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so call. So there's a little circle thing. There we go. Good, like, um, so hi and welcome everyone before. Before I introduce you to our wonderful speaker today and highlighting what she'll be discussing, I wanted to welcome everyone back to the virtual carnage Virtual Cardiac Journal Club who've been before and for those who haven't been. And for those who haven't been, this is really accessible to all. The goal is to share that expert knowledge across and a free platform drive that interest in research and sciences and to work collaboratively collaboratively with the aim of improving that healthcare service we provide to our patient's so making accessible in this platform. So we can all access that cutting edge knowledge. And if you're new to this platform metal, how can you enjoy tonight? Well, whilst you won't be able to join in with video or audio, you can ask questions in the Q and a section for out, which we'll get to you at the end. Um, all you need to do there is select the B Q and A button that should be in the right hand side of your screen type in your question and compose and select send. I believe that will be anonymous, or you can at least select that not anonymous if you wish to do so. And Becky's very kindly offered to address those questions at the end for us. So let me give you a little brief introduction to Becky. So Becky is a clinical scientist. She is the lead lead cardiac scientist for, um, adult congenital heart disease at Barts Heart Center. A specialist service that cares for over, I believe Correct me if Ron over 15,000 adult congenital heart disease patient's, um, following that transition, Uh, from Gosh, um, and Becky is very passionate about education, and I can ask I can vouch for that Sorry personal myself in prep from IBSC written exam when she kind of walked me through congenital heart disease cases. Um, otherwise I would have been in probably in some trouble, and it came to the video questions. But so here's Becky. Um, so Becky tonight is going to be focusing mainly on a research side effects. Um, and it's, uh, the title for talk really leads into The question is, should we close close all septal defects. So without further do Becky, take the reins. Thank you very much, Gavin. And then thank you very much for that great introduction. And then, yeah, thank you very much for having me to speak on this platform and evening all And so I'm just going to share my slide. So, Gavin, just let me know if these don't share appropriately, but you should see the first screen there. Um, So I'm going to be talking this evening about maintaining patency of atrial septal defect. Specifically incessant conditions. I know. Previously, my talk was just maintaining patency of septal defects, but I thought we'd really hone down on on atrial septal defects in selected conditions. So just an overview of this talk this evening, and we're going to just briefly remind ourselves about the indications for ASD closures. Um, then we'll go on to when we might want to avoid closure. And in what scenarios may we wish to create nasd, um, in certain patient's and what is the latest evidence in this area? So just to make sure that we're definitely still awake after a busy Tuesday, and I thought I'd start with a case study where we get to review the patient's details, and then I'll give it to pass it to the floor to allow you to make a decision of how you'd like to, uh, manage this patient. So this is a 27 year old female she presented with palpitations to her GP. Um e C g showed incomplete right bundle branch block. And and these are her summarized echo findings. So if you see the bottom left hand panel, hopefully you can see my cursor on the screen. This is a pediatric orientated image that we often use in congenital heart disease and particularly in pediatrics. But just to orientate you This is the left date room here. This is the left ventricle. This is the right atrium, and this is the right ventricle into atrial septum. And then on the right side, you have your bike able view in the subcostal imaging. So this is the S V C IV. See, this is the interatrial septum. This is the left atrium here, the right atrium below and the tricuspid valve. What we can see is a deficiency in, um, into atrial septum, consistent with a typical second, um, a S D. And we have a dilated right heart, and I haven't shown the Doppler assessments, but there is no evidence upon hypertension. So what would you like to do for this patient? Would you like to close the defect either? Such war Percutaneous. Would you like to plan to close the defect? But wait. Maybe until the patient's a little bit older. Or would you suggest no intervention? So I will leave it to the floor to make your decisions. So whilst those are coming in, Becky, Um, to me, at least the cursor isn't showing across the screen. Unfortunately, uh, which just makes your job all the more fun. Um, okay, So while we're waiting for the decision to come in and maybe this will help you change your mind, the bottom left hand panel is an apical four chamber of new. On the left side is the report. On the right side is the right heart with the atrial at the top of the screen and into atrial septum is in between showing the deficiency of the atrial septum. Okay. Yeah. So Oh, there we go. Almost. I'll give it a couple more seconds. Just close and rise. If you're just about submit. Cool. Look at me. Nice. Good engagement. So we've got 16 responses there. I'll just read it. I'm not sure if it's showing on your screen there. Becky, I'm nervous. I I could hit certain things, but I could lose all, Uh, so we have 76% close. Um, 11% plan to close, but wait until the patient is older and 11%. No intervention. I'm going to close that. And let's just see if that pops up in your screen now. It doesn't. Okay, Cool. Thank you very much. Thanks, Kevin. So great. So the majority were absolutely correct. So, um, we would elect to close this defect either by search, surgical percutaneous, uh, methods depending on on the size of the rooms. But this looks good for, uh, percutaneous closure. So this is consistent with the 2020 s E guidelines for the management of a C h d. Patient's and you can see here in the red box any patient who's got an ASD with evidence of right heart volume overload and no signs of promise. Arterial hypertension and should always go onto a S D pleasure regardless of their symptoms. So very good. And then case number two. Um, so this is a 75 year old female she presents with Dyspnea. She has a background of hypertension and atrial fibrillation, and she has been referred for an echo. And these are her echo images. So again, in the central panel here, we've got an April 4 chamber view, but orientated in an adult orientation. So this time we have the right heart on the left side of the image. Left heart on the left side of the images we had before, Um, and the ventricle at the top ventricles at the top of the image. And what we can see is a significantly dilated left atrium, significantly dilated, right atrium, mildly dilated, right ventricle. The parameters assessed came within mildly dilated range. And we have a good ejection fraction of the left ventricle. Further assessment. Again. I haven't showed the doctors on on on this image image, but diastolic function assessment showed and left actual volume significantly dilated at 90 miles per meter squared, um, raised pulmonary artery, systolic pressure at 50 and an increased average et prime of 20. So these parameters are consistent with heart failure with preserved ejection fraction. So significant diastolic dysfunction, which is common in in this population with hypertension and what we call hep F in the left hand panel or the right hand panel. Sorry, What you can see, this is a kind of zoomed zoomed in, uh, sub costal long axis image. You can see a small, very small ASD with the left to right shunt. So probably around five millimeters for the A S D. So what would you do? Management options and second time, final time to the floor. Would you a close the defect be plan to close, but wait till the patient's older. Remember, she's 75 or C would you balloon test closure of the ASD in the cath lab, measure the left atrial pressure, um and then make a decision from there, the clues probably in the, uh, the options. Just while we're thinking, I just wanted to kind of focus on this heart failure with preserved ejection fraction element, because this will be the area that will be we'll be talking out about for for a good majority of this talk decisions. And Gavin, have we got some schools through? I just realized I was talking to my mic was off. That was great violence. Oh, no, it's not responsiveness or, uh, got good engagement there. Uh, so 16% closed effect, 0%. Um, wait until the patient's older 83% balloon test closure and calf lot measure L A pressure on the side. Yeah, perfect. So, again, majority and definitely correct. Well done. So we would balloon test the A is the closure and test. What left actual pressure does, um So again, this is consistent with the 2020 guidelines. It suggests that any patient with an ASD um, an evidence of raised left ventricular filling pressures. We should perform a balloon testing to carefully estimates, um, the l B filling pressures. And if we think that there's going to be a negative impact for that patient's closing the ASD and therefore potentially increasing the left actual pressure even further than we shouldn't go ahead with ASD closure. And I think in particular for this patient this is a very small ASD, hardly any right heart debilitation. And actually, this can benefit this patient because it's providing a bit of a blow off foul for the left atrium, which we know is hypertensive. We know when this patient exercises. She's likely to have symptoms of this near. Very good. Thank you. So a little bit about heart failure and why we're talking about it today. So it is a global issue. It affects approximately 64.3 million people worldwide, and we're sort of seeing up to 4% of, uh, country population and being diagnosed with with heart failure. We know once a patient's been diagnosed with heart failure, their survival over five years is quite poor, so you can see the graph on the right hand side here. Um, survival is actually less than 40% at five years, both for patient's, with heart failure and preserved ejection fraction and heart failure, and reduced ejection fraction. And there's actually no significant difference between the survival of patient's with preserved ejection fraction and reduced ejection fraction. So why does diastolic dysfunction matter? Well, diastolic dysfunction causes an increase in the L V stiffness, which relates to, uh, elevated left ventricular filling pressure and therefore, uh, an increased left actual pressure. And this is really important on exertion. So we know that a lot of these patient's may have perhaps a normal, slightly elevated left actual pressure at rest. But as soon as they exercise, as soon as they go up there, go up the stairs at home and they can have symptoms of Dyspnea, um, and Pommery edema or exertion. And I just thought I'd show a picture of the steepest staircase in in in the world. Apparently, this is a in a mountain in China, and you'd think that some of our heart failure patients' may feel like they're climbing the stairs when they're when they're climbing at home. Um, we know that this, um uh, significant diastolic dysfunction is associated with an increased mortality both in our hep F and rff populations. And and therefore, it's really, really important that we address. We address that with threat therapeutic options and onto that, we know that there's good evidence for our patient's with heart failure with reduced ejection fraction that we've got good medical therapies, um, enable good treatment outcomes for patient's. But actually, there's no therapeutic options available and for our significant diastolic dysfunction patient's. And this is something that obviously really needs to be, um, improved to improve the outcomes for this patient group. Really interesting study from Do Park and group from the General of Clinical Research in Cardiology and demonstrated this really interesting data that showed patient's with heart failure. And atrial fibrillation actually do better when they have an interatrial shunt. Um, so the orange lines demonstrate Patient's without shunts, and the blue lines demonstrate patient's with shunts what you can see in all categories both heart failure, atrial fibrillation and a combination of heart failure and atrial fibrillation that all groups do better free from heart failure events. Um, with with with the presence of of an inter actual communication. So what does this mean? So, uh, we had excellent group of scientists and engineers come up with the idea. Well, if these patient's can do better with into actual shunts, and what about the patient's that don't have into actual shunts already? Why don't we create a communication and help to improve, um, improve the outcomes for these patient's? So in comes the H will flow regulator. So this was a device that was introduced probably back in 2014, very slowly and effectively is almost exactly the same as an ASD closure device. It has two disks, and it's implanted in the cath lab percutaneously. But the only difference compared to the ASD closure device is it simply has a hole in the middle. So it's creating, um, an ASD. It's a very, very simple procedure. A patient will have a natural septostomy and then this implanted again to to create a natural septal defect. So what's the evidence? This devices has sort of been implemented since 2014 in clinical trials. What? What's the evidence that we have up until now, in 2022? Um, so this is quite a nice meta analysis that I suggest that you read We're not going to focus on it today. It was released this year. However, the data involved in in the meta analysis was, um, extracted up until mid last year. And there's a couple of really important research papers that have actually come out since that time, which provide incremental data, uh, over and above, um, this this data that was found in this meta analysis, Um, my little rubbish red lines demonstrate the two studies that we're going to focus on in this talk. And that's the reduced lap heart failure trial, which has, um, two stages to it. Um, and the A f r pre pre live trial, um, which again has several papers associated associated with it. And the papers in this meta analysis are slightly older than the ones that will discuss, um, today so on to the real stuff onto the research side. So Well, firstly, start by giving a bit of background of the trials that have been taking place. Um, this is the reduced lap heart failure trial that was published in The Lancet in 2016. Um, it was a phase one trial for this, um, a f r device. Um, it was a prospective and non randomized study. They recruited 60 for patient's who were over the age of 40 and all fell into the category of having an ejection fraction greater than 40%. So preserved or mildly reduced ejection fraction, um, PC wedge pressure of greater than 15 millimeters of mercury. So we know this is a reflection of our left atrial pressure. Um, that's at rest or greater than 25 millimeters of mercury during exercise and and an nyha class of 22 to 4. So these patient's were taken into the cath lab, so you can see this lovely image. On the right hand side is a very busy cath lab with a poor patient on the on the table having a right heart catheter at the same time as performing a supine exercise using this bike. So not the most comfortable procedure, perhaps, um, but yeah, well done to him for doing that. So all patient's were moved on to have a right heart catheter looking at their cardiac output. They're right. Actual pressure, their PA systolic pressure and their primary capillary wedge pressure both at rest And during the supine exercise, uh, at both at baseline and then six months after the a fr implantation. And the measures that the primary outcome measures assessed in this trial were safety and efficacy of the device and functional capacity and clinical status. And these were both assessed over six months. What were the results? So the results were extremely encouraging. So almost all parameters that they assessed had a clinically uh, sorry. A statistically significant difference. Um, from baseline before the a fr implantation, um, to six months follow up. So the nyha class, as you can see in the top left hand corner here the median class significantly improved from class three to class, too. The mean six minute walk test that they performed, um, improved significantly from 313 to 345 m. And and then the the top right is the Minnesota Living with heart failure questionnaire, which is a common question there used to assess patient symptoms. Um, in heart failure, you can see a significant reduction in that score and a significantly improved exercise exercise time in that lovely supine exercise assessment. Just a little note to say that when we're looking at nyha class, um, in an un blinded study, we obviously know that we may be subject to some unintentional bias. The patient's know that they have this a fr um, implanted. And this may skew. Um, this sort of subjective analysis after implantation so busy slide would probably ignore the the top top bits. But just to demonstrate the four bottom panels and demonstrate a significant improvement, um, in the hemodynamic parameters, uh, exercise either at 20. What exercise And that peak exercise. Interestingly, there wasn't a change, a significant change in their wedge pressure at rest. Um, but we think this is sort of less important, given that most of these patients have significant symptoms on exertion and the left lateral pressure increases exertion so that the wedge pressure exercises is probably the key. The key figure. So the conclusions from this phase one trial were that the A f R implant is feasible. In Hedgpeth Patient's um, there were significant improvements in the wedge pressure nyha class and six minute walk test at six months, um, suggesting a potential clinical efficacy. But of course, further randomized control studies were needed, um, to finally determine the efficacy and safety of the A f R. But good, positive early results so on to the pre live study. So there's three papers at the moment that have been published in this, uh, with this trial. The first was back in 2019. There was a single center experience. Um, that's worth reading in 2022. But the one I wanted to focus on is the, uh, study from 2021 that was published in the European General of Heart Failure with the greatest number of patient's assessed and again very busy slide. But the protocol was fairly similar to the reduced lap trial. Um, in that patient's were taken to the cath lab and their baseline wedge pressures were assessed both at rest and that exercise and patient's with, uh, wedge pressure greater than 15 at rest and greater than 25. Exercise were included in trial. Um, the big difference with this trial, this is why I put my little star There was that these, uh this study actually has included patient's with heart failure with reduced ejection fraction as well. So patient with significant diastolic dysfunction plus reduced ejection fraction. So they had two arms of this study. If the patient's met the criteria for the wedge pressures, they went on to the cath lab to have a balloon atrial septostomy, um, and an implantation of the A F R device. So you can see in the bottom left hand corner. Here we have 20 for patient's with heart failure with reduced ejection fraction and 29 patient's with heart failure with preserved ejection fraction, and the primary endpoint that was assessed was serious adverse device effects. So any device dislodgement any embolization, anything related negatively to the device. Um, and the secondary endpoints included human dynamic variables within the cath lab, the same as the previous study patency of the device. Clinical variables, including Nyha class and six minute walk test UH, pro BMP assessment and echo measurements. So a summary of the results the implantation of the A F R. Was feasible in 98% of the patient's, um, during one year follow up, there were no shunt occlusions, no strokes and no worsening of right heart function. And at three months, we can delve deeper into these, um, these assessments. So what we have here is a breakdown of our palm, a capillary wedge pressure in all patient's, then to the right patient with reduced ejection fraction and then, um, at the end with preserved ejection fraction. What you can see is the wedge pressure significantly reduced in the in the patient group, um, and in the preserved ejection fraction group, but didn't reduce significantly in the patient's with heart failure with reduced ejection fraction. The pro BMP assessment was very variable at baseline and actually showed no significant change across all groups. But of course, that is likely to do with the high variability throughout. Study Nyha class, much like the previous study and significantly reduced by one. Um, and that's across all of the groups and the six minute walk test for most for the whole patient group reduced significantly. Um uh, sorry. Increased? Improved Significantly. Not reduced significantly. That would be worrying, um, and the six minute walk test for the patient's with heart failure with reduced ejection fraction, um improved significantly. So across most of the time parameters and across most of the patient groups, um, the six minute walk test improved. However, at 12 months, you can see my little star there again. 12 months for the patient with heart failure with preserved ejection fraction. There was actually no significant change in the six minute walk test compared to baseline. So a bit of an outlier there. So again, conclusions from this study exactly the same as the first. A f a f r implant is feasible both in heart failure with preserved ejection fraction, but also incrementally, uh, patient's with reduced ejection fraction. Um, the wedge pressure reduction and improve improvement in symptoms, quality of life and exercise capacity again show clinical potential clinical efficacy. But they again concluded that further randomized trials were needed to really truly assess the safety of this efficacy of the A f r. So on to the big beast. This is the reduced lap heart failure to trial that was published in The Lancet earlier on in this year. So it wasn't part of that meta analysis that we saw earlier on. And this really is the biggest study. Um, seen in this field at the moment, um, they managed to recruit an amazing 626 patient's. Um, uh, it was a randomized trial, blinded and sham controlled. Um, so they had patient's randomly assigned either to having the HDL shunt device or not having a sham procedure. Um, so patient's were literally taken into the cath lab had headphones put on. So they I couldn't hear what was happening had femoral access performs, Um, and 314 patient's had the device, and 312 patient's didn't go onto the device. So the only people that knew who was randomized to what was the intervention list? Um, the patient's weren't aware their heart failure and cardiologists were not aware either. Um, I don't really need to go over the inclusion criteria. This is exactly the same as what it was in in in the original in the original trial. Um, the difference again with this study is that they measured more, uh, sort of longer endpoints. And and we're more focused on, um, heart failure, heart failure events, um, and, uh, nyha class a longer time period compared to, um, the previous studies. So the primary endpoints included hierarchical composites of cardiovascular death and nonfatal ischemic stroke that was assessed up to 12 months. Um, there was an assessment of the rate of total heart failure events. Um, and a change in the K C C Q score, which is again, another heart failure, uh, sort of quality of life assessment. Um, and further secondary endpoints were assessed. So total heart failure events up to a time period of 24 months. So definitely the longest time period assessed a change in nyha class at 12 months. And and again, a change in K. C. Q, uh, score at 12 months. Unfortunately, um, the primary efficacy point, um did endpoint didn't differ between the sham control and the HDL shunt device. There are actually no significant differences found between the groups in the individual components of the primary endpoints. Um so what we can see here on the left hand side, this is the incidence of cardiovascular death or nonfatal ischemic stroke. And what you can see is very low number of events in both groups. But there's no significant difference between the two groups. There's actually a slightly higher although nonsignificant incidents for the atrial shunt device group. Um, And on the right hand side, this is the cumulative incidence of heart failure events over a 24 month period. And again, what you can see, um, is, uh, no significant difference in the heart failure events between the HR shunt device and the control the control, uh, group so disappointing results overall for promising very promising start. But if we start to break down, uh, the data, what we can see can see the bottom, uh, panel he. The median change for nyha functional class from baseline to 12 months was actually significantly different between the two groups. And there was a change in nyha a an improvement and then y h a class and for the HDL shunt device, Um, but what we also see in the K C C Q score So the quality of life score is that both groups actually improved in this parameter. And it's really difficult to actually see, um, sort of an actual treatment effect of the actual shunt device if you've got an improvement across to across the both both of the groups. Um, so I think this is something that really needs to be further explored and sort of extrapolated. And from this study, when the group went further into, uh, the assessment of the individual parameters, they performed a subgroup analysis and looked at the differential effect of, um, device treatment by pre specified groups. And they found some really interesting, uh, some really interesting points. So this is a slightly busy forest plot breaking down different elements or different parameters that they assessed and what they found. If you see in the center here, the left hand side is groups that favor the atrial Sandton. Right? Is groups that favor that the sham control? What you can see at the top bit is that feet, mails actually favored the HDL shunt device, um, significantly over males. Then, as you increase your right actual volume, you're looking at poor outcomes. So a lower right. Actual volume is consistent with a better outcome and or favoring of the H L shaped device. And then if we look at our primary artery systolic pressure at 20 watts of, um, uh, supine exercise, what we can see is the higher or the lower the Pommery pressure the better, or the more favorable that atrial shank devices. So I thought it just kind of conclude that at the bottom of this slide that actually three groups were shown to have worse heart failure events associated with the device. That's men right? Actual volume index over 29 mils per meter squared and the PA systolic pressure greater than 70 at 20 watts of X. What's of exercise? And if we were to remove these groups of patient's out of our assessment, Uh, in this study, you may find, you know, a different a different conclusion. And we know that actually, if we when we have included these patient's in this study, we're drawing, um effect towards the null hypothesis and therefore finding no significant difference and further post hoc analysis and demonstrated patient's with peak exercise upon the vascular resistance. Less than 1.7 would would units appeared to actually benefit from the shunt, with significantly less heart failure events and a change in the K C C Q score compared to patient's with the PVR of greater than 1.74. So what were the conclusions from this study? A placement of H sham device did not reduce the total heart failure events or improve health status in this heart failure population. However, what we've teased out further towards the end is this. Subgroup analysis and the post hoc analysis identify subgroups that demonstrate worse heart failure events with the A f R, but also in turn maybe suggesting populations that will favor, uh, the implantation of the actual flow regulated device. So it's not just patient's with elevated left actual pressure on exercise, but really honing down a little bit further into the into the population and trying to understand right who are the patient's within this population that could potentially respond, um, to this to this device. So a little bit of summary, hopefully just to kind of bring it all together with a lot of information there. But, um, to conclude the FR device has been proven to be a safe intervention with very few adverse effects. Um is associated with significant reduction in Palm. A capillary wedge pressure improved six minute walk parameters and nyha class. However, the most recent and significant study appeared to show uh, uh does not appear to show a significant change in the heart failure events or health status for patient's with preserved ejection fraction so disappointing neutral results. However, important lessons have been, uh, has been, uh, sort of left from these trials that provide necessary insights for future studies. We've identified potential, um, populations within our heart failure groups that could potentially respond well to this device. And this is particularly important as we circle back to the beginning of the talk where we remember that diastolic dysfunction in our heart failure patients' really has no therapeutic options at the moment. Um, this is beginning to show attraction. There are some favorable results here, and I think further assessments and further trials need to be performed to really understand and the usefulness of this device. And I thought I'd show here a couple of, um, sort of add ons to the papers that have been published. So the left hand side is the new, updated Prolieve, uh, results that were literally just published within the last few days. And this is actually sort of been joint on to the A f R. Frost, which is a new heart failure trial. Again, Um, looking at the A f R. Device and its role in patients with significant diastolic dysfunction. So I think keep your eye on those and watch this space and thank you very much for listening. Any questions? Happy to take done it again, uh, spoke with not turn my mic back on. Uh, so I've just popped into the message, section it in the chat. So please, pop any of your questions in there that was Just want to say thanks for that, Becky, that was really, really good. Um, it was really insightful. Was really concise. Lovely, great stuff. Um, from I was just wondering, I guess maybe from my sports background, my question kind of comes from it is, you know, in those initial trials where they looked at the six minute walk test and they looked at the sublime test. Well, perhaps it's not so possible in the former, but did they do anything to control for a learning effect within the patient's, so to do anything, just from like a trial run off the test initially just to ensure that we're all familiar with or anything like that. It's a good question, actually. And it's not something that I've read within the papers that they Yeah, and I think that's true both of the six minute walk test and also the supremacy pine exercise bike as well, which is something that's really unnatural. And if the first time that you've done it is when you're in the cath lab and having the AF are implanted than actually probably going to do better on on the supine exercise test after the a fr. Device because you've done it before, so it's a good question. I can definitely go back and have a look. But I didn't read anything about them sort of doing any and normally to begin with. So most likely haven't I would guess, unless they would have mentioned it. Uh, it's an interesting limitation. Um, one of the questions just has come in is, uh, do the A fr patient's required long term N Oh, I'm going to have to spell your second, um, forgive me NOAC therapy can read it. I again, uh, so do you f our patient's required long Do the the do the f f our patient's required long term n o a. C. Therapy? Um, I'm not sure. I think the only thing that they really require is, um, anti coagulation within the first six months as the same as a atrial septal defect Closure? Um uh, and then any normal heart failure medication that they would have, um, as per they're sort of usual. Um uh, heart failure. Um, treatment. Really? Yes. I think Anything specific to the devices. Just anti coagulation. Yeah. Cool. Um, another question from me. Uh, sorry. Just I'm interested. Um, did they just wondering, Did they do anything to control exercise or any exercise rehab within the patient's between the two. So, two cohorts, Not as far as I'm aware, gained nothing. Nothing within the studies about that would be really tough today. Um, cool. Uh um, those are the questions that I came out from that that was really good. Um, if anyone has any other questions, please pop the main. I'm gonna send a feedback form through for everyone. So if you can take a moment to complete that. That'd be amazing. I'd like to thank Becky Heaps for doing that. Talk is really, really good. Uh, no worries. I'd love to have you on again in the future, if that was of interest. Um, yeah. Um, And if anyone has any questions, I'm sure Bheki wouldn't mind addressing those and follow up over email or anything like that, if you do. Yeah. Cool. Alright. Thanks for everyone who's attendant tonight and enjoy the rest of your evening. Thank you. Thanks. Thanks, Kevin. Cheers.