Talking Tall Rounds: 100 Years of Heart, Vascular & Thoracic Care

Podcast Transcript

Announcer:

Welcome to the Talking Tall Rounds series brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Lars Svensson, MD, PhD:

Well, good morning, and welcome to this, I think, very interesting session celebrating 100 years of Cleveland Clinic, and particularly the contributions of the heart, vascular and thoracic surgery sections, and our team to the advancements of cardiovascular disease over the last 100 years.

Lars Svensson, MD, PhD:

You're going to hear a lot of exciting stuff. Some of you will know the history, obviously, of Sones in the first catheterization and Favaloro and his contributions to coronary artery bypass surgery, but many of you may not know that the first on-pump stopped heart with cardioplegia was done in 1956 by Effler and Groves. And you'll hear other presentations that will highlight other things that Cleveland Clinic pioneered in cardiovascular and thoracic disease. You're going to hear about the pioneering work, for example, on mitral valve clips, which was first done by Pat Whitlow. You'll also hear about the endovascular pioneers and just general vascular surgery pioneers we've had here, the privilege of working with at the Cleveland Clinic. So we've all had wonderful mentors, and we are going to have the superstars who are currently with us presenting on the history and some ideas of what we may look forward to.

Samir Kapadia, MD:

I'm going to talk about the coronary angiography discovery and interventional advancements in Cleveland Clinic. So, this is the historical day in cardiology, August 30, 1958. That is Mason Sones standing below, and he's injecting dye in the aortic root. And the catheter falls into the right coronary artery, and there is a beautiful picture of the right coronary artery. Patient does well, and that is the beginning of selective coronary angiography. Just for fun, we reproduced that when we are doing TAVR. See our catheter jumped into the vein graft of the right coronary artery in an 88-year-old patient, so this was 26-year-old patient 50 years later, and same, patient did fine. So this is just the beginning of the observation, where selective angiography started.

Samir Kapadia, MD:

If you look at this from 1960 to '70s, the selective angiography led to many different kinds of surgical innovations, similar to what Dr. Bakaeen just pointed out. So Weinberg operation was in 1966, and then interposition graft by Favaloro, and then the bypass surgery in 1967. So this was mainly the advancement in surgery with select angiography.

Samir Kapadia, MD:

I have a few memories shared by Dr. Simpfendorfer. This is the ashtray of Dr. Mason Sones. He used to keep this ashtray in the cath lab. This is a picture of Dr. Simpfendorfer with Dr. Sones, and the four legends for our cath lab, so Dr. Heupler, who was the Cath Lab Director after Dr. Sones, Dr. Shirey, Dr. Proudfit and Dr. Sheldon, who was the Chairman of Cardiology. This is a very useful group of people who started many different things in Cleveland Clinic.

Samir Kapadia, MD:

So if I had to list the accomplishment in 1980s. '77, Gruentzig performed the first angioplasty, then Philips in 1978, performed the first Swan-Ganz catheter in Cleveland Clinic. Then Dr. Phillips and Dr. Heupler went to Zurich in 1980 to learn angioplasty in two days. So they learned the angioplasty in two days, and they performed the first angioplasty in Cleveland Clinic in 1981. This was followed by Dr. Simpfendorfer and Dr. Franko doing angioplasties at that time.

Samir Kapadia, MD:

Dr. Holman was recruited from Emory, and he popularized... He was the fellow of Dr. Gruentzig, and then Dr. Pat Whitlow came from UAB, and he started the biliary stents in coronary arteries in late 1980s, exactly in '87. And Dr. Whitlow and Dr. Groar were the first people to start peripheral angioplasty in the cath lab. And Dr. Dan Phillips and Dr. Heupler did the first aortic valvuloplasty in 1984, and that was successful. Patient walked out of the hospital when the patient was actually in a balloon pump and very sick at the time of doing this valvuloplasty.

Samir Kapadia, MD:

1985 was a historical year for the intervention cardiology, because four giants, Dr. Judkins, Dotter, Sones and Gruentzig all passed away in that year. In 1990, we saw many different devices. And so the first coronary stent was performed by Dr. Ellis and Dr. Topol in '93. That was the dedicated coronary stent, the Palmaz Schatz stent. Directional atherectomy and rotablators were introduced in 1990 by Dr. Pat Whitlow and Franko in Cleveland Clinic. Laser was also introduced in early 1990 by the same people.

Samir Kapadia, MD:

Coronary stent was performed by Dr. Jay Yadav in Cleveland Clinic as the first thing, and he was the pioneer in having embolic protection devices. He invented Angioguard and then commercialized Angioguard. And this was also a major advancement in coronary intervention and peripheral intervention.

Samir Kapadia, MD:

2000, we saw several different things, and this included the PFO closure in the cath lab. Believe it or not, this was in that timeframe. Myself, Dr. Tuzcu, Larry Latson were involved in this initial expedition, and then the left atrial appendage closure was also in 2004. Again, Dr. Tuzcu and I were involved. MitraClips was 2004, where Dr. Patrick Whitlow... in the picture there, you can see Dr. Whitlow, and Dr. Rodriguez there.

Samir Kapadia, MD:

So these are the... They did the first MitraClip in Venezuela. This is a picture from Venezuela. But he did the first MitraClip also in Cleveland Clinic, and then first TAVR was in 2006 with Dr. Svensson and Dr. Tuzcu, and the Tandem Heart, the percutaneous support devices, became available in 2005, which we started here, and then Impella became available in 2009.

Samir Kapadia, MD:

The first TAVR team, as you can see, Dr. Svensson, Dr. Whitlow, Dr. John Webb came, Dr. Tuzcu, myself, Leonardo Rodriguez, and our fellow Dr. Ghopal, and Dr. Lee as our anesthesiologist, all were there in the... And there are several nurses, and our research coordinators.

Samir Kapadia, MD:

2010, or in that decade, we saw the first transcatheter mitral valve placement by Dr. Gillinov, Dr. Mick, Svensson, myself, Tuzcu, and Krishnaswamy, and then we did the first tricuspid valve replacement. This was the first ever in the world, with Dr. Navia, Dr. Krishnaswamy, and Dr. Harb. And then the robotic PCI was started in 2019 in Cleveland Clinic, and the first commercial Sentinel device, which was the embolic protection device, to prevent the stroke at the time of TAVR was also initiated in Cleveland Clinic in 2017.

Samir Kapadia, MD:

This is the picture with Dr. Navia, myself and Dr. Svensson, and Dr. Krishnaswamy doing the first percutaneous tricuspid replacement. And the first percutaneous mitral valve replacement, and this is with Dr. Marc Gillinov, Dr. Svensson, Tuzcu, Mick, myself, doing the first percutaneous mitral valve replacement in 2016.

Samir Kapadia, MD:

I want to say that this is... Just the first is not important. We need to grow. We to create large programs and team efforts. And this is just to say that this is after several years, when Dr. Tuzcu was leaving, this is our team of people who are very involved in making TAVR collaboration and growth a reality. Again, thank you very much for this opportunity to share this incredible journey of multiple innovations in cardiovascular interventions. Thank you.

Faisal Bakaeen, MD:

The CABG revolution and evolution occurred here at the clinic, and heralded the industrial phase of cardiac surgery. As you heard from Dr. Kapadia, the first CABG was performed in 1967, and this publication in 1970 in JAMA by Drs. Favaloro and Sones established CABG as a safe and effective treatment for coronary artery disease. Let's hear it from Dr. Favaloro in his own words, reflecting on those early days.

Dr. Rene Favaloro:

That was a teamwork. Was not my work, was the work of the surgical team, was the work of the clinical team. No question that I developed some precise idea in particular areas to develop coronary bypass, but it's not my contribution. It's not a single contribution. The individualistic approach is not the solution. The medical profession is also not the solution in our society. We have to think about that working together is the best approach. And that was the approach at the Cleveland Clinic.

Faisal Bakaeen, MD:

Very wise words from the father, the humble father, of CABG. As you can see, Dr. Favaloro and the Clinic got it right many years ahead of everybody else. The importance of collaboration, teamwork, alignment of specialties around patient conditions for the benefit of the patients. So the current institute and umbrella models champion by Dr. Svensson, Dr. Roselli, are natural to us. They're in our genetic code.

Faisal Bakaeen, MD:

The next advancement in CABG was in 1986, with this famous publication in the New England Journal of Medicine by Dr. Loop and associates demonstrating the superiority of ITA-bypassed LAD, better graft patency, and better patient survival.

Faisal Bakaeen, MD:

Dr. Lytle later showed us that using two ITAs added an incremental survival advantage to CABG, and recent work at the Clinic emphasized two important concepts with significant practical implications, and that is, use the second ITA to bypass important coronary targets, because there's a dose-response relationship between the myocardial mass supplied by ITAs and patient survival.

Faisal Bakaeen, MD:

The second is, the configuration of the ITA in beta grafting had no impact on graft patency. Therefore, the goal in beta grafting should be to maximize the reach of the ITAs to reach all important targets.

Faisal Bakaeen, MD:

In addition to pioneering multi-arterial grafting, the Clinic harnesses new technologic advances in CABG. For example, using temporary mechanical assist devices to optimize patients in the preoperative period. For example, using the Impella device to safely perform CABG in patients with low EF and heart failure. And this is a fruit of collaboration between cardiology, heart failure and cardiac surgery under the leadership of Drs. Soltesz, Tong and Estep. The outcomes have been excellent.

Faisal Bakaeen, MD:

What we do at the Clinic drives the clinical trials and informs the guidelines. Indeed, we set the benchmarks, and what we do here today at the Clinic is a sneak preview of what surgery looks like in the future elsewhere. CABG constitutes a third of what we do in cardiac surgery. The outcomes have been excellent. The mortality has been consistently less than 1% throughout the years for isolated CABG, even in redo CABG. And current cutting-edge work is investigating the use of multi-arterial grafting and redo CABG. Think about this. Redo CABG is technically complex. Multi-arterial grafting is a technical feat. Surgeons at the Clinic, with their expertise and their skill, are able to combine both of them for the benefit of their patients.

Faisal Bakaeen, MD:

Less invasive procedures are offered selectively and when appropriate, and we never compromise patient safety or the effectiveness of the procedure. As Dr. Svensson reminds us, quality is untouchable. We believe that quality and innovation run hand in hand, and they complement each other. We use cutting edge imaging to verify the patency of grafts in the OR and before patient discharge. No patient leaves the hospital or the OR with a graft down.

Faisal Bakaeen, MD:

In summary, CABG started at the Clinic, CABG evolved and will continue to evolve at the Clinic. CABG is now a niche practice, and surgeon experience and skill is critical for excellent short and long-term outcomes. In conclusion, our collaboration, our teamwork, our excellent leadership, our care and compassion for our patients and each other is what sets us apart. And that is why I'm confident that the Clinic would lead in coronary care for the next 100 years. Thank you very much.

Eric Roselli, MD:

I'm going to focus on innovations in aortic surgery. Disclosures are shown here. You can see that more than one fifth of the operations that we do involve the thoracic aorta now. In our department, it's become a really dominant part of what we do, and that's occurred over the last quarter of our existence. You can see in 2001, when Dr. Svensson arrived here, he really helped to build this aorta program. We are now clearly the largest aorta program in the country, and have been for several years. And you can see by the multicolored bars that the types of operations we do has changed over time as well.

Eric Roselli, MD:

And as we've heard over and over again, that innovation is not only part of our mission, it's really helps to define who we are in this place. We heard about how cardiovascular surgery, and medicine really developed here with Drs. Favaloro and Sones, and I had the real distinct pleasure of having good timing to learn to a lot of these new techniques from Roy Greenberg, who was a great pioneer, who was with us for many years and is no longer with us physically, but with us all the time in the operating room.

Eric Roselli, MD:

One of the things about the aorta is the more segments that are involved with disease and the more complexity of the disease, the more it provides some unique challenges, and we've developed many innovations around how to handle this. I'm just going to talk about several of these, but one of them, if we really step back, is the way that we've developed this multidisciplinary disease management plan, which requires all the disciplines around it. Our Cardiology team, Imaging and Clinical team has really been critical in helping to build this program.

Eric Roselli, MD:

The Critical Care team in J31, what used to be a coronary ICU, is now really a cardio aortic and cardiovascular triage unit. They've done an amazing job helping us take care of these patients, and our image team and follow up has helped to build this, as well as our clinical genetics and so many other caregivers. Some of the things that have really been innovative, again, in the way we care for these patients, is the way we think about how to operate on them and when to operate on them. Dr. Svensson, what has been commonly referred to as Svensson Index, even though he doesn't call it that, we all do, and even people from other institutions do, was validated by work from Dr. Desai and the group in Cardiology. We've used machine learning techniques to... And with the help of Dr. Blackstone and his team, also to better understand diseases like bicuspid aortic valve aortopathy.

Eric Roselli, MD:

But really, the heart of what we do for aortic surgery is operate. And I'm going to start with talking about the aortic root. These are just some of the operations that we do. The ones on the left are pretty common everywhere else. The ones on the right are common here. Aortic valve root replacement and aortic root replacement, aortic valve repair using this modified reimplantation technique, is not only great for this root pathology, but has become commonplace around here so that we can save many of these valves that we see. We've also not only performed these valve-preserving root replacement operations for people with connective tissue disorder, but we've developed ways to save bicuspid aortic valves using similar modifications of this technique. And you can see that this part of our program has grown really rapidly in the last decade and a half. I don't have the numbers for 2020 on this slide, but it's maintained at about 120 operations per year.

Eric Roselli, MD:

We've also applied some of the things we learned from Dr. Cosgrove and how we can become less invasive with aortic valve surgery to aortic surgery. And this is a slide that's really most remarkable. Dr. Lytle published a paper about 20 years ago. He was really instrumental in helping us to build our thoracic aortic program, and he and Dr. Cosgrove helped to bring Dr. Svensson here to take it to the next level. But he had published a paper that talked about a mortality rate of around 10% to 13% for aortic surgery. Now you can see it's less than 1% for our elective operations. And when you come to the Cleveland Clinic, your mortality, it's a quarter of what it is at comparable university health systems.

Eric Roselli, MD:

It's really amazing, and it's a testament to the teamwork. We've developed new techniques for replacing the aortic arch. This is a technique that was developed here, this branched stented anastomosis frozen elephant trunk, and now in its various iterations, it's going to be studied in a physician-sponsored IDE regulated by the FDA. And you can see that 90% of the arch replacements we do are with these frozen elephant trunk techniques. And it was 130 of them in 2020, which is just a massive amount of aortic arch replacement surgery. And all of this clinical work has led to the development of new technology with our Innovations Institute. We've got patents on this device, and we're going to see this hopefully become commercially available in the next few years.

Eric Roselli, MD:

We've also been leaders in the use of endovascular technology for treating the aortic arch. These are just some of the industry devices that are in investigation, and we're leading many these investigations in our Institute. And a lot of these branch devices are based on the pioneering work of Roy Greenberg. We're going to hear more about that from Dr. Lyden at the end of today's discussion, but his work, which went on for over a decade, actually stimulated many of the industry partners and competitors to develop their own devices, and we can see many of these are currently investigational to treat the branch segments of the aorta. But when we treat our patients with complex disease, we really need to tailor what we do for them, understanding all the benefits and limitations of what we can provide in our own limitations.

Eric Roselli, MD:

One of the things that we learned and we've studied, and this was also with our team from the critical care unit, was that there was an unmet need for treating patients with dissections of the ascending aorta. We defined this group of patients, you can see that pie chart on the right and realize that some of these patients probably, if we had a better option, might be treatable. And we redefined what this treatment zone is as we studied what we were doing with the off-label use of stent grafts in the, ascending aorta.

Eric Roselli, MD:

And now we've led as the highest enrollers in this early feasibility study with an industry-sponsored, site-specific design for the ascending aorta, and we'll be leading the pivotal trial, which will be beginning hopefully in the next year. And so with this new technology, you can see our treatment paradigm for our type-A dissection has changed a lot. It's no longer just, "Do we operate or do we send them to hospice?" Now we think about stent grafting. We think about hybrid approaches for more extended repairs. You can see that video spinning around the left was a 91-year-old patient who had a dissection on the table during a TAVR procedure.

Eric Roselli, MD:

Our team came in, worked alongside with the interventional cardiologist, and this guy is doing fantastic after what was a really potentially horrible complication. What's next in this space? The Endo-Bentall, maybe. Well, Dr. Svensson and Dr. Greenberg thought about this a long time ago in this innovation spirit that we have here. And just this year, we saw this procedure was actually done for the first time in a human down in Brazil. They had an outstanding result, a very interesting case, and we'll see much more growth. But again, going back to how we innovate at every level, when it comes to acute aortic syndromes, we've developed these networks with Paul Schoenhagen, the imaging team and the critical care transport and ICU teams. We can get our excellent high-quality emergency care to patients within a much broader radius, a couple hundred miles, the reach of our helicopters and transport teams, to get patients here so they can all benefit from it.

Eric Roselli, MD:

And then in the chronic phases, we've also had many innovations. You can see just some of the several techniques we use to handle these more complex, late complications of people who survive these dissection problems later on down the road. We've led the way in this therapy, working together with vascular and cardiac surgery and anesthesia teams. We've also seen a growth in these rescue operations where we extend open repairs after previous endovascular repairs. We're going to hear from Dr. Lyden, again, how this technology has really come together full circle.

Eric Roselli, MD:

We also have expanded working with our pediatrics team on providing complex repairs for a congenital disease that we see, often late stage, in adult patients, and stepping back and working across the street with our basic science partners in the Lerner Research Institute. We've also really made some great headway, both in discovery and in understanding of what's happening in this disease process at multiple levels, looking at it from the mechanics of what happens in the aorta, which will help us to develop new devices, and looking at the details of what's happening in the aorta, so we can improve not only our understanding the disease, but hopefully future therapeutics.

Eric Roselli, MD:

And, as I stand in here delivering a Tall Rounds, I think it's important to note that these came from what were our aortic meetings. We had these slots on Wednesdays and decided we could do a better job of bringing a multidisciplinary team together, and that's what we're doing with improving the way we educate people. This fall, we're going to have our next comprehensive, lifelong and expeditious care of the aorta, the CLE Aorta meeting. Look forward to seeing you all there and talking more about all the great advances we have. Thank you very much for this opportunity to talk today.

Sean Lyden, MD:

When thinking back through the 100 years of vascular surgery, we've certainly also gone undergo a lot of change. If you look at the last a hundred years, era one would sort of be antiquity and reparative surgery. Era two is when we started having really growth of open surgery. Era three is endovascular surgery, and I think we're now starting to enter era four, which is balance. So if we look at how we started, it was really ligation of aneurysms, learning at do arterial anastomosis, repairing torn arteries and sympathectomy, and really, that brought us all the way through the fifties. If we look at really when things started to development, it was right around then with the development of low-extremity bypass in 1948, the first description of an aneurysm repair in 1951, and then carotid surgery by Dr. Eastscott, Pickering and Rob in 1954.

Sean Lyden, MD:

War actually has had a dynamic impact on the development of vascular surgery because of the need to repair soldiers, and World War I is when we really started experiencing direct arterial repair. Dr. DeBakey and Simeone championing arterial repair then in World War II, but the development of MASH units in the Korean war, the vascular Vietnam registry, which really helped understand how patients did, and then the development, the most recent conflict in the Middle East, with Forward Artery Surgical Teams, where we bring actually repairs to the field.

Sean Lyden, MD:

If we talk about our department, Al Humphries began the Department of Vascular Surgery, and he actually created the first allograft bank in the entire world. And so they had the ability to actually treat arterial aneurysm disease before there were surgical grafts. Dr. Beven then overtook the department, really saw an open case explosion, really treating all facets of arterial disease both with bypass and aneurysm disease.

Sean Lyden, MD:

One of the most important papers in the history of vascular surgery was by Dr. Hertzer, which was done in conjunction with both the cardiac surgeons and the cardiologists looking at classification of a thousand coronary angiograms and patients really defining the risk factors of vascular disease in our patients and those that need repair.

Sean Lyden, MD:

Our department was then taken over by Dr. Ouriel, who both grew us into a regional practice, worked with Jay Yadav and leadership for development of carotid stenting, and really recruited myself and many others to really grow our endovascular capabilities, and then Dr. Clair, who challenged us to improve our quality. So if we look at the endovascular explosion, when Dr. Ouriel came, Dr. Clair had just gotten here, but Dr. Ouriel came and recruited Drs. Sarac and Greenberg, the following year, Dr. Srivastava, myself the next year, and Dr. Eagleton, so there was this little Rochesterian component. Dr. Ouriel came from Rochester, and all of a sudden five of us came from Rochester. I remember when I was looking for a job, Dr. Ouriel said I couldn't recruit anybody else from Rochester, and being from right down the street in Youngstown, I was quite disappointed, but fortunately, I decided to change his mind, and I got here instead.

Sean Lyden, MD:

With that, we really took off. And I know Eric showed you really the 20 years following, but really, the growth of minimally invasive repair took off when he brought a bunch of us in, as this was just starting to develop in our specialty. Vascular surgery only did open operations through the '90s, and with some important advancements, we really started taking off first in the aortic world, and then in every space we can with minimally invasive approaches. As we started to adopt endovascular therapy, it was with clot-dissolving therapies, with thrombolysis, with minimally invasive aneurysm repair, with the development of carotid stenting, with aortic stenting and paper showing equivalent outcomes from open surgery to stenting of the aortic segment, and then really going down the leg. First, the femoral segment, the popliteal segment, using both angioplasty, atherectomy, and stent, and then going up the aorta, the thoracic aneurysm repair, and then once again, below the knee into tibial angioplasties.

Sean Lyden, MD:

If we look at how endovascular surgery developed, the first peripheral angioplasty was done by Charles Dotter in 1964, but really, where it took off for vascular surgeons was Juan Parodi, who trained here at the Cleveland Clinic, was the first person to describe a minimally invasive approach to aneurysm repair. Instead of a 10 to 14 day hospital stay, the patient was done with small cutdowns in the groin and went home in two days. Tim Sullivan was the first to bring endovascular to our department. He had went out to learn it and really brought it to the Cleveland Clinic, but it really took off under the guise of Dr. Ouriel, and his first partnership was with the division of cardiology and national leadership of carotid stent trials with Jay Yadav. I'm going to talk about Dr. Greenberg in a minute, but he helped innovate many of the things that we do standard today, and things that are still undergoing trials to try and get them availed to us. And then really, Dr. Clair pushing us to say, "If we can do it minimally invasive, why not try?"

Sean Lyden, MD:

Dr. Greenberg was my medical school roommate, and dear friend, but he brought the Cleveland Clinic both physician-sponsored IDEs. And under his guise, we actually had seven. We first started with complex endovascular repairs when no one else had availability of that. We then started in thoracic repairs, and had an aortic catastrophe for type B aortic dissections, ruptured thoracic aneurysms and traumatic rupture. We did the first fenestrated repair in the United States here in 2001. We did the first branch repair in 2002, and the first iliac branch in 2002. We then went on to start doing ascending arch repairs in conjunction with the cardiac surgery team, and there's a long list of world leaders that have come out of development of the program from the Cleveland Clinic.

Sean Lyden, MD:

He also looked at what was being done in C5, and developed a Vascular Core Lab, and we now lead many trials in terms of imaging for the Vascular Core Lab. So what would've been the trends from 2015 to 2020. We really saw the growth in our department of regional physicians, comfortable with endovascular therapy, but in the United States, when this came about, we saw the loss of open skills and volume, and less open experience of graduates outside of our program, and really starting to see increased referrals of endovascular salvage, and patients that had failed endo that need open surgery. So we've then looked at our results and we've just recently published our results, and patients that would otherwise be considered high-risk failed carotid sense or other things, and our outcomes of open surgery and high-risk patients being equivalent to minimally invasive approaches at other places.

Sean Lyden, MD:

We've also looked at our treatments of visceral and renal aneurysms, and found we have both open and endo approaches. And so I think we're sure now starting to enter a period of balance. With the increase of placing minimally invasive devices, unfortunately with that, some people don't do them as they should be used, and we've seen failures, and we've defined, really, the natural history of conversion and removal of aortic stent grafts, as well as the ability to partially save aortic stent grafts. And as Dr. Roselli showed earlier, really now, the growth in the thoracoabdominal segment, where we do a lot of hybrid explants and hybrid procedures to save patients.

Sean Lyden, MD:

I think the last thing I'm most proud of is that we've continued you to maintain that open volume, and we've shown here that at our regional aortic center, you can actually teach people to do both open and endovascular surgery, because we are both surgeons and interventionalists, and that's unique to our program here at the Cleveland Clinic. So in conclusions, vascular surgeries continue to evolve over the last 75 years. The evolution will continue, and the clinic has helped define this evolution and leads the way. Thank you.

Lars Svensson, MD, PhD:

Thank you for joining us this morning. I hope you found it interesting, and you're welcome to contact any of the speakers, and contact my office, or Katie Breznai, who has been involved together with Brian Kohlbacher in putting this excellent series to together, and enjoy your time for the rest of the day.

Announcer:

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