab, the OR. Or in the sandy beaches of Miami during a Sky Fellows course, Nico and I have been through the trenches together for years now.

It has been an amazing honor of my life to share my training journey, Nico, with you, and I just couldn't be happier also sharing this moment on the show with you. So Nico, welcome to CardioNerds. Thank you very much, Amit, for the great introduction. It is my great pleasure to join for my CardioNerds debut. I have the honor of introducing our faculty expert and also...

I want to say, personal role model, Dr. Samir Kapadia. Dr. Kapadia is the chair of the Robert and Suzanne Domsic Department of Cardiovascular Medicine, Seidel and Arnold Miller family. Heart and Vascular Institute at the Cleveland Clinic. He's a professor of medicine at the Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.

Dr. Kapadia received his medical degree with honors from NHL Municipal Medical College in Gujarat, India. He completed his internship and residency in internal medicine at Baylor College of Medicine. followed by fellowships in cardiology and interventional cardiology at the Cleveland Clinic, where he served as a chief interventional cardiology fellow. Lukin Kapadia was appointed to Cleveland Clinic in 2003 as a staff interventional cardiologist.

Prior to his appointment to the Cleveland Clinic, Dr. Capadio had an academic appointment at the Department of Medicine at the University of Washington in Seattle, and he was an interventional cardiologist at the VA of the sound healthcare system in Seattle. Whether in the cath lab, pubmed, or behind a podium, Dr. Kapadia is a world-renowned expert, a reputation built on years of experience with the entire gamut of interventional

and structural procedures and prolific research endeavors resulting in landmark publications in high-impact journals. Dr. Kapadia, it is... My honor to invite you back to Cardoneers and introduce you tonight. Thank you all of you, first of all. It is my great pleasure to be on this particular... topic as well as on CardioNerds and Amit, Nico and all of you are so close to me that it feels like that we are going to discuss these things.

in our office at Cleveland Clinic. So I'm very excited to be part of this very interesting and dear to my heart presentation. You know, as Nico said, that it has been just our privilege to learn from you day in and day out. And it is So exciting to share some of that with our Cardiners audience. Again, joining us today, I'd like to welcome back Ahmed Ghanim and Chelsea Twinnaboa. Guys, you want to introduce yourselves? Chelsea, you want to go first? Yes, sure.

Hello, everyone. My name is Chelsea Amotinaboa. I am a cardio nurse intern and an internal medicine resident at the Stony Brook University with a keen interest in cardiology. Hi, everyone. I'm Ahmed Gonim, a cardiology fellow at UPMC in Harrisburg. I'm also a graduate of the inaugural class of the CardioNerds Academy, a former house chief and a current house faculty leader in House Eindhoven. Very excited to be here today with you, Dr. Kapadia.

So great to meet you both, Chelsea and Ahmed. Dr. Kapadia, as we all said, it is a great pleasure for us to be with you today. You have made some incredible contributions to the field of structural heart interventions and specifically transcatheter. aortic valve replacement. The TAVR has transformed how we care for our patients with aortic valve disease. It has evolved magnificently since its FDA approval in 2012.

It has now become the standard of care for the majority of patients with aortic stenosis. With more than 92,000 TAVR procedures performed in 2021, While the advent of TAVR has prolonged and improved the lives of many patients, it is not without risk. Today we would love to learn from you about stroke as a complication of TAVR. So Dr. Kapadia, how frequently does stroke complicate tower and why does it happen? Let me put it in perspective so you know. So when we try to do the first...

partner trial. So this was the partner 1A trial where we compared the high risk surgical patients for surgery versus TAVR. So SAVR versus TAVR. Believe it or not, the end point was death and not stroke. So the stroke was not a primary end point. It was the first time that Dr. Schaaf

wrote an editorial in the New England Journal of Medicine saying that there was a 5.5% stroke rate. That's what he cited in this particular group. And this was going to be a problem. So he said that the one thing to correct if you are going to have TAVR valve available in United States, would be to correct the problem of stroke. And it was fairly intuitive at that time because

When we did the tower initially, we always did it in general in a station. When the patient woke up, we kept checking whether they could move their legs, arms, smile, because when we crossed the Arctic wild, there was no more scorn. in front of the aortic valve and there was no flexion in the sheath. So when we passed through the aortic arch and through the aortic valve, it was somewhat clear that...

we could scrape some of the things from the aorta and the aortic valve and cause embolization. And most commonly, the strokes happen immediately after they woke up from the anesthesia. So... It was right procedural. And it was fairly obvious that this was happening. Some patients, when we saw initially, it looked like that the stroke happened 12 hours or 24 hours after the procedure.

And this was typically related to hypotension or something that happened after the procedure or we reversed the anticoagulation. And then when we did the CT scan many times, we found calcium inside of the arteries in the brain and we could retrieve it. Sometimes, you know, during neurointervention, we could retrieve it and it was very clear that this was calcium particles.

either from the ERDA or the aortic valve. So it was very clear that this was happening at the time of TAVR procedure and it was related to embolization. And this was the initial

hypothesis, and then it turned out to be true. Thank you for going over that historical perspective, Dr. Kapadia. Thankfully, stroke remains a rare complication and potentially with a decrease in trend over time. innovations in both technique and device design, but it is a feared complication. And many patients, rightfully so, are more afraid of a debilitating stroke than any other complication. And that brings us to risk prediction.

which is helpful both for appropriately counseling our patients for shared decision-making, as well as for employing strategies to mitigate that risk. So Dr. Capadio, what are the predictors of stroke during and after TAVR, whether... patient-related or procedure-related? It's a very important question. So first, you know, initially when Dr. Pudet, one of our fellows, we looked at the TBT registry to say that is the stroke common or not?

in the TVT registry and at that time the stroke risk was about 2.4% and it was stable over four or five years. Now with the newer valves the stroke risk has decreased. And it's probably in the 1.5% range, but it's not that low, you know, 1.5%. Remember that when you do a percutaneous intervention with stenting, it is 0.1%.

it is one in a thousand chance to have a straw and this is 1.5%. So this just tells you the relative risk of straw because people come to the CAT lab think that we are doing something similar. to what we would do like stenting when we are doing a valve replacement so the expectation is of that level so now when we say that okay the stroke risk is less but you know it's less than five percent that used to be

And it's 1.5% or 1.2%. But still it's not like PCI. Now when we try to find out that what are the risk factors for stroke. It is very interesting because we try to look in partner study, we try to look for a lot of retrospective registries and what we find is that age. aortic valve calcification, severity of aortic valve calcification, severity of the aortic arch calcification, bicuspid aortic valve probably because of more calcium, or valve in valve again.

because of poor calcium or friable tissue, are all associated with higher risk of stroke. But remember that we are doing aortic stenosis treatment with transcatheter vial. So all vials are calcified. All aorta have some calcification. So it is very, very difficult to say that this patient is at high risk and this patient is not at a high risk and we don't need to do anything further.

stroke remains unpredictable. And this is a very important message that it is extremely difficult currently to predict stroke. And this is the reason why All the studies that we did, including protected tower, we could not enrich the population. We could not say that, okay, now we are going to do it only in a certain age or certain group of patients and try to see if this works or not. So this is an important concept to keep in mind.

that even though we know which patients have a slightly higher risk of stroke, in an individual patient, we are not able to predict stroke. So this is the challenge of therapy that it is difficult.

to identify patients before you do the procedure. Wow. Thank you, Dr. Claudio, for your insightful teaching. Many important takeaway points. in what you just said. It always truly amazes me how technology evolves to allow us to help more patients in the safest way possible. This past year, I was fortunate enough to be an ambassador.

at the TCT 2022 conference, where you presented the results of the protected TAVR trial about the use of a cerebral embolic protection device during TAVR. So before we delve into the details of the trial,

Dr. Kapadia, can you teach us about the available devices to prevent tavern-related strokes? That's a very good question. So, just so you realize that the embolic material is... coming out from the aortic valve and or ascending aorta or in some cases the ventricular side so the way that you can prevent the emboli from going to the brain

One is the filter and this is what came from the Karate literature that when we did Karate stenting, we put filters and this has been like that from late 1990s and the Enchugard became available. The initial idea was to create some filters that would stay in the carotid circulation and that's where the sentinel device came into play. Then there are other group of devices that came.

which were called the deflectors, meaning that you cover the ostea of the great vessels by putting a cover on the arch and this would deflect the emboli. from the arch and the emboli will go down to the descending yoda and will not create stroke. So there are several of these deflectors that are available. The main important part of the deflector is that the deflector should remain stable.

should not rub on the aorta and should remain opposed to the aortic wall so these are the different deflectors of different mechanisms to be able to attain that so either by certain kinds of propping mechanisms with a nitinol or covering the entire aorta or going part of the deflector into one of the great vessels, it stabilizes itself.

So these are the different types of deflectors that are available. And then there's a combination. So you can have a deflector and then whatever you deflect, you can catch in a filter. So that way it does not go into the descending order. So there are deflectors, filters, deflectors plus filters or you can also have filters in two arteries like how the sentinel has and then cover the third artery with a deflector so that it...

deflects that part and covers all the three arteries. So these are the different types of devices that are available and there are probably eight or nine devices that are currently already tested in humans. different forms. Some of them go through the radial arteries. The sentinel goes from the right radial artery. Protombo in another device goes to the left radial artery. And then there are several of them that go through the groin.

either from the pigtail side or from the device side. So there are several different mechanisms of inserting these different devices at the time of procedure.

Thank you, Dr. Kapadia, for going over this overview of cerebral protection devices, including the Sentinel device as filter, whether it's used alone or in combination with a deflector. Which brings us to the protected TAVR trial. a multi-center randomized controlled trial in which patients were randomly assigned in a one-to-one ratio to undergo TAVR with cerebral embolic protection, or the CEP group, or without cerebral embolic protection, or the control group.

The trial showed no difference between groups as regards to its primary endpoint, which was clinical stroke within 72 hours after Tabler or before discharge, whichever came first. However, patients in the CEP group had a significantly lower number of disabling strokes than the control group, a secondary endpoint. Dr. Kapadia, how do you think clinicians should interpret these results to guide their patients' decisions?

Very good summary. So, just to put it in perspective, that when we did the partner trial, you remember the first trial, which is whether the device should be approved or not, was 350 patient trial. So it was randomized to either device or nothing, but 350 patients. Then all subsequent partner trials, you know, ranged from 500,000.

1,200 patients, but nothing. That was 3,000 patients. Same with the self-expanding valve. And the TAVR valves are sold for $30,000 and the emboli protection devices are $3,000. So... In order to have an approval for a device, that is an ancillary device, to do a trial of 3,000 patients randomized in each arm is in itself.

a very important accomplishment in my mind because the industry has to support this kind of effort. We have to design a trial that is relatively inexpensive and we have to make the end point such. that we can study them and we can make sense out of them. So when we designed the trial, we said that, okay, we want to have, again, all patients because we couldn't tell which patients would have more stroke or not. So ideally,

We want to put it in outpatient to see if the strokes can be reduced. And we wanted to do a trial with all strokes because in the initial sentinel trial, we saw some signal in all strokes that were reduced. and we wanted a neurologist to see the patient. When we did the analysis, what we found was that all strokes, although were reduced, were not statistically significantly reduced. However, the major or

We call it disabling stroke. That's the right word for that. So reduced statistically significantly in the CEP group compared to patients who did not use CEP. How you interpret the data when the primary endpoint is not? positive and then can you really interpret anything that is called a secondary end so this is a difficult question so typically i would say no you cannot because you know you are now exploring

So you have to have multiple comparison kind of situation where you have to use different kind of statistical analysis to say that whether this is really significant or not. And it would be a hypothesis generating statement. However, We are studying stroke as a primary endpoint and disabling stroke is part of the primary endpoint in the sense that it is a very important part.

of the primary and we are not saying that how many patients were discharged or how many patients are dead or something different hospital stay we are talking about the same description of the endpoint so this is something to keep in mind And then the second part is that if you look at the patients who had disabling strokes in both the control arm and the CEP arm, do we really see a difference? So if you are a clinician and if you're doing a trial,

You also want to know that really when these patients have disabling strokes, what kind of situation happened when we had already put a CEP device. So if we had a device in place and they developed a disabling stroke, was it working, not working, what's happening? So what we found was, and that's why in the paper itself, I put all these eight disabling strokes and describe them so that people understand that what really happened. So very interesting.

So, except for two strokes that are not understandable in the sense that that happened in the area that should have been covered by the filter, four or five of the strokes happened in the areas that were not covered by the filter. And very importantly, Two or three strokes happened in the patients who had hemodynamic instability, meaning that the patient had a left main closed, they had to put impeller, do CPR, another patient had valve embolized.

and then they have to go another valve. So if this kind of major things happen, where the filter is, what the filter is going to do is difficult to understand. So as a clinician, In the control group, the disabling stroke happened when patients were, after the procedure, they couldn't move the right hand, left foot, something like that. So this was very clearly a signal that the device was working.

in the places it's supposed to work. The device did not work when it's not supposed to work. So again that gave me an idea that at least we can depend on the result of this trial to say that in order to prevent disabling strokes.

we should consider to use the emboli protection device. If you didn't use it, would it be considered irresponsible? Probably not, because currently, you know, this is a hypothesis generating statement. Very importantly, I also want to point out one more thing that if you are looking at an evidence, you should learn to look at the evidence in a supportive way in the sense that whatever other data are available.

So if you look at the NIS, which is a national administrative database, if you look at that and say that people who had CEP and stroke, what was the death rate? And the death rate was lower. compared to people who had stroke and no C, meaning again that the major strokes would prevent. Human clinic database, same thing, that we find that there were almost 17% death rate.

before we started using CEP with stroke. Strokes were not frequent, but still the death rate was high if you develop stroke. Whereas after the CEP use, nobody died with a stroke. So the major strokes were rare after putting a CEP device. So what does the protected tower study mean? I personally think that it is a very traumatic complication to have somebody to have stroke and if you are going to be able to prevent

disabling stroke. This should be considered as a very important indication. However, this is still a hypothesis generating statement because we don't have a primary endpoint of disabling stroke. We are still waiting for the British trial, which is 8,000 patients. They already enrolled close to 4,000. So hopefully, you'll be able to see the differences a little bit more clearly.

than what we saw in the protected tower trial. Dr. Kapadia, thank you very much for the insights into the design of the protected tower trial and for providing us with all the granular details on, you know.

what's involved in the assessment and evaluation of the results and how you do that assessment. And while the differences in the primary endpoint or primary point of all stroke were not statistically significant, As you said, the secondary endpoint of clinically disabling stroke was very different between the two groups. And disabling stroke, it's a major complication for the patient, but it's also a big burden for the families. This piece of information, this result, certainly generates...

hypothesis and deserves further study. Can you tell us a little more about the planned trials to study? this concept further study the impacts on disabling stroke and also any ideas on how to investigate better like the patient or device selection so thank you Nico for the good question so I think There are no major new trials that are going to address which patient population should use the emboli protection devices. However, the most important prospective randomized trial

that is ongoing and present, very similar to central trial, is going to enroll 8,000 patients. So we are going to see that particular trial results and we may have insight into saying that this particular patient is 8,000 patients. So it is possible that we have identified the high-risk group. If you look at the current trials that are planned, they are all planned to either compare the debris collection with Sentinel because

As you know, the central device is approved for collecting the debris at the time of tower. It is not approved for stroke prevention. want to have another device approval, you can have another device approval which can have the collection of debris similar or more than Sentinel. The other way to get a device approval would be to say that we study

the MRI hits in the brain and in the initial central trial that we did, we did not find statistically significantly lower MRI hits in the brain. Now with better all the four vessel protection, we might be able to see that. And we learned from the central trial, initial central trial, that everybody could not come back for the second and third MRI. So maybe we simplify the protocol.

And also the pacemaker rates are lower so people can have the MRI done again. This is another method. But again, neither of these two device comparisons are likely. to provide a patient-related information to say that which patients we should use this or not. So currently, I would say that we have some idea that the bicuspid valve involved.

self-expanding valves are at higher risk of stroke. Maybe those patients we should definitely consider to use it. But as time goes, there are a lot of machine learning and AI mechanisms that people are using. to say that if they can predict stroke prior to doing the procedure, and that might be something of interest, depending on where exactly is the calcium, how the valve is going to go, which valve we are going to use, how tortuous are the vessels.

All those factors you could put into equation and come up with a risk of stroke or risk of no stroke. I think that's more important. And if you are not at risk of stroke, then obviously you don't need to use the EPT.

or CEP. This is all very interesting, Dr. Kapalya. We're all definitely looking forward to the results of these upcoming speeds. So in assessing the value of novel therapies, We're looking at the safety and efficacy, as well as the cross-effectiveness and eventually access. Protective tavern, amongst other studies, has shown the safety of the sentinel device.

In terms of efficacy in the protected TAVR trial, the number of patients needed to treat to prevent one additional disillusioned stroke was 125. So Dr. Kapadia. What are your thoughts on the cost-effectiveness of cerebral embolic protection devices, such as the central device, and will this be specifically evaluated? Again, this is a good question.

is in the center of the hospital administration's thinking or in the thinking of healthcare delivery and for Medicare and things like that. However, when you are treating a patient, for the patient you know or your family member or patient family member. Cost is important but what is the cost effectiveness to prevent a stroke is a very tough number to come up with.

You know, for the life-saving cost of a device, initially in the United States, they used the dialysis as a measure. So, you know, $50,000, $55,000 was supposedly. cost to save a life now what is a cost to save a stroke is again extremely difficult to know so one other way of cost effectiveness is to say that if you develop stroke, what would be the cost to treat the stroke? And if you prevent a stroke, whether, you know, the device is equal in cost, this is one way of looking at it, obviously.

For the patient and for the families, this is a terrible comparison to say that, you know, if you develop stroke and if the cost is more to keep you alive or to treat your stroke.

That's why we are going to use this device. You know, we are trying to prevent the stroke. So there are several analysis like this and it appears that you could argue that it might be again what level the cost of the device you put in that would equal the cost of stroke treatment versus stroke prevention and that number may be you know, $2,000, $3,000 depending on different analysis you do and also the different kind of patients you treat because 16% or 17% of the patients die after a stroke.

in the TVD registry with Dr. Foudet when we did the analysis, that was roughly the number. Now, if you are going to die, the cost is obviously somewhat less because you're not going to stay alive. long-term cost. If you're not going to die and if you're going to be disabled, then obviously the cost is going to be higher for the stroke.

And the cost, whether you calculate during the hospital admission or ongoing cost is another consideration. So this calculation of cost-effectiveness is quite complicated for the stroke in itself and its implication.

for the consumer, the patients and for the healthcare administrators are also different. So this is a difficult question to answer.

Yeah, challenging math indeed. There's a monetary cost of stroke, and then there is also all of the intangible costs of a disabling stroke for the patient, their family, the entire environment around them. But this has been really a great discussion of... all of the work that has happened and the work that continues to happen in the pursuit of understanding, quantifying, and eventually mitigating stroke risk around TAVRs.

But at this point, Dr. Kapadia, I'd like to turn towards the broader challenge of running randomized controlled trials, an area on which we Cardiners are just beginning to get more perspective via the Cardiners Clinical Trials Network.

Would you please speak about running an RCT on a commercially available device? And that too, an international trial through the COVID pandemic, i.e. protected TAVR. Again, you know, I think I must congratulate career nurse for... putting this network in place with the fellows to be able to recruit patients and to be able to be involved in the clinical process of a randomized nature and be part of the science and part of innovation that comes with it.

In the protected tower, of course, we started during pandemic and we finished during pandemic. So it was, I think, a miracle that we could do this. So we started all the sites during pandemic. And the reason why we could do this is because we also kept the endpoint at 72 hours or at the time of discharge. So we didn't have to follow the patient, so they don't have to come back. However, if they had a stroke,

or if they developed a stroke, then they would have to come back at 30 days to see if this was disabling or not. Now, how important and how difficult it is to do the trial is As you pointed out, the device is available commercially. So people will use the device only in low-risk patients because if they thought that somebody was high-risk, they would not like to randomize this patient in the trial. And sometimes...

It is hard to convince people to do that because of course patient is at the center, not the science. So this is a challenge. So whatever people feel comfortable with, we should allow them to do and just so you know. In Cleveland Clinic, I could not randomize the patients because we didn't have equipoise because we were using central device in all patients before this trial started. So we did not enroll any patient in our trial.

So this is something to keep in mind that when the commercial device is available, in order to prevent the bias of enrollment, you have to either not do the trial in the centers where there is no equipoise or... convince other people who are just starting and again other centers which were not doing sentinel and now we are starting so they have a learning curve of using the device so we try to say that okay if you have to know x number of cases before

you participate in the trial. So there are a lot of complexities and uncertainties in how you roll out the trial and how you interpret the data of the trial because it's very possible. that in the same centers there are people treated with high risk and therefore the stroke risk is lower in the overall population. We don't have a very good handle on this particular situation.

But during the trial, we tried to tell the investigators to be mindful of this, to say how they enrolled patients and prevent the bias.

Thank you so much, Dr. Kapadia, for teaching us today about stroke and TAVR, what we can do to prevent it, and what to look forward to in this space. It was such a pleasure having you here with us today. But before we go, I would love to hear from you with your incredible experience in structural interventions. What makes your heart flutter every day at work? All the fellows, maybe the excitement with interacting with smart people.

and doing new things and more than anything else you know when you treat the patients and the patients feel better that is the ultimate pleasure that you can help somebody that did not have any other option so all of these things are very important part of our daily life that makes us work hard and enjoy what we do.

What a great discussion, everyone, and so relevant to the work we do every day caring for patients with aortic stenosis. I would like to thank Chelsea and Ahmed for planning this very educational episode of CardioNerds.

And of course, I would like to thank Dr. Samir Kapadia for sharing his expertise and teaching us about the very important topic of stroke in TAVR. Dr. Kapadia, before we close... I want to take this moment to reflect on the impact that you've had on the field of structural heart disease generally, but also on my and Amit's training personally.

We are at the brink of graduating after eight years of training and about to embark on our own careers as faculty interventional and structural cardiologists. Truly, this would not have been possible for us without your mentorship and support. Personally, I've had the fortunate and unique privilege of learning directly from you as your clinic fellow.

before joining you in the cath lab and the OR as an interventional fellow. And I would like to say the following. Being originally from Greece, one of the subjects I studied extensively in school was the Hippocratic Oath. One of the main points of the Hippocratic Oath is that we should treat the person who taught us the art of medicine, medicine was considered mainly an art, like our parents.

And that we also have the obligation to teach and pass this torch along to the next generations. Having worked with Dr. Kapadia closely during the past five years, I have to say that besides... a compassionate physician, master clinician and operator, and researcher scientist, he is truly an artist in the way he practices humanistic medicine and interventional cardiology.

Dr. Kapadia, I and the rest of your fellows could not be more proud and grateful that we have had the opportunity to learn from you. Thank you, Dr. Kapadia, for everything. Oh, that's such a nice way to put it. I must thank you all. And you in particular, Nico, because you spent all these five years working with me in the clinic and Amit to start this amazing platform of interaction with the fellows.

As you graduate and as you go to the next level, remember that you are constantly going to learn what you learned the details in during your time here at Cleveland Clinic. is not going to be the most important thing. But after you forget everything that you learned, what you just said, what you learned without knowing what you learned is really what stays with you. This is what really you will build on.

and continue to enjoy, continue to be reflective, continue to be thankful, and treat everybody equally. I think it will be a great future for structural cardiology and all of you. who are going to practice in the future. Thank you very much again, Dr. Kapadia, for your advice. We will keep it in our hearts for the rest of our careers and lives. What a great session. Thank you, everyone.