Great. Thank you, Sahil. Thanks, Ted and Don and Sahil for setting this up. My goal in the next 10 minutes or so is to review the competency as well as procedural numerical requirements that we identified would be appropriate for structural heart interventions, as well as what is an appropriate training pathway for an individual to get appropriate, not just training, but be able to be adequately prepared for independent practice in their focused area of interest. We did the same exercise that we did for peripheral vascular interventions for the structural heart interventions. What we decided to do, and this is an important differentiator versus some of the other procedures. TAVR alone, we defined as a numerical requirement of 50 TAVR procedures with 25 as primary operator. The definition of a primary operator, by the way, is important. It's relevant here, it's relevant for the peripheral vascular intervention space, and frankly, for all trainees. It's the person who is, as a trainee, performing most of the procedure independently, and of course, would have to be under direct supervision of a faculty member. Half of them, you have to be that primary operator, and you can be someone who is trained in TAVR with 50 TAVR procedures and not be doing any other area of structural heart interventions if that is not your career focus. If on the other hand, you want to work on the left side of the heart for left atrial appendage closure, tear, mitral balloon valvuloplasty, and also PFOASD closures, to get into that space, you need a lifetime minimum foundational experience of 50 structural heart procedures and a minimum of 20 transeptals. The transeptals have to be through an intact septum, and so this becomes a subtle and important differentiator. You can be a TAVR operator and not do any other structural heart interventions, and of course, you would be an interventional cardiologist who is trained in coronary interventions. If you want to do any other structural heart interventions, then you need a foundation of 50 lifetime structural heart procedures. If you're going to work on the left side of the heart, you need to have at least 20 transeptals that you need to be fast out with. Now, again, just like all the other areas where we try to identify minimum procedural numbers, we looked at previous published data. Most of which is various consensus statements. We also looked at what would be the FDA or industry requirement for certain devices, and we wanted to ensure that we took all of those issues and numbers into account to come up with these recommendations. A lot of input went from not only the group that was overseeing the structural heart component of the document, but broadly, the entire group and then, of course, the various reviewing entities. We also wanted to address adult congenital heart disease interventions because there are two pathways to this. There are a lot of, of course, pediatric interventionalists who are in this space, but this is primarily focused on the adult interventional cardiologists who is board certified in interventional cardiology and is also interested, not just in structural heart, but specifically adult congenital heart disease interventions. ASD and PFO, we called out in both tables. But beyond that, you can see the list of various procedures and we wanted to make sure that we came up with minimum definitions or minimum numerical requirements for things like pulmonic valve implantation, treatment of aortic coarctation with stenting, pulmonary vein stenting, and other interventions that have traditionally been done by adult congenital heart disease specialists. This in some ways is probably one of the most important single figure of the document. The goal here, and there's a text that's in the entire document that goes with this particular figure, is to try and get an overview of how long and what type of pathways exist for training in the various areas of interventional cardiology. One important facet is that we want to emphasize to everybody, this is a seven-year training in length. The cognitive knowledge that is required to practice interventional cardiology really starts to be acquired in internal medicine residency, continues in a cardiovascular diseases fellowship, and then in an interventional cardiology fellowship. We did feel that the broad knowledge base for all interventionalists should encompass not just coronary, but peripheral and structural interventions. The indications, the management of those patients longitudinally. But when it comes to specific technical skillset acquisition, it can begin for non-coronary, peripheral and structural within the three-year cardiovascular diseases fellowship, once level 2 competency in diagnostic cardiac catheterization has been achieved. That means six months of training with a minimum of 300 procedures. After that, you can start to acquire initial technical training in peripheral and structural interventions. But those numbers do not count unless you go on to complete an interventional cardiology fellowship during which you might acquire enough numbers for minimum competency. If you don't, then you can have focused additional training. That additional training can be in peripheral or structural interventions or even some complex coronaries depending on your career focus. We did not define a period of time. It doesn't have to be a full year. It could be as short as a month and it could be as long as a year. It all depends on the environment of training that an individual trainee might be in. The other part I should re-emphasize is that any individual interventional procedure only can count as one. We have 200 PCIs as a minimum, 50 additional can be coronary, peripheral, or structural. That's here in the middle of the figure. The coronary physiology and intracoronary imaging procedures are in addition to these. They cannot count as interventions. They are on top of the 250 cardiovascular interventions that we have defined.

structural heart interventions

training pathway

TAVR procedures

left-sided structural heart interventions

adult congenital heart disease interventions