Great. I'm going to start. Thank you so much, guys, for an incredible presentations. I think that it's so nice how they're all intertwined with each other. They all kind of connect. I have a question for the surgeons because there's been a lot of questions about the syntax score and the fact that we downgraded it, the use of it. I would think that it matters more to us as interventional cardiologists than it does to you, particularly because Frank just learned how to calculate it, I guess, the other day. I wouldn't think that it would matter so much, but there have been some discussions among certain communities who have been concerned with the fact that without an objective measure of complexity, it might leave the interventional cardiologist to sort of say, oh, yeah, that looks severe or oh, yeah, that doesn't look severe. Did it bother you in any way? Well, obviously, you were the ones who made the recommendations, but have you heard any concerns from anybody about the lack of objectivity in determining severity because we're not as often using the syntax score as opposed to just saying the components of the lesion warrant a high complexity? Well, our interventional cardiologists rarely actually calculate the syntax score, and you're supposed to have a couple of cardiologists there doing this. We rarely do it. We do rely on them to say, well, this is high risk, left main, tortuosity, you got some total occlusions, left dominant system. They rarely actually calculate the syntax score. I have not heard of any concerns in our hospital, and likewise with surgery, we don't really care about the complexity of lesion. We care more about is there condom available? Are there targets available? And the things that add up to the STS score, liver disease, kidney disease, things like that, we deal with the entire patient, whereas the cardiology, interventional cardiologists can usually get the patient through a PCI even when they're high risk, they have cirrhosis. That's not the case with surgery. So, not infrequently, I will ask our cardiologists what their chances are of getting somebody through a PCI when risks are exceedingly high. But to answer your question, I've not heard any major concerns. I'd be interested to hear what my other surgical colleagues have to say. I have heard that as a concern, but in stating that as a concern, it suggests that our relationship with our colleagues is not a collegial one, and that we need some sort of number to say, oh, well, this is very complex, it should be surgical. And our, at least here, I find that our relationship is quite good. And it's often that the interventionalists will call me and say, I can do this if you really think they're a bad candidate for surgery, but it's going to be really tricky because of, you know, the trifurcation or the bifurcation or the tortuosity, as you said, Frank, or some other complex calcium. And so, it seems, you know, as you said, we don't routinely calculate it, it's kind of cumbersome and takes a while. And we sort of eyeball it and say, well, this would be high syntax. And so, therefore, you know, I think that downgrading it was appropriate. All right. Next question I have is actually... I think Mario might have... Oh, Mario, I'm so sorry. No, no, it's okay. I mean, I agree with what Jennifer has said. I heard the concern, I don't understand the logic of it, of the concern, because first of all, it has been shown that there is a lot of variability in the calculation of the syntax score by different operators. So, I don't think that the syntax score is such a solid, objective measure. There is a large variability depending on who is calculating it. And then we haven't said in the guideline that the complexity of the disease doesn't matter. We actually have said that it does matter, but the syntax score doesn't correlate with the outcome. And so, the fact that we don't have a good metric, it doesn't seem to me a justification to use a bad metric. And I agree. And I think that what Jennifer said and what you're sort of saying is that it's collegial and we're going to say, this is a really complex case that we don't feel is best approach with PCI. And we don't need to calculate a number to say it's 33 or whatever it is. So, the next question I have is, you know, we talk about surgical risk and we talk about factors that make you decide for left main disease, PCI versus CABG. John or Mauricio, do you guys ever sort of incorporate the decision beyond sort of just like, again, beyond the syntax score and sort of think about the things like, will this person need mechanical support and will this support sort of increase the risk of the procedure? Or is it, you know, distal left main is pretty much, or an osteo left main is pretty much a no-brainer. Is there any feature of the anatomy that would make you not really care so much about the syntax score or whatever? I think that, well, I like the case that Frank showed because that patient got five opinions and finally got a very good treatment. But if I've been in that situation, like your interventional cardiologist, where the patient would not have an STS score of one, but it'd be much higher and it would be put upon us as interventionalists to proceed. And the other factors that come into play are whether you need directional or rotational arthrectomy and large, larger guides, for example, just to expedite, facilitate the treatment. Then the other question is whether there are total occlusions that may or may not be crossable. So some of those factors come into play as well. We were not an institution that relied very heavily on supported cases. I mean, in other words, we did not use balloon pumping or impella very frequently. We thought that a 10 or 15 minute intervention was better than the vascular risk. And I think that our approach has been borne out because of some of the reports that I've seen lately about supported PCI. So I couldn't agree more with John. I think there are left, I mean, there are many flavors of left mains and there are many flavors of patients with left main disease. So you have a shaft osteo, you have a bifurcation. In addition to that, you have to consider the extent of coronary disease in the rest of the anatomy and how much you have to work. So a radial, you know, radial axis with six fringe in an osteo left main can be done very quickly in a patient with a preserved ejection fraction. I think it's not about left main or no left main. It's the entire context and the hemodynamics of the patient. So for some reason, many interventionists came to believe that left main equals support, and that would not be more far than the truth. I think that the time of ischemia, the ejection fraction, how much you think you're going to have a patient stressed and with shock waves or prolonged inflations, complexity of stenting. I think that a left main can be done in the cath lab very easily, very quickly. Obviously, after a heart thing discussion and a complete agreement and involvement with the patient. Yeah, I think you make a good point. We're really moving away from mechanical support. We look a lot at the LVEDP. That kind of changes us. One last question, because I think we need to move on, but Jennifer, you had an incredibly beautiful model for the heart team at Johns Hopkins. I guess the question I have is, and maybe it's for other people or maybe it's for you, Jennifer, how do you handle the day-to-day cases? You showed some great weekly meetings, but in actuality, we have a lot of our non-STL elevation MI patients coming in and can't really wait till the end of the week to have that discussion. So is there any sort of more formal plan besides just calling them up and saying, hey, what do you think? That's a great question, Jacqueline. I wish we had a more formal plan, but we have a 24 hours a day phone call where we can all get on for a patient that's in shock. It's the shock team and they call the same people on the phone. But for the day-to-day, if it's not near the day of that meeting, for example, I saw a patient two days ago and the patient really wants PCI, even though CABG is probably more appropriate. And so I told them the risks and benefits. And then unfortunately, the interventionist couldn't come by until today. And so we weren't all together in the discussion, but at least we each gave an opinion. So I don't know how you could do it every single day or 24 seven. Maybe other people have been able to accomplish that. We had a heart team that was established in 1989 in Ocala, Florida. Our group, our private group consisted of cardiac surgeons, cardiac anesthesiologists, and interventional cardiologists. We were all in the same group, all had the same administration. The operating rooms are right next to the four cath labs. And we were all good friends. It's like the Johns Hopkins. We were approach. We were very collegial. It was just wonderful. So we could get real time consults, left main on the table, multi-vessel disease, you know, surgeons 50 feet away between cases, come over, take a look, families here, meet the family. Families are watching the case from beginning to end. They watched the entire PCI. I just can't imagine a smoother system with the patient at the center. We have two cath conferences a week, but most of the decisions, uh, taking the heart team approach are done on an ad hoc basis. We frequently get calls from the cath lab, Frank, can you look at this film? What do you think? So, well, you know, I think you need surgery, uh, or I think it'd be high risk PCI. Uh, it has done immediately. Um, if it has to be and otherwise later in the day, um, if it can wait, but you know, it's done on an ad hoc basis. As a surgeons and interventionalists, do you guys think that it's okay to do a left main ad hoc? Um, our cardiologists tend to refer left mains to, uh, to surgery, especially if they're, uh, they're diabetic or, uh, have a reduced ejection fraction or have concomitant other disease. Um, you know, if we think they're very high risk for surgery, uh, they will do them, sometimes begrudgingly. Uh, we again also have a very good relationship with our interventional cardiologists, but most of the left mains are referred to surgery, unless there's some compelling reason why they were very high risk. All right. Thanks. That's great. Those are great. It sounds to me like we're, I think we're doing the same thing at our hospital. Um, as everybody here has mentioned, we have one question from the audience from Dr. Ahmed and, um, you know, and I think it's an interesting one and I hope we have time to just answer this because I think everybody's wanting to know what to do. It doesn't have to do with our guidelines because we stood free of this in our guidelines because, uh, we didn't have enough information on PCI and LV dysfunction, but, um, how would you treat complex CAD with LV dysfunction in somebody who's asymptomatic? So anybody, please open up the question. Well, I think that patient population probably has the most benefit. Somebody has severe coronary disease with reduced ejection fraction, even if they have silent ischemia or stable angiognaths, the people that have normal ejection fraction and three vessel disease, I think the controversy arises. So unless it's really abysmal, uh, we will go ahead and do bypass surgery, unless there's some compelling reason why they can't have surgery, then we'll have a PCI. So that's the question. You know, it, it, we, we, it goes without saying it's a class one for surgery if you can do it, but now they're, and they used to feed back to us and say, well, we can't do it. They're too high risk. And then we do the PCI Mauricio or John, what are you doing now? When those surgeons come back and say they're too high risk, are you going to now do the PCI or are you going to wait and see if they have symptoms? And we saw the, the ESC just sent the revived trial with PCI for, uh, LZ dysfunction, which didn't, which failed to show benefits compared to optometrical therapy at three and a half years. Exactly. In view of the revived trial, what are we doing? So I think we have to think again, we have to look at the lesions. We have to see, we have to look at the patient. We have to, um, uh, understand whether or not there is ischemia. I think that if there is ischemia, uh, it's valid to do it. If, uh, we haven't tested for ischemia, maybe not do it. I think we have, uh, we'll have to internalize all these results and start thinking about, uh, how we're going to, to do these patients. Have you changed, uh, John? No, but I was thinking about the logic that we, uh, that I expressed earlier. I don't think it applies here. You know, if, if surgery is good for patients with multivessel disease and, and left ventricular dysfunction, um, is, is stenting as good as surgery in this setting. I think there's very little evidence that that's the case. Um, investigators have looked for improvement in left ventricular function and improvement in survival in patients undergoing PCI ever since the advent of this type of therapy, and it's been hard to prove. So I'm not sure it applies to, you know, and, and automatically translates as a survival advantage for such patients. And intervening on asymptomatic patients. I know surgeons don't like operating on asymptomatic patients, except when they have severe LV dysfunction. Um, and we feel the same way in cardiology, I think. John, do you have anything to add? No, I think, uh, I, I agree. I mean, I guess I agree that we have not been able to prove that, uh, PCI for revastilization, uh, is, is going to benefit. We may just be failing to be able to prove it, but until we can, I think we probably have to, uh, be very selective, uh, maybe apply, uh, as Mauricio said, more stringent, uh, ischemia testing before, and to make sure this is ischemic cardiomyopathy, uh, and maybe see if we can dig further into, um, uh, viability testing beforehand. But Jacqueline, just to add that there is a ongoing randomized trial that is testing PCI versus scab in patients with left ventricular dysfunction. It's called STITCH3. It's a multinational effort. So hopefully in some year we will have more data. Yeah, and I would think then the population is going to be very STITCH-like. So if they can get surgery, there's certainly somebody with good, good, you know, distal targets and somebody who would potentially benefit from revast, so maybe we'll see what that information shows. That'll be great. All right, I think I'm going to pass this over to JP or Mauricio to take over for the next half. Thank you so much, guys.

syntax score

coronary artery disease

collaborative approach

left main disease

clinical trials