TPES 2024: Dr Tonia Tauh "Top Echo Articles of 2023"

it now gives me great pleasure to announce our last speaker for the session this is my very good friend Dr Tanya ta she graduated from the University of British Columbia and then pursued a clinical Fellowship in cardiovascular anesthesiology at the University of Washington in Seattle with with Professor Bard Tanya is a cardiac anesthesiologist from Colona General Hospital and unfortunately we recently lost her to the structural heart Imaging team at the Royal Colombia in Vancouver we're still a bit sad about that her main interest is 3D echocardiography for structural heart procedures focus and Med medical education thank you so much for joining us da we're looking forward to your lecture uh thank you very much El Marie uh for the invitation it is uh an honor to be here um and it is I did my fellowship at University of Washington in Seattle with Dr Bard mckinson who was a um instrumental mentor and still is uh so it is really an even an extra honor to be on the same panel as him um uh I will be speaking to you today on the latest in Echo choreography um and uh my images are nowhere as nice as Dr mackinson but it is the uh this is an image a 3D echo of uh the very first um uh uni cusped aoic valve that I saw um on my in my fellowship conflicts of interest I do not have any and the objective um of this talk we be um in my uh uh in my research and looking over all the journals we'll be talking about uh two journals on my cardiio strain Imaging and its utility um there were a lot in the last few years on aortic stenosis and so we'll be talking about um moving towards 3D Echo cardiography towards assessing um aoic stenosis and then uh there will be uh we'll talk about one journal on the 2D and 3D assessment of RV function uh this year a few months ago a state-of-the-art review came out on myoc cardiio strain Imaging um discussing its current practice in the future and I do think that we're moving more towards strain rather than and moving away from uh EF assessment using B Simpsons bip plane um and at the same time this group from Norway also did um uh accumulated uh some reference ranges for GLS strain um for the cardiac Chambers the so the two groups together the two journals together spoke about how GLS using speckle tracking in evaluating um early subclinical LV dysfunction it is um it assesses longitudal function and it is is uh assessing the fibers that are most sensitive to esmia it is good at uh early detection of hypertrophy increase W stress and reduce arterial compliance and it has been shown to be superior to lvef by Simpsons bip plane and predicting survival outcomes it is also reproducible regardless of your training in Echo cardiography and in those with reduced EF GLS of the RV um of less than 177% was independently associated with increased mortality um the downside to GLS would be the same as uh EF um is that they're both dependent on loading conditions so the state-of-the-art review has this really nice uh infographic showing why GLS is better than ejection fraction in assessing LV function so here you'll see that the longitudinal myocardial fibers make up the subendocardium here and doing a remodeled uh ventrical it is the ones that's where the um most sensitive to uh decreased profusion and esia so it changes the most here in B down here when they did EF as a function of uh GLS the EF didn't decline as much and when EF is a function of um uh CC circumferential um contractions the uh EF decline a lot more so EF is more of an assessment of your circumferential contraction rather than longitudinal and over here this is a really nice uh diagram showing that if you look at the red line that's um represents LV wall thickness of 2.5 cm and in the blue line here it is 0.5 CM as so as the wall thickens so um as the wall thickens your EF Remains the Same but your GLS declines and that's because as your LV hypertrophies your um the cavity in the LV declines and gets smaller so your you're able to contract and eject um the same amount of volume but you're um that is still LV dysfunction um even though EF is the same GLS is probably most uh sensitive and most studied in aortic stenosis pathology so um in those undergo and Tavi Baseline GLS with that less than 16% correlates with all cause and cardiac mortality it has worsening functional capacity it increas has an increased incidence of atrial fibrillation more severe aoic stenosis and most of these patients have coronal or disease requiring revascularize ation and the recovery of GLS correlates with symptomatic Improvement and improved prognosis something that um perhaps EF um alone does not convey and the Norwegian group um basically uh took about uh 1,300 patients in this part of Norway and um accumulated some reference data for GLS the youngest uh patient is 23 years old the oldest is 94 with the mean age of 57 and they were able to um give a reference range of for the LV is around minus 16% for the RV is around 177% which is a nice number because it correlates with tapsi so you can remember that and then of course for the left atrial strain as well left atrial strain is used to assess the degree and severity of AIC stenosis as well as um atrial fibrillation and then r a strain which is a measure of RV dysfunction so all the numbers are around the same with - 16 -7 -7 and 17 um so um in summary in terms of global uh longitude and restrain I do think we're moving we should be moving towards assessing that rather than um uh EF alone and most of uh the software um in your machine should be able to do Global longer to restraints um and I know that EF is usually a better tool to communicate with your surgeon um but I think the more we use it the more um the more um I think they will ask and and we can even educate our surgeon surgical colleague on the significance and the sensitivity of uh GLS uh moving on here uh we'll be talk about uh three studies that talk about the um the advocates for 3D analysis whenever we are assessing um aortic stenosis so the European uh group here from the UK actually um released a clinical consensus statement uh last year on the multimodality Imaging eotic stenosis uh advocating for 3D Echo um uh cardiac M as well as CT um the Italian group also um released this comprehensive uh review on evaluation of iotic stenosis and then the Toronto group um uh released this paper through BGA education on the clinical applications of 3D Echo and I'll be focusing more on the aoic stenosis aspect um the state-of-the-art review did this nice infographic on the proper I guess the more comprehensive assessments of aoic stenosis and I think many of us use color Doppler already in 2D 2D Echo and then uh it's important to add on 3D Echo and then if you um Dr Boer Marson showed a nice uh 3D multipler reconstruction of regurgitant jets uh and assessing um uh as well as the lvot and the aoic valve anulus and the aoic stenosis assessment is not complete without LV functional um assessment using ejection fraction as well as Global longitude restrain and then um in the future um there's now the use of artificial intelligence and um deep uh learning models here as you guys all know the lvot and the analyst when you measure in 2D um you are you prone to having um uh errors because you are measuring only in 2D and if the lvot measurement is off that can also um uh miscalculate your annulus so here is a multi um planer uh assessment bya 3D of the aoic valve annulus this particular annulus is quite circular so it's not really a big issue but um most of the time you'll find that a calcified disease aoic valve would be quite asymmetrical um uh here most of the measurements are around 2.6 but we've had uh um uh assess values of 2.1 by 2.6 and to be able to convey that to your surgeon you know early on say hey my valve is very asymmetrical it's 2.1 by 2.6 at least then they can as they're scrubbing they can think about planning for um atic loot uh enlargement or unplan for it um and last week I had a patient who CT um of the aoic valve showed that the anulus was um 2.1 so the surgeon was planning for uh a root enlargement and then when when I went into assess I found that the Val was actually 2.3 by 2.4 and you could see the relief on his face and he said are you sure um it is and I said well my 3D Echo has spoken um uh I'm I'm certain that it is it is um bigger than 2.1 and um and he was able to put a 23 mm valve and no need for root enlargement um similarly the use of 3D Echo can be used in uh particularly if your Center there's a lot of aortic valve um repairs so measuring geometric height cooptation height uh commercial height for bpit valves um and allowing and giving the surgeon a sense of what they have to do uh in repairing it and the probability of uh a repair success so in um uh aoic valve stenosis assessing the LV is just as important and over time when you have chronic pressure overload on the LV um the LV hypertrophies and over time the oxygen um demand will increase and the oxygen supply should be able to meet and that's a well-compensated LV in severe aoic stenosis that's uh that myocardial oxygen supply um does not meet that demand and so the LV The myocardium starts to fibros and also um it can also lead to apopto apoptosis and sell death so you have the cavity getting smaller you have increase in fibrosis and apoptosis the EF can be preserved or increased it can also be preserved increase in severe aoic stenosis as we many of us have seen just because the cavity gets smaller contractility is able to um eject um a smaller volume um and then here are some of the findings for after aoic valve replacement immediately after and late after where you get remodeling and the cavity increases back in size and the hypertrophy declines um the in assessing for the LV we assess for ejection fraction and Global longitude restrain as well as stroke volume my video is not playing but that's okay is um so this group here Philipp um uh who is I think is a a big expert in aortic stenosis in particular low for low gradient um aoic stenosis um tagged on to uh this partner two trial data so if you guys remember partner one was when they proved that Tavy and surgical AVR was equivalent in high-risk um patients with severe stenosis partner two trial found the same outcomes for moderate risk uh patients and all these patients uh around you know 1,600 patients had a lot of echo uh data um and so Philippe took this data and was able to Stage them over um four stages in severity of aoic stenosis stage one there's no cardiac damage patient has just severe aoic stenosis stage two is when you have LV damage chronic pressure overload damaging the uh the myocard and causing also diastolic dysfunction and EF will start to decline stage two you see a backflow of damage into the left atrium and mitro valve where you have moderate to severe mitro regurgitation you can also see um the onset of atrial fibrillation and then in stage three where you have ponary hypertension as well as perhaps severe TR and then the last stage stage four is where you have V dysfunction and he was able to show that for each stage increment there is a one-year mortality increase by 45% that is substantial so onee mortality risk increased by 45% every time you move up a stage this shows you that it's really important to assess not just the atic valve but the LV also the left atrial uh and if you can do an left atrial strain if you can't assess for uh my valve assess for um TR and RV dysfunction and if you have RV dysfunction in aoic stos it's usually a very very bad uh prognostic sign and then this is one example of artificial intelligence in um assessing in amalgamating all that data that's out there um this uh Journal J from jaac also just came out recently shows that they were able to um use a previously validated um deep learning model for that predicts diastolic dysfunction and be able to predict um the progression of aoic stenosis so a deep learning model by definition just means that you have this deep neural network that's three layers or deeper so you have input data input layer which is your Echo cardiographic features and then all this data that's out there that's three layers or more defined a deep learning model and then you have an output so here's an example of how deep learning models work in aortic stenosis so you have what this group did was that they took three different sets of cohorts of patients that have early signs of aoic stenosis so in this group called The a i is the arthrosclerosis risk in community cohort there was 5,000 of them and 900 of them had only aortic Val sclerosis but they were Echo and had these nine echocardiographic features and they placed that into they took these patients and put them into the validated um deep learning model that predicts the probability of diastolic dysfunction they follow these patients over a span of seven years and stratify them into high risk and low risk low risk is defined as the progression of to have a diagnosis aoic valve as well as um uh needing some sort of aoic valve intervention and this validate this um deep learning model was able to correctly predict which patient will become low risk and which patient will be high risk in further adding to this neuronal network they will um they used all the information that was in this cohort and added into the validated model so you add on another layer uh of network they also took um another group that has moderate mild moderate aoic stenosis um defined by Echo and cardiac Mr and also did the same thing place them in ran the model through them followed them for two years stratify them and again the model was able to correctly predict which patient will go on to have Intervention which one will have um diagnosis fa bosis and they also did the same thing with the PET CT cohort and the PET CT cohort essentially these 18 patients had um uh biomarkers taged to show inflammat markers and actually all 18 went on to have um aoic valve severe aoic valve stenosis um and these are the nine EOC cardiographic features that they use in the Deep learning model most of them are uh LV function diastolic function and RV function um assessment and it is uh quite fascinating that um artificial intelligence can predict just if you have aoic V sclerosis how in seven years time you can you have a high probability of getting of having aoic bosis so um I think if we can intervene working towards intervening before LV dysfunction before moving along the stages um patients would do better so in summary in terms of where aoic stenosis assessment is moving towards uh well I think we should do a better job and and and try to lean towards um um using 3D uh in assessing theic valve itself as well as LV function using um GLS and then knowing that in the future there is uh deep learning models and artificial intelligence coming down um in the last part um we'll talk about the right ventricle and where um assessment um of right ventricle is moving towards the right ventricle um is a very tricky ventricle it is not a straightforward uh shape it is uh you can tell here that there's um there's an inlet and an outlet and then the free wall which then wraps around the LV so it makes it a little bit harder to um to assess it by Echo um so we have a few ways in which we assess the right ventricle I think a lot of us use tapsi it is simple it is reproducible um here the the pictures on the uh right here is through trans thoracic uh e an assessment of tapsi um and then we um some of us also do tissue Doppler also on the lateral wall of the RV um unfortunately both tapsi and TDI uh only measures the longitudinal contraction of the RV wall um a better assessment is through fractional area change um and it is down here where you um can take um the uh RV area in Di and minus that over uh the area in syy and it gives you a fractional area change that is a more accurate measure of RV function than tab c um and then there's 3D assessment of the RV as well if you can I think most um software out there is available for um a quick uh Rd sorry 3D RV EF uh assess and the cut off is usually 45% and you can even classify a mild modate or severe 30% being severe RV dysfunction and rvef is probably the best um measurement out there right now in terms of independently associated with cardiac and all cause mortality for Maze um in patients with any cardiac diseases so RV dysfunction in combination with any other cardiac dis diseases is usually um increased in oost Morality um if your program can do a 3D EF um it will also have uh 3D RV and systolic volume index to the patient um body surface area because it uses the volume in order to um uh calculate EF um and the volume uh is used to classify patients who have prary hypertension who are have either decompensated or compensated RV failure and um the uh reference value for n systolic volume of greater than 140 Mill per meter squared is considered dysfunction and decompensated RV failing um as the RV fails it dilates and when it dilates to certain um volume it can become decompensated um here is an example of 3D rvef where you take um short AIS view at the medial side short axis at the basil side and then four chamber view of the RV and the program then gives you an rvf this is less than 45% so there's mild RV dysfunction here and the index is 66 which is um small and compensated RV strain is also another um uh another nice uh way of assessing the RV very similar to Long longitudinal Global strain on the LV um when you take uh different views of the RV you can run the software through and it gives you a nice uh picture of uh what's happening in the early stages of RV dysfunction over here it also gives you rvef and you can see pre-incision was normal immediately post um as the chest uh opens up and you open up the pericardium you have the RV has more space so they um The Strain uh improves as well as rvef improves slightly and then after whatever procedure they have um stal closure rvef comes back to Norm and um RV strain and rvef is a better measurement of RV function more so than tapsi more so than um tissue doubler um but it does take time and I know that you know when we are doing Echoes for these procedures we're moving along very very very quickly as quick as we can so we can report our findings but in RV dysfunction if you have patients with RV dysfunction um usually taking the time and assess uh the RV in in multiple different ways um just because tapsi and tissue Doppler is so restricted so multiple ways of assessing the RV and this leads to the end of my talk how you said 20 minutes so I think I'm 20 minutes da thank you very much for the Fantastic talk I am really enjoyed that we're going to open it up now to the panel we have some interesting questions that already came through I think the first one is for Bard the question is in your department how do you um go about training for these Advanced modalities and you're practicing cardiac anesthesiologists what do you think is realistic a realistic expectation for everyone and then also do you think this should be implemented in the nbe exam because currently there's very little 3D actually in the advanced Peri operative exam yeah these are excellent questions thank you I would say the following first of all there is a paper from uh not this year but last year that we came out with in conjunction with the as so you can find it also for free as standard recommendation on how as cardiac anesthesiologist as opposed to um a cardiologist you can actually pursue this type of training and um I've really been part of that effort to illustrate that we're well positioned to come on and join a structural heart team such as uh Tanya Tim to is now going to do in in Vancouver which I think is great um within the fellowship the way that we've done it we've um offered opportunity for elective time in the structural uh Suite uh the fellows can come at any point in in time that they're not needed elsewhere in addition to really dedicating a month or or weeks of time to come uh there's also scheduled times um with us but it may or may not be sufficient I think when I think back to um for instance what Tanya did she came Whenever there was a moment of time uh to come across and and take a look what we were doing in in the Interventional space training our own faculty is time consuming and and tedious and not always successful to be quite Frank too because it this is not for everyone I have to remind the audience that this type of Imaging is just very different you have to be always on um last week for instance I I did two days and there were long days and you see several cardologist come through as the anesthesiologist of record and you're still there and and you have to be in the procedure you have to constantly avoid complications and and guide the procedure in its best way uh and the communication flow is much more continuous than it is in the operating room where it's maybe a sporadic assessment so you do assessment preop you have a Al be a brief conversation maybe with the surgeon and then maybe some other interaction but it's more pointed and and and constrained for for certain periods of time uh you have to be ready to um to really go into detail and communicate at all times and and then ultimately you also often asked to make a call and make a help with a decision maybe even more than when in the peroperative space we present um the evidence and what we see but ultimately maybe the surgeon will make the decision more on their own again depends on the personalities thank you very much for that uh for that answer I think that's something that we struggle with in in uh in all of our department is that um the software keeps changing and then there's new stuff available and the training is not always there where as a fellow you've got a lot of time to train but once some of these been in practice for a long period of time it becomes more tricky to actually do that I I think also the next question is for for Fabio in relation to this with these new Imaging modalities that we see is there a lot of artifacts that we have to take into consideration that you wouldn't see or wouldn't have had previously yeah I think like in terms of like 3G artifacts the like the way they occur are pretty much similar to the way the 2G artifacts occur um normally we see like um some artifacts caused by the devices that they are implanting so we need to make sure like uh first of all we need to rule out like any complications um anything that you don't know exactly what is happening but we see especially like um in the or like I'm not involved like um that much in the structural heart program in our hosital but in or in the you see a lot of like artifacts on 3G also it's important to rule out anything that you don't know exactly what you're looking at and and make sure you you you present the proper information to our surgeons and I'm pretty sure to card ol as well thank you very much Fabio Tanya I've got some questions here for you as well one from the audience the first one is is in what way will strain measurement in the O change the operative or surgical anesthesia management um that's a great uh question because uh obviously you can uh tell that strain um is a very good uh tool to use in predicting uh long-term outcomes uh but I'll give you an example of what happened in the O last week uh normal patient coming in for cabbage normal EF no Regional W motion abdom mality like many of our patients uh coming in for cabbage and they ended up doing six bypasses but the strain was minus8 that is substantial um so I've communicated that to the surgeon and of course the surgeon's like you know what is strain is that is that better than EF and so I was able to say you know it's actually it's a better better indicator for um for mortality and survival uh benefits and and then as we were coming off um there was torrential torrential M um so I I was able to tell them that hey the LV even though it is normal EF and no Regional War motion abnal there's actually a lot of dysfunction and damage uh caused by the uh by the esia that's not conveyed in in in normal values but your strain tells you that uh the torren Mr is probably from this underlying dysfunction give it time and if your graphs are adequate the Mr should subside um and it tells you you know that um that I think it gives you a better of better picture of how sick the patient is despite having normal values that um that I think I asked him hey when we come off can we come off slowly don't come off so fast like any other normal EF and no Regional War motion abnormalities so yeah so I think I think it does it gives you more sensitive um uh valuation of your LV yeah I I fully agree I think also the other question I have for you is do you think our Cardiology colleagues should start doing strain on the LA and LV instead of debine stress testing for patients that have low flow low gradient now we've had had the recent arrest because of that in the in the exercise lab oh I think the data is um there's a lot of uh research and validated data for low flow low gradient with dobutamine I think La strain I I think it's still coming up and I'm not sure that is um It is Well validated yet it is well it is it is for right now it is I think another data point for us to point towards um LV dysfunction um I think it would be you know as you guys know with low flow low gradient as um you have to have lots and lots of data and I think the the stress test has been so well validated but if you can't um I think what they I think they would move towards um getting a calcium score before debam stress tests perhaps that might be a way um too um yeah and maybe maybe yeah you have a good point maybe moving towards um assessing La strain and I I believe it is uh I I've done it a few times and it's actually quite quick on the newer software is not as timec consuming as you think um not like um uh you know as Bard mentioned even just last year it took us forever you have to go through Q laabs to assess all this strain but now with just one or two buttons your strain comes up very very quickly uh so time efficiency becomes an important factor in the O but yeah I added a brief comment in the chat to that question really confirming that there's not that much out there yet to prove that it helps right in the acute setting um but it has certainly been shown even peroperatively to have prognostic value and so I think that's important to to recognize that's that's a good starting point that said most of the strain data out there in studies are certainly based on TR thoracic and there's still more work to be done with regards to transer Echo obtained images that then are used for strain quantification thank you very much um and I have another question for you so in patients that have got P2 prolapse sometimes what you see is that you've got a bit of proaps of the anti microwave leaflet as well sort of like a pseudo rapse how do you distinguish or how can you use these modalities to distinguish between the two when you tell the surgeon especially with the minimal races when they go before they go on pump whether he needs to do anything to the Anor mical leaflet yeah that's a that's an excellent question I I think the key is again to be as cognizant as possible as intentional as possible uh to get the best possible image and then look in multiple planes and cropping planes and what I do for instance if I have a potential for a BAL prolapse I may take the 3D onast View and then maybe crop in with a flexible cropping plane from one side or the other and um and then and then rotate the image around and kind of look from a different perspective often looking from the annular plane perspective and so you see what's coming up and what's not um the the biplane Imaging also helps with that but again you have to be aware of how you coming down with a tilt plane and sometimes you're for shortening things and you're cutting obliquely and thereby reducing a a perpendicular image that may not fully display the pathology um so I think really being aware of the complex three-dimensional space and um and then also at times shifting from um temporal resolution to more spatial resolution may help so there are ways to affect your image acquisition especially if you use 3D where maybe the emphasis doesn't need to be on a good high frame rate but maybe the the emphasis really needs to be on a spatial resolution and you you have to stop in insistently anyways to fully understand uh lastly you can you can still use quantitative assessment tools and again as U Tanya just said some of these tools are now pretty quick and they they do a very quick um assessment of the surface of the leaflets if the leaflets are well enough shown in the 3D data set and then with that you get pretty good information of what is above the annual plane and what's not excellent thank you very much just want to check in the Martin go ahead uh Bart referring to what you said and you are heavily involved with nbe and looking at our guidelines this is where we started how we can standardize uh this additional modalities 3D modalities so to make sure that we are speaking the same language is it where the main difficult comes uh if you can comment on that yeah another excellent uh question thank you um so I think it's twofold one is what works for you in your particular setting and be that in the operating room with our cardiac surgeons or be that in an Interventional suite and you know what are the expectations from your partners again surgeon or interventionalist you have to be somehow on the same page you have to uh find ways to uh determine convention I give you one example you may have noticed in some of my multipler views that on the left lower maybe the short axis of the mitro valve was still upside side down as opposed to the 3D in the right lower corner um those may be examples that maybe I got several months ago and maybe now I've been more aware of using because it's quicker and I also have more memory options meaning I can go to a um um set home stage meaning I can I can arrange my images in the multipler fashion and I can give the machine an indication that whenever I go back into a 3D image for the mitro Val I want it to be dis displayed in this multipler fashion and so I take an extra step and and rotate Z if you will with the Z axis and rotate everything so it's on fuss but again if I do that all a sudden my Interventional cardiologist may say like well that looks different you know what have you done and so you have to be very um clear in your communication when it come comes to training and setting standards I I do believe that there's no way around and having um the Canadian Society of echo cartography or the As and both International the Europeans agree on on real standards and guidelines and how this should be displayed and that's what we try to do with the screening paper where we had really an International Group come together uh to inform these AS stand standers and then lastly back to the training uh again the the the training um paper that we put together for for what you know what's the expectation how many let's say mitro clip or mitro Tia procedures do you have to have done so that you're good to go and that that you are actually in a good position to guide these procedures uh We've agreed on minimum numbers again they're a little bit arbitrary but came about based on our combined experience it's a it's a new evolving specialty of Interventional echocardiography and we are kind of um you know trying our best to come up with setting expectations appropriately uh we certainly want to increase the number of folks that can participate and I can assure and encourage the audience from a peroperative point of view I do think we are extremely well positioned uh short of hospital and uh reimbursement questions they're all separate and they all have their their their um their focus and need to need to improve I do believe from an Imaging point of view how well we image with transo regardless if that's a small probe that are coming through or a bigger um standard adult probe we are extremely quick and transitioning from our perative phase to actually bringing about information I know this for many industry Partners Abbot or or others who are imp you know planting mitro clip for instance when they open up a new program and they see there is a cardic anesthesiologist involved they're quite relieved and happy because it's going to go uh going to pick up you know speed much much more quickly thank you that's excellent thank you very much for a fantastic session thank you again to Martin and Marcus for having us and really congratulations on a wonderful preoperative Symposium I'm going to hand it over to Marcus now I think we'll we'll wrap it up a little bit over the time thank you so go ahead Marin so indeed it um brings us to the end of our today's Symposium uh as always there is many thanks um to express first of all to all our and this most of you managed to stay till very end thank you so much uh once again big thanks to organizing and planning committee for all your help advice and time commitment um I think this wouldn't be possible if we are not constantly challenged as bulard mentioned by cardiologist by our surgical colleagues that's a probably one of the strongest stimulations um to keep and and be up to date uh the big thanks to our patients that's where it all starts they subjected to our our Echo examinations and uh and to our learning just want to say thank you to all uh the new collaborators that we have now you know each year we try to reach out to more and more centers in order to establish um both collaboration networks for research for teaching for presentations and you know to have uh a number of new centers that we've never worked with before uh step up to the plate and add to the Symposium was really uh it was really uh something special I think you know you never had speakers from Japan before and uh and and Halifax is a new center for us as well so that's great I just want to make sure that we take the time to thank uh Mark and Fatima from Ardine as well as another thanks for Sarah Russell for all her hard work and putting everything together and uh again all the participation and attendance from the audience has been fantastic the last couple of days has really enriched our Symposium we want to just encourage you to fill out the evaluations uh not only is it useful for us in order to tell us what went well and what didn't go well what you enjoyed and what could have been better but also there's a one of the most valuable things for us is to fill in the part where it asks about topics that you'd want to hear more about in the future that that would that's really valuable for us in order to develop the programming for the next year uh we're looking at around the same time September 2025 so uh we'll keep you up to date with regards to uh those things but uh if you submit the the uh evaluations then we we'll be sure to send out your certificate of attendance in your CME credits uh early uh this week and next and I would like to remind everyone um especially in context of recertification for peroperative Te exam uh it's changed recently there's no reexamination anymore but you need to have certain number of points and this particular Symposium gives you 12 hours which which probably will be helpful okay so thanks everyone and we'll I think we'll wrap it up there enjoy the rest of the weekend and uh really appreciate all your involvement thank you very much a [Music]