Kearney's Coronaries

In this episode we sit down with Kate Kearney, MD an interventional cardiologist with a specialization in high risk coronary artery treatments.  This specialization is a fellowship training pathway at UW Medicine Heart Institute called a CHIP fellowship, in which Dr. Kearney thrived in 2018 and now teaches.  She is also focused on SCAD (Spontaneous Coronary Artery Dissection) as well as the diagnosis and treatment of women's coronary artery disease.

1:34 - Background
3:15 - Choosing Intervention
4:40 - Unique Make-up of Fellowship
6:00 - Specialization within Interventional Cardiology
9:10 - The draw to Chronic Total Occlusions
10:45 - Impact of Work
13:00 - Benefits of academic team culture - shout out Cath Lab team
14:00 - Better every year
16:10 - CHIP * Complex High-Risk Indicated PCI.
17:35 - Collaboration between surgeons and interventionalists
19:25 - Hybrid Coronary Interventions
24:35 - Devices in Circulatory Support + Stenting
30:10 - Coronary and other device evolution
32:40 - STAR (Subintimal tracking and reentry)
37:10 - The MONGO Story - To be discussed in a future episode
37:30 - A growth mindset
40:15 - SCAD (Spontaneous Coronary Artery Dissection)
45:32 - Women + Chest Pain
52:28 - Teaching the Mindset
54:50 - Past-Fellow Shout Out
58:50 - Work-Life Balance (Boundaries)

Contact Dr. Kearney - kek35@uw.edu
Fellowship Program
22:50 - Dr. Kirkpatrick Grand Rounds - Cardioethics of Heart Procurement after Cardiac Death

Transcript

0:00

This is coffee and cardiology. In this podcast, we sit down with the faculty from the university of Washington division of cardiology to discuss the very latest in diagnostics therapeutics. And as a special bonus we ask what makes our cardiologist tick? Do you remember how to do this? I think I remember it's been a while, but I want to personally welcome John Michael, back to the microphone after being off for a while. Thank you, John Michael, you've been busy. It's been exciting. A new new baby girl in the world. So very exciting. Marygold mayor. I like that name. Thank you. Yes, always, you know, sleep. it's, it's hard for me to, to state any, you know, lack of sleep working around surgeons and interventionalists <laugh>, but I'm always, I always try and keep myself humble on that level, but it's, it's really good to be back. Well, it's great to have you back and your enthusiasm was much missed over that time, but now we can ramp up again. We're so glad to be able to do that. And speaking of interventionalists, who sometimes don't get enough sleep, we have been waiting actually a while to get Kate Carney on this podcast and scheduling hadn't worked out until now, but I can't think of anyone better to have in your first podcast, back to the microphone than Kate. She has been a stalwart here at the university of Uh, but Kate, tell us where you come from and where you did your training and, and what brought you out here. Stalwart is a good word. I have been here something like 13 years. So I did a lot of my training here. Um, but I was from the Midwest group up in Michigan. My folks were from New York. So they said you can't stay here.<laugh> just see a little bit more, um, and actually followed my brother to case Western where I did undergrad there and then med school in Pittsburgh. So I was kind of making my way along the rust belt. And my brother had actually just moved here to work for Amazon. And I really liked the area and I was sort of coaster bus for residency. So I was lucky to land here. And then really I had no intention of staying for much at all after residency, but, uh, kind of one thing led to another and then I stayed for cardiology. And then I stayed for interventional, um, as you've kind of outlined with some of our other faculty interviews, the place changed pretty quickly and our kind focus and volumes and perspective in the cath lab was quite a bit different, um, pretty quickly in my general cardiology training. So yeah, it was just good timing. I was lucky to stay here and then at some point they couldn't get rid of me. So <laugh>, I'm just around. But I do think some of the operators know me by voice and first name, which is means you've been here too long. Maybe. I dunno. No, no. We were actually fortunate to keep you here. So what, what, what were you intending to do heading back east? Yeah, I, I think I thought I'd end up in New York for some part of training and, you know, the historically really strong interventional programs So yeah, I was mostly just figured I'd follow the training paradigm and see where I landed, but it's lucky to stay. So it sounds like you were pretty much determined for interventional from pretty early on. Well, that's inter when I started fellowship, I definitely had that goal in mind, but then, you know, as things go and you get different experiences, I had sort of been she, so along more of an acute care pathway, like maybe doing CCU, I think a lot of folks had encouraged me to consider transplant for that side of things. Um, and it was actually, I think April stumping Otero was like, well, take all this noise and what everyone else is telling you, you know, what would you do? I said, well, I always thought if I did another training year, it would be interventional, but I just don't know if I'm really any good at it. Or, you know, it's just hard to tell. It's a very different thing. we do so much medicine training. There's a lot of unknowns of going to kind of this whirlwind surgical year effectively, you know, the decision making and your thought process is quite a bit different. Um, but I was fortunate that in our lab, you know, they didn't really, they just sort of cut through all that and so well get in there and we'll, we'll figure out if you can do this or not. So, um, I basically just the day I told Jamie McCabe that I thought I wanted to do this. He was like, great, okay, here's the plan. And next day he is showing me me how to do PCI. And it just sort of took off from there. So they were an unusually embracing group, which I think really speaks to how our mix of fellows in the last few years differs from kind of the national norm. Well, talk a little bit more about that. How is that unique? Well, historically there's about 5% of interventional cardiologists are women. If you look at board certifications, that numbers definitely increasing in training. I think the last data we got from sky is it's more around 17%. So it's definitely clipped up a bit, but you know, over the course of a few years, um, we just, we historically had a lot of women in our general cardiology program and we had several candidates who went into it, who weren't necess much like me sort of interested, but weren't really thinking that some people hadn't really considered it much at all, but had a similar background of maybe considered surgical specialties, liked the physiology and other aspects of cardiology and found themselves here, um, and sort of got pulled into it a little bit later in their trajectory. So it didn't come in as kind of our stereotypical interventional candidate. So I think that, yeah, that changed things quite a bit. So we were certainly the outlier for the number of women we had in our training program over the last five years. That is phenomenal. Uh, you are a specialist in a particular area. Uh, there's a lot of, not of all of our listeners may be aware of sort of the, I don't know, say new breadth, but the breadth of interventional cardiology, careers, maybe you could talk a little bit about what that breadth encompasses and then what you specifically are an expert. In. Yeah, it's an interesting shift because you mentioned, you know, we do so much medicine training and this very focused interventional year, which is quite variable for folks. I think if we compare our notes kind of around the country and I can't really even imagine going out on my own with just that one year of training. So I, I do think the, I, I can imagine it, but there's a, a strong sense of when you walk into a case, we often don't know what we're going to find in the coronary space in particular. And there's a lot of, of, I think there's a lot of motivation that when you don't like what you see,<laugh>, you know, there's a, there's usually an outlet. They're not a good candidate for PCI. We kind of turn away from what the indication was and just say, well, based on the findings and my training was certainly very different in that aspect. And I think, um, you know, as leaders of our program, both bill and Jamie really share this idea on opposite ends of the spectrum within the interventional space. Jamie's, you know, more focused on structural these days and taking that over and to Fastly new areas, and bill has done the same in the coronary space in his career, but where they really overlap is they're not, they don't pigeonhole themselves of, you know, if this is the classically described way of doing this, or this is kind of the typical thing, they look at vindication and the problem, and then they try to problem solve around that. And I think that creativity has really driven, you know, kind of the culture of our group. Um, and one reason that they pair somewhere, but there are so many different aspects of interventional these days. So I don't do any structural work, but that space has blown up for sure. In the last 10 years, you know, the partner trials were running just after I did residency here for TAVR, and then now that's just commonplace and kind of everywhere. Um, so I think it's pretty incredible how much that's changed, but because of that, you know, I think folks who just had original coronary training, unless they've picked up that skillset, very, you know, piece mail along the way, it's hard to just walk into interventional space and do everything these days. So at the fellow programs, we often hear folks say like, I wanna do MitraClip and this and this and this and CTOs and all that. So I think I, from my perspective, if you just say yes to coronary disease based on the indication and not if you like how it looks or you're certain, you can make it look beautiful at the end. Um, that's part enough for me. So I really focused on the coronary side and obviously lucky to have bill here. Who's really, you know, driven a lot of the space there in particular with and just some of the different techniques. But the way I looked at it was sort of that extra of training. If you're always dealing with these difficulties and problem solving, then worst case scenario, I go out and be a stronger interventionalist and be management and be able to handle things in acute scenarios, you know, faster and safer and all of that. So, um, so I think for me, that's what really drew me to that aspect. And you do go into it with more uncertainty. And I think our strategy is often thinking of leaders, the 12 things that are gonna get my way and make this hard or terrible, or potentially a complication. Um, so our mindset is just different, I think, because of that. Yeah. What, what in, what was sort of the thing that drew you into that space of particularly chronic total occlusions? What, what is so exciting about that for you? Or what, what has driven you to make that your career? Yeah, it's a good question. I think when I first saw these or heard about that, it seems, it seemed very far away from what it was after. I didn't say, I don't know if I really into that, but what it really comes down to is when you meet the patients repeatedly, who've been told there's no option or nothing can be done. And they, they look the same as the patients who have and they don't really care if it's easy or hard, they just wanna feel better. So I think it was largely those folks who just often had no options and really the barrier was our technical skill set. And so having luxury of seeing people who have broken through many of those things and can be more creative and kind of push that from a technical side and measure that with the safety aspect of things, you know, I think that was very eye opening. So that's really what drew me to it. And ultimately once you're in there and doing that problem solving, I just found that, you know, from a mental standpoint, interesting too, um, the structural stuff I'd always thought was great. And we have such a strong valve and echo program here. I was, I thought I'd really be drawn to that. But from the procedural side, it didn't the 3d orientation, all that just didn't make as much sense to me. And so you sort of vote with your feet and I found myself standing in the corner cases for hours instead. <laugh>. So, so that's where you go. Do you, do you have, uh, cases that, that really have confirmed your decision, people that you have seen come in, who've been told there's no other option. And then they walk out having received the option that you provided for them and their lives have been changed. Yeah, of course there's a number who are quite sick and they stay quite sick. So I think we're honest with ourselves and it is a humbling world. We live in with the kind of sickest heart, you know, heart failure, patients, cetera that we see here, but there are a number. And I, I think it just speaks to the sort of randomness of connections in our world. We had Katie Dawson was our recent chip fellow and she had a friend from residency who's a hospitalist nearby. And he said, you know, this guy had an outta hospital arrest and his angiogram sounded pretty terrible. And he's been here three weeks now, just sort of dwindling, and they're gonna put a trach in cuz they can, you know, he is having all these issues that really sounded more cardiac driven. But, um, obviously we didn't like what we saw and he's a high risk complex guy, but, um, I think through a lot of work on our triage team and everyone actually got him to transfer over with the idea of going back, which is very challenging and they give credit to the team who sent him too, you know, they'd been doing a lot of his chronic care, so they got him here and we did a series of, you know, CTOs and dealing with things he was prior cabbage and just had kind of nasty anatomy. Um, but we had the rare luxury of getting to see him in clinic. Cuz there was some follow up coronary work that we had said, well, we've done enough for now. Let's see how things go. And we'll talk about bringing you back. So at the luxury of seeing him, his son happens to be a family doc and just seeing how much better he's doing compared to someone we didn't think would get outta the hospital is just really inspiring. That that is inspiring. That's great. I love what you said about partnering with referring clinicians. And it's not something that we're trying to, you know, take over, but you provide something that can't be provided elsewhere. And as part of that team caring for the patient, you have that opportunity to, to really come in there and intervene when they're some cases there's no more hope or, or someone's run into run into the end of the capability and now it's time to actually refer on and, and really take that opportunity. I'm sure you have many other stories like that. You're being very humble about, about only mentioning one and, and even leading with the fact that it doesn't always work, but I know that you've been able to help so many people that must be so satisfying. There are some big differences about our workload and just our focus, right? You know, we have the luxury to many of our friends doing this are trying to get case done, have to go to clinic, read echoes. You know, they don't let me read echoes here for a good reason anymore.<laugh> but we have people like you for that. So we get to focus on these cases and do that day in day out. And there's many aspects of care that we quite frankly can't provide. Right? We don't folks live too far away. They've got lots of things that we don't really have the bandwidth for either, you know, I'm in barely in clinic. So I think from a follow up perspective, we realize we don't offer all of that care by any means. But, um, but we can be a popup file for these situations where it's like, well, that's gonna be more challenging. And you know, the biggest reason why I stayed and why will probably never leave is our cath lab staff in the team culture here is really what allows us to do this. So it makes a big difference. What are some of those challenges you still feel you're, you're working to overcome and you're excited to kind of, you know, keep chipping away at, and then things that you see kind of maybe as, as someone getting into this space can really focus on to maybe advance their career even quicker. Sure. Yeah. I think balancing your time as a doer person trying to do all this, you know, we try to be all very involved in education. I've been lucky with the sponsorship I have from folks here. I've had an opportunity to do that. So we've got conferences, we've got training courses and folks that come here. Um, so certainly that's a big aspect of it. I think from our own training program, you know, that's one thing I'm working on a lot that people don't really get a lot of mentorship on, quite frankly, I think in our space in particular, that sort of like you do the case and you have a training watching you for much of it and they do do some of it. And there's not a whole lot of rules around how to really make that person capable when they go out to handle this, cuz they're gonna be taking care of people. Right. So, um, I think we take that seriously, but with the complexity of cases we do and how sick the patients are, there's a lot on our radar of how to manage that safely. And obviously it's not good for trainees to have bad outcomes either. So I think, um, we work on that a lot, but that's certainly a challenge and you know, I'm lucky that I have folks like bill around, but I also can't be bill or at least not yet. So <laugh>, there's, there's. Some, you're pretty close. I have to say. Work on it. But so I think that's a, a big piece of, you know, teaching some of these things where I'm not sure how we're gonna solve the problem yet. And when to take over, you know, that's a, a big thing that I I'm working on that build been mentoring on too. Um, and then yeah, just balancing all of that. So I think one thing we can do more of is be involved on the research side. We've done a better job of kind of organizing our clinical trials, but there's this wealth of data that we probably haven't been capturing. So now that we're kind of coming up from air after the last few years, that's one of our next big focuses. And just, uh, for some of our listeners by bill, you mean bill Lombardi, mm-hmm,<affirmative> we've had on. Um, and, um, and I, I was wondering also, if you could define chip. Yeah, it's a word we've gone away from, it's basically complex high risk indicated PCI. So obviously there's lots of things we find that maybe don't need to be done. Um, but I, I truly think the high risk cases are not the ones that are being overdone. It's the low risk stuff and what we're trying to focus on. Um, I like this line from John spurs who had done some training here and has done a lot of outcomes research in cardiovascular disease. He's not an interventionalist. He says the number of PCI being done in the us is probably the right number. It's just the wrong people. <laugh> <laugh>. So we have like some that are quick and easy and it's just so tempting. It's like low, low consequences, but maybe unnecessary. And then I think lots of people who have a good indication, but there's some other challenges where they land and they're not a good surgical candidate. And so they're turned down. Um, so it that's sort of, we've shifted towards just calling it high risk PCI cuz complex is a word that, you know, is very much in the eye of the beholder. And sometimes cases you think will be simple when you get in there, they are not <laugh>. And so I think what we're really looking at is the complexity is often technically driven and that, you know, what's complex to me versus bill or Jamie versus a new trainee is all wildly different. So what really, probably better characterizes is the high risk component, cuz the patients have high risk features, whether it's driven by their anatomy, but often their heart failure and their comorbidities and frail teams such. So it sounds like what you're talking about is really a team sport and one in which you don't just offer the technical procedure, you're actually offering a global assessment of what's going on and treatment for as appropriate for more than just that anatomic lesion. Yeah, no, it's a really good way of describing it cuz so many of these patients are ill. We know that <laugh> and I think it's sort of, they end up getting referred to surgery or heart failure or us kind of depending on who their touchpoint was. But when we see those patients, what we're trying to do, even more comprehensively I give surgeons credit for, um, partnering with us. There is that, you know, X number of those patients really should get an L V a D probably they're too remodeled. They're very high risk for intervention and they're a good candidate for advanced heart failure therapy options. We say, well, we might do PCI to try to bridge to that, but at least we've got that plan all on board or maybe given their state, we're not even gonna pursue intervention. Um, and then some of those patients will benefit from cabbage and we can get them tuned up enough. That seems like they're a good enough candidate for that. And some of those patients will do better with PCI as a bridge, to maybe becoming a better candidate or just to try to avoid those other things. So I think it is a space that there's not a regular cookbook kind of approach mm-hmm <affirmative> but, um, but we're fortunate with kind of the collaboration that we have here that, that works pretty well. Cuz everyone has enough business. So it's more about, do we think this really helps this person right now? Or is this a plan B. That's great. I, I wonder if you could talk a little bit about this concept of it's it's not necessarily PCI or surgery, uh, but maybe it's both, maybe it's neither, maybe it's something else. How, how do you sort of navigate that space? What sort of creative hybrid options are there that are sort of gaining more favor or gaining less favor? Yeah, no, it's only a few places I know have seem to do it really well. And I think there's probably some obvious challenges of volume and sort of focus of most centers. Their high risk complex anatomy patients will tend to go to PCI and other centers will tend to go to cabbage and that might be more of the cultural and skill set and focus of that group. So things sort of seem very obviously black and white, maybe if you're just looking at it that way. There's only a few sites who probably have enough overlap there that that's easily done. So I think the trials that have looked at hybrid Reva have been challenging. It's also to have an ironed out exactly how to do that, but there's plenty of patients. Um, and Emory's doing this quite well is where they'll get an off pump Lima and then they take care of the other coronary disease figure. They get the benefit of that. Keep the surgery simple, but other areas where the grafts tend to have more issues and especially given some other anatomical concerns, you know, while these CTOs don't have great targets, it's very distal. We have anastomotic problems actually make it much more challenging and not, um, in a higher risk of complications if we're treating those down the road. So we'd rather deal with that stuff up front when it's simpler from PCI perspective. So I think that's really the next wave is if we can do that. And so with, you know, we've got growth in our surgery department with interest in that. So I think that's kind of an exciting look ahead. The next several years is we'll be doing more of that. That's great. It just strikes me that, you know, we've known for so long that the benefit of surgery is Lima. We've known for so long that I don't know what percentage of graphs now are going down, despite our best efforts of pretreating them and bigger graphs and better graphs and whatever, but vein graphs are just not really meant for that purpose and they don't work and they're gonna see you sooner or later. So why not try these, these creative options of, of hybrid approaches and make that more of the standard? Yeah, I think it's more of a logistics challenge is why it hasn't been done before or that in particular that some of these issues were, you know, it's a CTO that was a big indicator for folks going to cabbage, not so much, whether it'd be a benefit of the Liba, but it's, you know, you're treating the right. So, and at least in the older trials, while those patients didn't get a graft there anyway, cuz for some of those issues they have. So, um, yeah, I think a lot of it is more about just that coronation and thinking outside of our own world, which, you know, from our standpoint, the division between structural and coronary has maybe helped with that. It's like, oh, well I don't do that, but I know more about it cause it happens in our space and that's also led to more collaboration with surgeons. And I think between that and the shock team efforts, you know, all of this, probably the more we work with them, the better we can fine tune all those approaches. Well, let, let's talk a little bit more about the shock team. We've, we've sort of talked about the, um, you know, offering something to patients who have no other options. We've talked about sort of the creativity of, of being able to use these hybrid approaches, even in but how about that shock, uh, situation where people are at death's door coming in, uh, what, what are we offering? What can we do and, and what role do you think interventional plays in that? Yeah, it's certainly, you know, sort of you gave a grand rounds this morning about examples of that. But I think there's a lot there that is so hard to tell over the phone with a one liner that we have limited information and sort issues that overlap with the pandemic, you know, you have to make decisions with information we have, and there's usually a very limited timeframe where to pursue. So some cases are pretty cut and dry. Like that's not a good situation. The person will certainly have additional complications from trying to provide ECMO or um, you know, even now we've got a slurry of devices that are mechanical support options, but none of them are perfect and they all have their downsides. So I think one thing I really like about working here is we are generally a say yes institution. So it's like, I don't know that this is gonna be great or easy, but I think this sounds like we should say yes and then we will figure it out.<laugh> so sometimes we'll get here and there's the turn of events or there's surprises or maybe they're not as good of a can as we'd hoped, but, um, but kind of just starting there is the easiest, honestly, because there's so many unknowns usually in that moment and you can only save a handful of those people to really discharge outta the hospital, but you won't save any if we don't try. So I try to say the fellows all the time when we're there at two in the mornings, like there's no shame in trying. And I think that if it's a reasonable approach and we're thoughtful, we use human dynamics and the echo and the clinical status and, you know, overlapping with their often acute coronary syndromes or ULAR issues and cardiomyopathy. You know, I think if we can parse all that out, that shock team is a lot more complicated than it used to be. Cuz it's not just, you know, the support it's like, well, how are we gonna get you off of that? Or what other options you have? Um, and I think that's kind of the most interesting thing about that. Spacement. Yeah. Could you describe the devices that we now have at our disposal a little bit? What are these devices you're putting in at two and have in the morning? Sure. Well the ones actually been the hardest to get and the simplest are bull and pump obviously. And that's what everyone's familiar with, cuz it's so widespread, but because there's no independent work from that, there's, you know, lots of other issues. Um, we have the whole family of Impella devices, which sort of took off, but I think there are a number of patients where when we're doing PCI and we're gonna rock the boat, that's one thing and some unloading and some benefit of cardiac output is helpful there. That is from a more limited time trial, but there's certainly limitations in these patients in shock, a very high percentage of them get transfusions or whether it's small assist or access site issues. So I think being realistic about, you know, that these patients come in so sick, it's hard to tell and all the propensity matching in the world and the data mm-hmm <affirmative>, doesn't make it easy for us to make that decision when we're evaluating them. So I think the biggest change that's happened in the last several years is using human dynamics there. Um, but I think importantly there's times other devices actually are better also. So now we've got, um, the Impella 55, which is typically surgically implanted. Although I think Jamie has a way to get it in just the surgeons will have to take it out <laugh> <laugh> um, and so, you know, I think that's one of the things of just the multitude of access options we have from his skill, um, working with our surgeons and some of those, and then some of the devices that haven't taken off as much because of ease of implantation, but I think are quite important. So the tandem family is great with mechanical valves, mitral stenosis, vie thrown by and things like that. Cuz we avoid issues with that. Um, and really from the right heart failure component, which like the right heart is just such a fickle character that versus many times we don't know exactly why it's so ticked off or what happened or how likely it will be to recover, but having support options there. And that case selection is something that's really evolving like in the moment, cuz we're learning more about that. So, um, we largely switched to the pro protect duo, which is a tandem device there. And the one advantage, especially during COVID is we could have patients on VV ECMO with that for quite some time and they can ambulate and all of that. So I think, you know, that space is rapidly changing. There's, you know, more industry partners that are jumping into that for sure. So it'll be interesting to see what kind of all comes out. Yeah, that is great. And you know, for some of our listeners who may not know what these devices are, essentially most of them, uh, the, the Impella devices that you mentioned actually consist of a little, very little motor, uh, basically with a propeller that will suck, uh, some blood from one chamber and put it into a different one on the other side of a valve. So for instance, the left ventricle into the ascending aorta decompresses, the left ventricle actually provides some augmentation of the cardiac output and up to five, almost six liters per minute with some of these larger devices. Um, and, and really it can be sort of thrown in, uh, I wouldn't say at a moment's notice, but you know, they're, they're implanted fairly easily can really stabilize patients. Um, we see a lot of stuff happen with them in the echo lab. They might get pushed too far in or come out entirely. And uh, a lot of excitement can happen when the patient moves, the device moves as well. Mm-hmm <affirmative> and then the tandem family of, uh, being able to insert actually through the OUS side, poke it across the interatrial septum into the left atrium, suck blood from there into an external pump and then put it back, uh, into the body, um, sort of by a way of a bypass sort of, uh, obviously not full bypass, but um, also really helpful as you mentioned in cases in which, uh, if you can't get blood to the left ventricle, the Impella's not gonna work so well, like mitral stenosis and things like that. Um, and then with the ProTech doing the same thing, basically on the right side of being able to support are, are we seeing a lot of these devices now being put in in maybe some community hospital, uh, partners and then, you know, clearly the patient needs to come to a higher level of care. Um, are, are they, have they sort of reached dissemination to that point where they're available in a lot of places or is this still kind of one of those more specialty things? Yeah, I think the frequency isn't high enough and you know, even for us, we have a, we spend a lot of time on protocols and evaluation and cuz the devils and the details it's like once we get it in that's one thing that the management and troubleshooting and some particulars with placement are really where probably there's divergence and these patients are so sick, they just don't give you any legal room. So, um, I think for all of those reasons, it's been fairly limited. So more and more places are getting sort of the smaller I propeller version. We mentioned where that sits in the LV and shoots blood out into the aorta. Um, that can be a way to stabilize patients, uh, in terms of that many other folks will come with the balloon pump, but by and large, the reason they're coming is because they have some component of RV failure. So we're deciding between dedicated RV support devices or ECMO. Um, and you mentioned that, you know, the big reason that isn't just there all the time is one, some of the morbidity with it, but also just resource utilization and availability. And I think the last couple years we've felt that more than usual. So, um, taking all that into account, those are the main reasons that people come over. Cause I think once it gets to that level and the resource intensity there, most hospitals haven't found a way to where that makes sense for them to support that just especially at the frequency that's happening. Yeah. Oh, that's, that's a really good. Point with, with these technologies. Is it, is it kind of around the, the Impellas and the support or stenting options? Like where are some of those technology evolutions happening and that you're excited for the opportunities that are coming and maybe what's long into the future where those opportunities. Lie? Yeah. I think one of the differences from the coronary space is there's been a lot of technology advancements. It's been very lucky to be starting where I am and they've figured a lot of it out and there's lots of devices there, but for a lot of it is the troubleshooting is more about techniques and problem solving and different ways to manage some of these issues and dealing with the complications of the devices we have. So it feels different there, whereas on the mechanical support side and to a large extent, the structural side, you know, there's certainly kind of creative techniques, you know, some stuff Jamie's doing of way to make a device. That's not perfect for this patient work with like two or three overlapping things is sort of out of my, you know, I can barely comprehend what he's doing half the time, but, um, but a, a large part of it is more technology driven that this is a device and the technology aids, this, you know, sliver of the population. Um, and on the mechanical support side, you know, that's kind of where a lot of that is biggest innovation was sort of moving towards a different standalone pump and then I'm sure there will be multiple iterations and we'll see what has lower rates of complications and some things like that. So, um, I mean, I think there's some exciting stuff on the coronary technology side that we'll see what happens, but, um, in particular we're involved with one device coming up soon in a trial, uh, called a perfusion balloon where basically we can, you know, tampon on any bleeding that's happening from within the artery while still providing blood flow to the heart. So like that is different something we haven't had available for quite some time. The older versions never took off cuz they weren't all that effective as my understanding. So, um, so there's some things like that, but a lot of what we're doing is gonna be more, you know, training and technique based I think. Um, but we'll see. And on the device side, I think the mechanical support options and things like that, it'll hopefully be more fine tuning some of these early prototypes that we've been using. So could along those lines, could you talk a little bit about CTO interventions and I have to admit that I haven't heard you or bill give a lecture on this recently. So I'm probably a little bit behind <laugh>, but I was always very sort of enamored with this idea of star and some of the other things that, I mean, first of all, that's just a really cool acronym. <laugh> true. Um, but, but maybe describe a little bit because this is kind, at least when I first heard this and I had not heard this in my fire institution at all, um, it sounded kind of crazy to be honest. Um, and then I see it work and I'm, I'm sort of a believer at this point, but maybe you could describe that a little bit more. Yeah, sure. I think it's a common theme in our world right. Of something that we tried before and we saw that didn't work and then somebody picks it back up with a new idea. So historically with we're either trying to wire right through it and staying in what was historically their, you know, inner lumen, but many times in these situations, even when we think that's happening, that's not it, you know, the plaque once it's secluded and fibrotic is all just a misma in there so many times. Um, it's often likely safer too, rather than taking sharp wires and trying to penetrate through this long distances and causing more holes in the artery. We can actually just sort of run around the, the blockage and stay within the wall of the artery. So the outer wall called the AMT is actually pretty use, um, like a blunt dissection technique. So if you think about surgery, they take a scalpel sharp incision, or they use the back of the scalpel just sort of, or their fingers just to cut through tissue plane safely So we're doing the latter here. Um, so basically of a, a wire that will fold over and sort of form a knuckle shape, like an umbrella hook. And we just basically push that forward until the target area. So in mind of those cases, we're trying to reenter a specific part of the artery, but one of the limitations of success rates in these is if that target is not good and it's very calcified and not healthy, there's not a good landing zone or in some of these patients, especially after bypass surgery and things, we actually have no idea where the vessel is. You know, we hardly see a shred of anything out there and we're trying to safely go get it. You know, how can't really just, we have no roadmap to follow. So this gives us a good way to often solve some of that ambiguity. Um, and the idea with star is that we basically that the dissection plane, the umbrella hook will just unfold and pop open. So Lombardi was involved in helping develop a wire, which then is named after him called the Gladia Mongo. But, um, that's one that is kind of a made to have a smaller loop that hopefully ranchers earlier, but there's several other wires that we've used, um, earlier, anyone being a fielder XT. So we basically advance that and it might just pop in. So there's really no, there, it's kind of a luck thing. It's also just the physics of the branch points where it'll try to pop in across the edge of the lesion. And really our goal is just to gain entry to the blood flow from the front end and the back end, if we can connect those two by ballooning, then the flow often will do a lot of the work. So it's a little confusing long winded answer to that, but basically if we can connect those dots and balloon it open a lot of times we'll restore flow and it will actually improve itself over the course of several weeks. So what we had to change is that the old days we would just stent all that stuff up and you'd probably shear off all these branches and the dissection planes, didn't all connect in a way that was favorable. So, um, they had a small series early in our experience here. And when we looked at patients about eight weeks later, they often had additional branches that had come back on their own. That's probably just the hydraulics kind of popping off into these areas. So sometimes that will do some of the work. And our main goal is by doing that, we can avoid some of the higher risk techniques that we, you know, in some of these scenarios, you just figure, we're trying to make people feel better is the long term goal. So if we can avoid some of these procedural risks, um, we think that we're onto something there, but there's a larger registry to help us kind of understand across multiple centers. You know, what is the success rate of that? When are we using it and what the timeframe is that a look. And what does star actually stand for? Oh yeah, it's basically, it's a sub Al tracking and reentry, but it's the idea is that you are tracking around the lesion in the sub space. Um, and rather than times where we pick a spot and try to reenter the artery right there using some other techniques, like a stingray balloon or other techniques that mimic that, where we're trying to pick a spot, take a sharp wire and poke right at that area in cases where that hasn't worked or doesn't seem feasible. Um, then this one is sort of a blind reentry. Like we don't get to choose it, but it'll pop in on its own. And it's kind of, you know, bill often refers to as a dumb pet trick. Like it's just kind of crazy that it works, but, um, but if it's safer for folks, then that's what we're after a lot of times. And, and why is Mongo named after bill? How is that connection? Oh, well Mongo is Bill's nickname, which maybe I should have him tell you it's from blazing saddles, if. You remember blazing saddle. Okay. I'm definitely gonna. You should video you, someone punching a verse that <laugh>. Um, but yeah. So how much of, of bill do you think you've absorbed in, in, in how you practice and do things versus, I mean, obviously you're treading your own path and, and as a leader, as a teacher, but. Yeah, sure. But he's obviously been a huge influence on like the way I do PCI and he and Jamie in particular, but all the folks I trained with, um, I think when we talked about, I remember talking with Jamie, we'll get together with the fellows right before I was finishing of, went with the hardest thing going out and it's in his case, he has this skillset and fearlessness that's been built on his management of all the issues and his anticipation of the problems and kind of knowing exactly when to do that or not. Um, that's been built by, you know, he's just his ability to remember this catalog of cases he's had and built off of that. Right. And he is, you know, in his words, trying to download that to us very rapidly. And he's a very effective teacher because he's so good at getting you into that and executing it yourself. But the hard part is like the mental pieces in most of the cases of when to pull the trigger on that or when to switch strategies and, and all those things. So what I'd said to Jamie then is the hard part is taking what you've learned from bill Lombardi and making it practical and safe in your own hands. Right? Because there's, I think plenty of people are like, oh, I saw him do that. It didn't go as great as you have imagined. So, um, whether it's not successful or just, you know, worse having a complication that you weren't anticipating. So I think that's why the second year of training is so huge for us here is, is, is it's hard to get all of that in a year, but that second year you're really building on this particular skillset, how to manage it. And, you know, keeping in mind that, like, I don't have to try to do all of that immediately, as long as we keep growing. And so we really talk about as a growth mindset of this is a skill set I'm focusing on this year. And for these six months, every chance I get to practice that, so that I'm more effective and safer at it when I have to use it is, you know, that's kind of the, the way we look at it. So he's obviously a big influence, always say, I hear between he and Jamie. I like hear them in my head if I'm stuck in the case,<laugh> <laugh> path logic. But I think for any training, you know, you just remember these things is you kind of remember your training, like, okay, well, we're getting stuck here. And if you can name the problem that gives you more of an algorithm of what to do. Mm-hmm <affirmative> um, and the hardest part is honestly, knowing when to quit, you know, you're, this patient came to you, they put their faith in, you allowed you to treat them. So you want to balance that need to help in that moment versus the consequences. If you're not going to be successful, or if you're trying too hard and you might cause a complication, I think that's the hardest thing in the first couple years to, to figure out. So Kate, we also know that you have a great interest in women's health and part of what actually a lot of women are dealing with in the coronary space, something called SCD, which is another great acronym. Um, can you describe that a little bit for our listeners who may not have heard it and, and what is it that we do to meet those needs? Yeah. So SCD is spontaneous coronary artery dissection, and it's one of those things that, you know, now in training, it's presented at so many of our conferences, and I think it's become more in the limelight, but it's funny that in the world of the cath lab, even now, you know, I had a case recently and a younger gentleman that until it was staring me in the face, I didn't recognize it. Cuz we had assumed it was another procedural complication. He had some clot that went down the artery, obviously, you know, and then we're halfway through. It's like, oh, he just had SCD in the middle of all this. So it's basically the hard part about it is recognizing it. It does typically affect PE younger folks, but generally those who don't have typical plaque and cholesterol or calcium in their coronary, they're healthy arteries that have a spontaneous dissection. So similar to what can happen in the aorta where people can have a life threatening event, basically a tear in the lining of the major blood vessel. This can happen in the coronary too. And the hard part is we don't really understand why there's certainly some hormonal overlap, which is why we see, um, the preponderance of cases in women. But there's also something that's especially in peripartum phases and um, around other kind of hormonal spikes. So there's probably some element of that, but there's many other patients, I think it's been underrecognized in men, like a lot of these things where we maybe just called it a normal heart attack, sented it <laugh> and didn't nobody thought anything of it. And they're just so surprised that the young woman had a heart attack that were maybe investigating more. So I think we have to be careful there, but um, but long short of it, these are healthy people who might be doing winds sprints or some intense activity or have some other intense life event and that spike or surge blood pressure or, you know, adrenaline or whatever, whatever it is kind of is related to that. So they basically get some bleeding that causes like a blood blister inside the blood vessel. And sometimes that can actually close things down or cause because the flow is so bad, clot will form. So I think recognizing it is important. Um, the biggest thing is that outcomes when we stent those historically have not been very good for probably a number of reasons, but some assistance are probably too small. If you put that in, you can just kind of propagate the dissection further. So the reason we have so much overlay with it is actually cause of all the CTO work where we're doing this stuff intentionally here, it's, you know, basically happening in front of you and you have to be able to navigate those issues, um, using some overlapping techniques, should you need intervention? I think the important thing is us being very unhappy with the way the angiogram looks and walking away <laugh> and letting the patient heal because the majority of them, if they don't need stenting acutely, that they're having a massive heart attack, et cetera, they actually can heal quite well if they just, we leave it and the blood flow will return and you basically, the dissection will heal and the vessel will look totally normal on a follow-up angiogram and the majority of those cases. So, um, so yeah, it's an interesting subset and probably a piece of why some of you know, there's a cohort of young women presenting in shock with acute I who are, have very poor outcomes or, you know, kind of average proportion to how you match all that. And there's probably some influence from that there or other similar peripartum events. So yeah, that's sort of how we got involved in that space. Just to clarify, sir, are you using the star method and, and doing it a similar way as a CTO to fix it or are you. You've been paying attention? Yeah, so I think one of the reasons why we're so invested in teaching these techniques in particular star, which is fairly straightforward is because it is a good bailout strategy. Whether this dissection happens from a catheter on accident as part of a procedure or from us doing an intervention normal cases, but also in these, when, you know, if someone is dying in front of you and they can't really get to typically these patients would be sent for bypass surgery, which has a host of issues too. So I think this is one of those things. Like the more people we can teach, this is basically our pyramid scheme. You know, the more people we put out in the world who know these, even the more simple techniques, they can use that to save one person in one of these scenarios. So yeah, this is, that's a kind of good place to pull that out as if someone's really in dire straits. And, and does do cutting balloons have any role in this? You mentioned blood blister and. Yeah, so that's one of the bigger things too. We've changed in part cuz of our dissection experience, but is if a cutting balloon is basically a coronary balloon that has some blades on the outside, um, particular, the one is sort of stainless steel blades that come out so they can help open up that hematoma space. And basically what you really just need is to relieve that pressure. So we can often get good results there, vocally and it's amazing once you improve the flow enough there parts that you couldn't even see before in the angiogram are just, they look totally normal. So this case that happened more recently, um, that was a younger gentleman. You know, we actually had a very small balloon down first, just so we could image and we took another picture and it looked so good. We just got the heck out of there. So you don't, sometimes you don't have to do much to make it better. And then you just let the vessel heal on its own. Could, could you talk a little bit in general, too, about women in chest pain? And I think this is also getting more play nationally mm-hmm <affirmative>, but boys have been neglected for a long time. It's very true. And I think some of the data that's most interesting to me is many women presenting with a heart attack did say they had chest pain. It's just not the first complaint or it's not the primary thing that they say when they're coming in. And overall there are so many men who have had late recognition of MI because they didn't call it chest pain or they didn't ever feel it. You know, they had indigestion or they had shortness of breath or they felt nauseous too. So I think people can have very variable symptoms from ischemia. So that's one thing we try to stress, but also, you know, even our patients partners will sometimes say, we'll be like, oh, well, women don't really have this problem is in this unusual or vice versa. It's the woman saying like, well, I don't really have to worry about it as much as him. And we're like, no, no, no. So I think there's still a lot of just public health level education. So it's good that this is getting more limelight. Um, you know, it's one of the, as like a outside perspective, it's sort of frustrating. They we've done a great job with breast cancer awareness and some things like that. And not to say that's not important, but you know, the amount of fanfare around that versus heart disease, which kills so many people and is, you know, arguably much more preventable I think is, uh, something we could do better. So as a field. And, and what about those cases in which there's no epicardial coronary disease or just a little bit mm-hmm <affirmative> we don't think that's causing an obstruction. There's no, uh, um, dissection and yet the patient is continuing to have what could possibly be coronary ischemia? What do we do in those cases? Yeah. Well, we've shared a couple of patients with that kind of syndrome and I've really, we came to study patients who had normal looking coronaries and symptoms that sounded like typical, like her heart pain, because they looked just like our CTO patients on the outside, they had bad symptoms. They were very limited. They were very frustrated. They were in and outta the hospital for symptoms all the time, going to the ER, at least because if you call any nurse line, you say I'm having bad chest pain. They're gonna tell you to go to the emergency room. And in a subsidies folks have many repeat procedures and stress tests and everything looks fine, but they're not satisfied by that. Or they're still having a symptom burden that they come back. So for that particular subset, um, we went down to Stanford and learned, uh, their protocol for studying microvascular disease spasm and looking at myocardio bridges, but basically a host of issues that can still cause heart pain that just don't look like heart disease the way we've always thought about it. So it's either small vessels, you know, we're working in the big branches. This is like down in the twigs of the arteries or it's a dynamic thing. So it's more like a Charlie horse that the vessel spasms down and can release and may not catch that in the act. So, um, that's a kind of area that's evolved a lot. And I think the bigger thing is now that we can actually identify what these patients have, you know, a smaller percentage of them but it's usually somewhere between 10 and 30% have spasm or some combination of that. And another host of patients have microvascular disease, um, and different subtypes related to that. So I think that best part about where we are now is that we're hopefully diagnosing people better. And for a number of patients, just knowing what the heck is going on is quite useful. Another percentage of people, we can really titrate their medicine. So they've been taking like the kitchen sink and we stop that. We hone in on a couple classes and just try to find a regimen that works best for them. Um, and then other folks, you know, we may can't fix right everything right now, but we at least understand it. And there are some interesting new therapies. So there's something called a coronary sinus secluded. We're not involved in that trial yet, but effectively we put a device in the coronary vein and that changes the pressure dynamics that folks sometimes actually get a lot of symptom benefit from that. Interestingly. So, um, it's in the very early phases, but now that we can identify and name the disease and identify the patients, we can hopefully study and find therapies that really work cuz there's a number of people who are so debilitated, they're considering transplant, which just seems like we should have something better than that to offer. Yeah. And, and describe the interventional techniques that we can use to diagnose these. Yeah. It's pretty straightforward. So we basically just put a catheter in and we inject, um, acetylcholine, which is typically used in at your eye doctor visit <laugh> to dilate your eyes. We actually in normal coronaries that will often have the coronary open up nicely, but in folks who are prone to it, they can have pretty significant spasm. So we see it right there in the cath lab. We give nitro as the anecdote antidote and basically correct it right there. Um, then we just put a simple wire down that has some pressure and flow measuring capabilities. And basically just by doing these measurements, which we do for, um, in a right hard, hard cast. So we use the same tech, same concepts in other aspects. It just hasn't the technology hasn't been reliably available to put in a coronary. So we have a wire that can do that. Now that's commercially available, um, that before you had to try to get off research, um, protocol. So now that we have this kind of regimented system, we can get data that's more specific. And then that gives us, you know, a better way to study these patients. Well, that's wonderful. Yes. As you mentioned, I have sent you a number of patients <laugh> because, and, and people are really frustrated as you said, because they have been blown off and they have been ignored and, and then you do an invasive test. It's clear that this is what's going on. Some of the times, sometimes it's not mm-hmm <affirmative>, but a lot of the time it is, and then you can titrate medicines, you can target what, uh, actually we can do for patients. But maybe most importantly, you give 'em an answer. Mm-hmm <affirmative> that is so powerful for some people. Yeah, I think so. It's just, we've told them there's nothing wrong with them, but yet every time they don't feel well, they're told to go to the emergency room. I mean, there's just like this dichotomy that doesn't work there. So I tell folks there's tons of limitations to what to But once we have some understanding, my hope is we can at least make a care plan that keeps them out of the ER and gives them control over their symptoms. And half of that is sometimes just knowing what it is. Yeah. And I can tell everyone from personal experience, it is a good idea to refer to Dr. Carney for these patients because she treats them with such kindness and understanding, and everybody's come back to me, just singing your praises constantly for that. I know you're not in clinic that often, but I think you need to be in clinic more just to, to be able to help with these patients. And then of course, when appropriate to do the invasive testing. Yeah. I think there's plenty of people who will do well when you just try some empiric medical therapy. So I always tell them, it's, it's rare that we have a purely diagnostic test that we're taking the cath lab for. So we understand that and if they're doing well, but as you said, I mean, it's this, it's more the patients that are so frustrated that answers. Well, you are actually in other people's heads now because you have played such an amazing role in inspiring, I think, particularly women, but I think everyone really in the way that you practice your craft and the way you do what you do, what is sort of your philosophy for inspiring teaching, ensuring that the next generation is gonna be following in your footsteps and, and doing the right thing. Yeah, it's a big question.<laugh> I think the biggest thing I'm focused on now in terms of recruiting is making folks realize that they, you know, this skill set is something we can teach you. And so people have the desire and the mentality of, you know, taking on these procedural sub-specialties cuz the decision making's a little bit different. Obviously the lifestyle think in some ways is much easier cuz we're pretty protected when you're in a case. Um, and others, you know, it's a little more physical when you're on your feet, we're in lead most of the time, that kind of stuff. Um, but altogether I think what folks really need is the recognition that they, that we can teach that and that that skillset is what's really empowering. So I think there's a lot of good work being done about recognizing, you know, both disparities in care and also the representation in particular, amongst interventional cardiology within our space. But more than that, you know, what our goal is is to make empower people by giving them that skill set. And so I think for women, historically, this was a big under area where folks didn't necessarily feel pulled into the group or that they, you know, would be successful with that. And so that's kind of our biggest realization is that them the tools and I'm gonna make you good enough that you will handle whatever else comes along. The support. And a lot of the other kind of soft skills are obviously important to, but, um, but that's a big piece of it that we're kind of thinking, looking ahead, how can we change the, the way interventional cardiology looks? I dunno. Do you want to talk about some of the trainees? I it's just, you know, it's well known around here that you're able to attract some of the best and brightest and, and inspiring them, um, both in the chip program and structural heart and everything else. And they consistently talk about the mentorship that they get. And you clearly get mentioned all the time in that they're so happy to be able to work with you. I don't know if you wanna talk about any of them, what, what they're doing, where you see them going. Sure. Yeah. I think you just going back through the last couple runs, we've had, you know, we're very lucky to had Katie Dawson and Logan Vincent just graduate from our program and commit to doing the two years. They we're both internal candidates and we're so good. We changed our policy to trying to keep an internal, external person to take both of them actually. Um, and Logan Vincent empowered powered through a whole bunch of stuff. She, um, had to manage during fellowship too, but she's just an unstoppable force that she's so committed to patients that basically all of their noise goes away. It's, it's kind of incredible. So she, um, had the guts to do another year of training with Jamie and all the crazy, you know, valve interventions and creative ways that they're treating people. And then we're really excited for her. She just started down at St. Vincent's in Providence. So I think that's a great group that they're already pushing the envelope, really patient focused in a similar way, broaden catchment. And you know, I think we'll be a great fit for her. So we're really excited to see, um, to see her work there. And then Katie Dawson just finished her high risk PCI year and managed to suffer through doing lots of cases with both me and bill. They have different <laugh> different issues, but, um, but you know, I think her patients and commitment to just trying to see through whatever we're worried about or uncertain of in a case it's like all of that is irrelevant in the decision making it's this person should have this attempt and then we get to work on figuring all that she's adopted that really nicely. And I think when she was looking around for jobs, it became really clear that she wanted to work at an academic institution, have a heart failure transplant group and all these things that we're talking about, like, what we do in the lab is one thing, but it's the whole team sport aspect of it that changes so much of how you approach patients. And she's like, I just didn't really wanna work outside of an environment like that. So I'm really excited for her to train additional interventional fellows there, um, and for us to have a connection Nu so that'll be great. Um, she's not too far from ran Davies, who is my first fellow who has just taken on an incredible volume of CTOs right out of the gates. And I think she is almost as fearless as bill and can just really kind of laser cut through that almost with a surgeon mentality and just really absorbed like a sponge, just so much of that stuff she got out of that, you know, she'd scrub with Jamie even instructional cases when she could just to get any access stuff, anything she could, she just soaked up and she's really been hitting the ground running. So we're really excited to see what she's done. I think she's gonna just continue to be a leader in the space. Um, we also have a couple of folks who trained with bill who are local now. So we're lucky, uh, work with Rob Riley and Amy Chaney are both at over lake now. So I think having an extension within the community is good. Um, and just a whole, you know, it's just gonna be more and more. So I think what we're really looking at is how can we set people up with the skill set, not only to, you know, twizzle these wires and star and all this kind of crazy technical thing, but if you have to take star to a cath lab, who's never heard of it and thinks you're totally crazy and they're not totally wrong.<laugh> you have to be able to manage that and train your team and work with folks and figure out who the right patients are. So, um, you know, fortunate bill has worked a lot on that aspect of things. And we talk a lot about leadership training and read you, you know, I wasn't sure how that would all pan out, but it does nicely give you a language to start with and a way for you and your mentor to think about, okay, you can name the problem and the challenge, and then you can talk about solutions and that's very different than just being frustrated. And oh, my group will never understand me or, you know, stuff like that, that I've often heard when folks get out. Wow. That is amazing. Where, where does like, you know, the, the personal side of this fit into all of this, like how to take care, oh, the balance outside of work, what does that look like for you and how bill maybe taught that, you. Know? Yeah. In a way. No, that's true. Well, he had me, we recently had a fellow's portion before the complications course and he knew that I was focused slash struggling whatever with this. So he had me give a talk on work life balance to the fellows and per usual, we, you know, tried to fit a case in before the course. So I'm running late and scrubs to give it. And I was like, this is exactly what <laugh>, what we were talking about. But I think, you know, I told them the good part, the great part about this job is it's something you live and breathe and care about. I mean, it is a part of your life. And sometimes that means getting up at three in the morning. And that first 30 seconds of getting out of bed is pretty hard, but once you're coming in, it's like, all right, we're ready. You know, you you're there, you know why you're going in. So I think that part is immensely satisfying and drives you that much. The hard part is figuring out where those boundaries come in, because there's always another patient or, you know, today where a little short staffed in the lab. So trying to sort out of how are we gonna take care of everyone we need to safely and not push that limit too much, but also treat the patients who are here expecting that service and, or have that need clinically. So I think that's where balance is always a mess in this world of clinicians in general, but probably even more so an interventional. Um, and so what we really talk about is boundaries that you can't really have balance, but you have to protect your at home time and, you know, family time or print time or other commitments that up. So you have the energy to go do this stuff, cuz otherwise I do. I mean, burnout is so real in our, in medicine in general, but I think in particular, if you're always taking that stress on you, you can only, there's a limit to that. You can only do so much. So we've tried to set pretty firm boundaries of like you're off off. And you know, we try to set it up such that we have a program. This has been a big emphasis of bill so that we can keep working when he's gone and that, you know, hiring Lauren Zia has been awesome. Cuz I think we'll have more bandwidth on some of the high risk coronary side without stressing our other partners like Christine Chung and Jamie to cover all that on top of everything else all the time is just, is challenging. So, you know, we have, um, I like the way Zack put it once is that the ven diagram of our group is kind of perfect where there's a lot of overlap of high risk patients getting PCI. That's just our bread and butter, but then we all have, you know, our windows outside of that. And there's stuff that they do, I can't even understand. And they're very kind of just let us deal with all the CTOs and some things like that. So, um, so that worked well, but, and you need that to be able to keep the ship moving while we're each individually away. Um, so I think that's an important piece of how to make it work is like you can't be the only person who can do that, even if you might prefer that for other reasons, um, that the team aspect is, is really important and then setting those boundaries. So for bell obviously, um, he took, uh, I think on this podcast he had talked about his sabbatical and um, in a sort in a sense, so he had took some leave over three months and at a very planned kind of impeccable timing for me to also grow in being the person holding down the for. So I think that was key cuz if he had done that the year before, I would've just drowned. Um, but it was the right time that had enough mentorship post-fellowship from him. And it was, you know, some cases were hard and I failed a few and like that's kind of, we went into it knowing that, but we would at least have that set up and, and the guardrails there. So I think that's a very important thing that he has tried to instill in all of us. Cuz looking back, you can see how you just get so overwhelmed with education and then you come home and you still have this job to do, which is your biggest commitment.<laugh> it's like there's a lot of noise that distracts from that. So building in a little time to just reset is certainly key. Is there anything else outside of the work that really reset you? Mm, for me it's honestly just being out in the woods with my dogs. You just, you just get out, you know, it doesn't have to be that far, but I think those for me, that's probably the biggest thing. It's also, um, I used to say so snowboarding also because we're so focused on doing it, then I don't think about anything else, but then I dislocated my elbow two years ago doing that. So nobody wants me to be reactive<laugh> in that particular sport. Um, but certainly other things I actually like for me running, isn't very good for that cuz I think a lot, but if I'm paddleboarding, like it's just, I guess it's a balance issue. I'm not good at balance. So if I'm paddle board, you're just focused on like what's in front of you and I, I, so those things I think are important in between for me. Awesome. That is amazing. Uh, it's just been such a pleasure to have you on here and thank you. You thank you so much for what you do. Not only for the patients for your, the way that you approach patients, which is so gently and yet offering so much hope to people who in many cases have had none, uh, before they meet you, but also to do it with such I think an understanding of the limitations of medicine and, and yet having a confidence in your own skills and the successes that you've had, that you know, that you have something that you can offer these patients. I mean that my patients have benefited so much from that. And I have to admit John Michael, sometimes I'll look oh, this is this isn't gonna work. And then, you know, Kate's like, yeah, it took us five minutes <laugh> and I'm like, okay, good. That's, that's excellent. But what you're, what you're able to do in there is just amazing. And I think it's, it's such a Testament to your skill and your ability to be able to, to do that and be able to offer hope. And I'm really glad that you do that. But even more that, to be honest, the people that, as you said, that you are mentoring whose heads you are now in that are, are channeling Kate. Every time they go into the, into the, uh, cath lab to do these procedures, that's just expanding your influence. And, and I think that's really what it means to be in an academic center and contribute to that education. And that's not just our fellows. That's like all the other, uh, things that you do, uh, to teach people that are coming in for day courses or whatever. And, and I love the fact that you don't just, you, you teach 'em about work life balance. You teach about how to run a team. You teach about how to make good choices about when to do this and when to stop, uh, that's the whole package and we are really fortunate to have you here. And we've been really fortunate to have you on and share this with us. It's great talk. No. Thanks for having me and for doing this. This podcast was produced with support from the university of Washington division of cardiology. We have no other sponsors.