Terrific. Thank you so much, Ted, for setting that stage and giving a little background on how we really arrived at our decision for these building blocks and the coronary intervention numbers. So as everybody knows, in the prior training statement document, there was a requirement for 250 procedures. With the recognition that procedural complexity has increased over the years and that there are more reliance on invasive diagnostic tools, the committee increased the overall procedural numbers to 300, but also recognizing that there's a lot of diversity in training programs and the subspecialties which they train fellows in, such as endovascular and structural interventions, there's a recognition that a lot of the knowledge and technical skills for these types of procedures overlap. So for overall interventional procedures, we kept the number the same, 250, because in the last 20 plus years of training programs and COCATs, this has produced highly competent operators with very good outcomes. We've given a little more flexibility. So when you see under the 250 interventional procedures, that includes a minimum of 200 percutaneous coronary interventions. In the past, there was a requirement of 250 percutaneous interventions and additional procedures that the fellows performed during that year were not counted towards competency. So with the recognition of the diversity in training programs, we've acknowledged that some of the procedural experience for the 250 can come from non-coronary interventions. So up to 50 of these procedures can include any combination of coronary peripheral arterial or structural heart interventions. So among training programs that are focused solely on coronary interventions, the 250 standard, which was previously held, would be maintained, but in programs that are training in more diverse types of procedures, there is some leeway in reaching that 250 numbers. Again, when we go down into the required subsets of types of interventions, you'll see that we did reduce the minimum number of overall coronary interventions to 200, but that still includes a broad range of types of patients, including clinical presentations, pathologies, and different anatomic subsets. And we recognize that there are a lot of anatomic subsets that require special expertise in procedural techniques. We do understand that at a procedural number of 2 to 250, that we're not going to be able to provide a comprehensive level of training to perform all types of high-risk PCI independently, but we understand that the fellows should gain competency in the knowledge, indication, procedural risks of these types of subspecialties and understand their ability to perform these. This year, in the training statement document, we've also added invasive diagnostic procedures. There was always a question in the past of whether these types of procedures could be counted towards the 250 interventions, which was not allowed in the previous document. So, experience in these invasive diagnostics was not at all tracked or counted in the previous statements. We've made an effort to emphasize the importance of both coronary physiology and intercoronary imaging as necessary training requirements for our fellows. We came about the numbers of 25 each for the hands-on procedural experience with both coronary physiology, such as fractional flow reserve and non-hyperemic pressure measurements, as well as intercoronary imaging, depending on the center's expertise, which could include intercoronary ultrasound, OCT, or both. The reason these numbers are not higher stems from a few facts, one of which is that in our national registry of the NCDR, which includes over a thousand institutions, the current numbers suggest that about 10 percent of procedures are performed with these adjunctive technologies, and so it is a very achievable goal. It is no way meant to intend that it is the end-all be-all with training, and certainly this is just for the technical performance of these, and additional training is always encouraged. What you'll see is that you may have recognized the absence of procedural numbers for certain very important skills that an interventional fellow must obtain by the end of the year. We've framed these as necessary building blocks for our profession. These are skills which are difficult to place a procedural number on because they may occur extremely infrequently, and learning methods may include other modalities than hands-on procedural experience, but if you go to the chart here, you'll see that the building blocks for our profession and the core expectations for fellows are broken down by the different subspecialties which they are trying to obtain competency in, and for coronary intervention, of course, catheter skills are our foremost goal of training, and you can see the range of types of lesions that we are speaking about. There's definitely a heavy emphasis on access site and closure, which should include multiple access sites, including radial and all forms of extremity access, and also large-bore access and closure and use of ultrasound. In terms of procedural complications, the hope is that these are uncommonly seen, but every fellow must have some experience with complication management and prevention, and we emphasize a list of important skills that each fellow must obtain by the completion of fellowship, and you can see these listed there. Additionally, as the complexity of PCI has grown over the decades, artherectomy and plaque modification is extremely important, so we recognize that skills for plaque modification are a requirement, and these may include use of rotational or orbital artherectomy, intravascular lithotripsy, or eczema or laser. Again, not every center may carry all of these modalities, but it is important for a fellow to gain an understanding of each of these, and lastly, mechanical circulatory support, which has become so important in the era of high-risk PCI and shock management. Each fellow must be well-skilled and versed in that, and of course then we have additional skills that are under the peripheral vascular and structural heart intervention core competencies, which you can read here and some of which will be touched on by my co-document writers. So let's move on, and we can go now to the other sections. Dr. Parikh.

committee decision

procedural complexity

coronary intervention numbers

training programs

adjunctive technologies