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There's a 12 week teaching program that has been designed alongside asset for young budding surgeon. UM, This week we'll be having to webinar sessions. Actually, today the Webinar session will be on cardiothoracic surgery given by Mr Daria Condo Ra, who is a consultant cardiothoracic surgeon at Leiden University Medical Center in the Netherlands. And tomorrow's Webinar session will be on urology given by consultant. Mystery may hasten before I. Before I give the presentation over to Mr Can Dura, we'll be giving a short video on, uh, on excision of sebaceous cysts before we head off to the video. I would like to thank asset for helping us develop this course like to give a huge thank you to m d u for sponsoring us. Um, a huge shoutout to medal for providing us a platform for certificate and feedback forms. So without further ado, do I'll show you the video on excision of a sebaceous cyst, right? Sebaceous cyst excision. Yeah, Excision of the sebaceous cyst requires some care, as we ideally want to remove the cyst without damaging or breaking the integrity of its capital. Start by identifying the margins of your cyst, you should plan to make a slim, elliptical incision to include the punked. Um, if this is visible, there should be no more than a few millimeters in width. Make your incision over the top of the cyst, being careful not to go so deep as to puncture the capsule. Once in the subcutaneous tissue, it's preferable to use blunt dissection to gently dissect down to the capsule before working your way around the margins of the cyst. Try to only dissect that which you can see otherwise. You risk puncturing your capsule, and you will leave yourself with more work to do. Once you have freed your cyst from the surrounding subcutaneous tissue, you can gently work the cyst within its capsule out of your incision. Occasionally, there may be a stalk at the base of your cyst or infection may have caused the capsule two days. The surrounding tissue, which may require cutting. Be sure what you're cutting before you cut to avoid inadvertent damage to other structures. Once you've delivered your cyst, you can close the wound as demonstrated previously with either an interrupted suture or some particular common pitfalls. Carelessness when cutting and dissecting or grasping the cyst capsule with forceps can lead to rupture of the cyst. In this instance, the sebum or infected material must be evacuated. And then the capsule broken up before cleaning as leaving behind the capsule will see a recurrence. Use some gauze to sweep the inside of the wound to break up the capsule. Once cleaned, the wound should be left open and loosely packed with gauze or ribbon to allow the wound to drain. So that was your short video on the surgical excision of a cysts. Sebaceous cyst. Now, without further ado, do it gives me great pleasure to introduce you to Mr Daricon Dura, who is a consultant cardiothoracic surgeon at Leiden University Medical Center, uh, in the Netherlands. Good evening. And one, Um, yeah, before we started, I also would like to thank you for the kind invitation. And, uh, yeah, especially Martin, who was, uh, very dedicated and calling me 19 days to make this happen. So yeah, she was very focused. So my thank you to her, Uh, and, uh, let me see. We had some problems with shedding of the videos and everything is at the presentation shop. Let me see if I can do it like this. I, uh, see some thumbs up, So looks like it's working. Um, I moved to the Netherlands, uh, 9, 19 years ago and, uh, the first image that I saw the hospital Where work, the, uh, live university medical center was this one. And I thought, Yeah, it's a nice place place to to go to, right? I mean, you can go working by boat, and everything is very organized and very yeah, quality of life will be great. There. Fortunately, things to turn out a little bit more messy than this. Uh, if you, uh, start doing cardiothoracic surgeon surgery, then, um, yeah, you have a lot of nice shifts, and, uh, life cannot be. It's not always as quite as, uh, this picture shows. Um, when, uh, Martha asked me to present something about cardiac surgery, uh, that week we had a very interesting case. Uh, woman that, uh, I thought it was a nice case to present, uh, this evening. Um, you already have the title. So infective endocarditis. Usually I will, uh, keep it, uh, has a secret until the, uh, till the end, But yeah, you already know what we are talking about. And this young young woman, uh, recent medical history about with, uh, amputation of the lower left leg because of the osteosarcoma and because of her cancer, she had those are implantation or portacath is very important for the history of this, uh, this patient, um she well, regarding symptoms. She had some very, uh, stories with some back pain, this pain here, but nothing really particular. But she decided to go to the general practitioner, which sent her home with some paracetamol just for the pain and some, uh, medication for depression. So she thought it was not a civic series. Uh, medical, uh, something very serious. And, uh, the problem is that after 10 days, she turned back with the fever with some, uh, literate mental status. That is very important. This story, uh, decrease during output. And she was very physical cold, and she was complaining of short terms of breath. Also, the, uh, port a cat was, uh, showed some superficial infection. And when the g, p, uh, scooters there her heart, she heard some, uh, historic Marmor, uh, on the left lower sternal board border. So my first question to you guys is, uh Can someone tell me what, uh, you will do in this case? So you have the general practitioner and you have oppression with high fever. Uh, with with yeah, some, uh, altered mental status status. And yeah, she's political warm. She's not really not eating enough. And she's, uh, complaining of shortness of breath. Uh, the border cut is information. What? What to do? Yes, guys, if you have any. If you know the answers, please put it on the chat so that we can tell, uh, Mr Candeloro, your answers a thesis. So someone said she needs hospital admission? Yes, immediately. Hospital admission indeed. Because the patient is then cardiogenic shock. Uh, and yeah, there, there there are several kinds of shocks you can. Uh, yeah, I think of, uh, hemorrhagic shock problem in shock. Except Ishaq in this case is cardio cardiogenic. And yeah, the patient is, uh, low BP because, uh, and she's, uh, altered mental status because of the, uh, brain hyperperfusion. And and this is, uh, not related to blow feeling pressure. Uh, so she was immediately omitted to our hospital, and what we saw when she arrived on our attention is a patient who is mot economically unstable with low pressure. She's taking Kartik. She has a I CVD and fever. Uh, she also has a cysto diastolic murmur. Uh, I would like to focus on the Bystolic Marmor early diastolic murmur, but she also has this. Um, yeah, please, on the left. Uh, and then that's painful. Can someone tell me what? What? What it is someone's mentioned. General Lesion's almost almost almost good. Actually, it's, uh, Osler node. Uh uh. This is, uh, I'll show you in a in a second difference. But the ostler node, uh, immune complex, Uh, the position. So is there is a active inflammatory status. A pair. And the patient is, uh yeah, complaints of pain there. Uh, there is There is. Also, we also mentioned, uh, the historic, uh, murmur and yeah, fortunately, presentation is not working properly, But what you see here is this the holier, uh, movement on the left of the anterior mitral leaflet. So here you have the left. Uh, atrium is the left ventricle in between. Of course. You have the mitral valve with the anterior leaflet and the posterior leaflet, and here you have the, uh, left ventricular ultra ultra or threat with the aortic valve and the ascending order. Uh, so here, you see that the the, uh, left, uh, the anterior, um lift led to the mitral valve is moving, uh, a little bit funny. And it's like swimming in the, uh, left ventricle. And this is due to the A century jet of the aortic regurgitation. So there is blood coming from the ascending Ortho to the left ventricle in front of the, uh, metro leaflet, and that's creates some turbulence in the historic phase. And that is the what we call post in Flint Marmor. Um, we mentioned the general lesion that are the HIV will go very fast year because we that yeah, you can find in every every book but general Asian are very fickle embolization, and usually the patient comes a little bit later with this, uh, with this, uh, Asian because, uh, necrosis needs to to, uh, demarcate so the patient. Actually, when we when we see this kind of lesion, the patient is not painful anymore. So it's a dead tissue. And this is the main difference for a clinician to know. Uh, between the ostler, uh, notes and the general edition. The general issue are not painful. Is that the That the issue there is that? And then, uh, yeah, it's also important to know the sprinter, uh, signs that are due to, uh, micro emboli just microembolism ation. That's also something that we see every now and then. And if you are, uh, yeah, lucky enough to have a stable patient that stays in your department for a longer period than what we usually I used to in characters etcetera. You can also ask, uh, your colleague of, uh, dermatologist department to check for is right, you know, And you can see these, uh, lesion, uh, which are not, uh, nice, uh, planets that, uh, hanging out there. But there are, uh, Vision's underrating of the patient. And that's not really also very yeah, a nasty complication, because the patient is, uh, um can get right at the end of, um so the we Actually, I already knew what was going on with this patient, but we wanted to, uh, be sure. And just before going to the operating room, we did, uh, transthoracic ikan. And so again, you can see the left, uh, trim the left ventricle This is the mitral valve. You see that on the anterior leaflet or the much about? He had a big vegetation and actually here. I like these images very much because you can see here that yeah, they're all the mitral valve and the aortic valve, which yeah, we usually imagine us to Different structures are actually one world, and one continues to the, uh, to the other. So you have, uh, anteriorly flat to the matter of all which continues with non colony cusp of the rt bowel. And when you have an infection here, it's very easy that it will, uh, transmitting it to the to the to the mitral valve as well. And when you have some such a big destruction of your valve, it's easy that to get, uh, massive privilege rotation. So you see that the aortic valve here is not uh uh, no. This is a massive, massive regurgitation. And in this four chamber view, you see again the left atrium, the left ventricle, and, uh, the mitral valve, which has a massive regurgitation with blood going up to the, uh, venous there long veins. And yeah, we can see also that tricuspid valve which is, uh, massive regurgitation as well. Just very shortly. These two images which are made without trans, um, Songo Echo. You can see that. Yeah, there is a big vegetation on the, uh, TriCor spitball and a bigger treaty. Vegetation. Also on that micro bath with huge our to about regurgitation. So the patient was in cardiogenic shock because she couldn't make enough output. Uh, cardiac output. Uh, because all the, uh, blood that was, uh, the the ventricle was popping up on the aorta was coming back to the left ventricle to the left atrium and back to the lungs. Um, just for the fun of it. You? Yeah. Nowadays, we also have the three D, uh, echo. I don't know if you are, uh, confident with that if you see it often in your clinical practice, but you can really see from a surgical point of view what the patient is and what the delicious thing is and where it is. So this is the massive, uh, hesitation that the patient, uh, so actually, we were pretty much sure that we what we that we were dealing with effective and local diet ease. Uh, here based. Yeah, shortly. I want to mention that Duke criteria. I'm sure that everyone knows them. But you have to keep in mind that, uh, what we are used to, uh, for the Diovan, what we usually use for the diagnosis for and local diet. These are the two major criteria, and the two major criteria are the positive blood culture and the imaging, whatever it is positive for infective endocarditis. Mantis patient arrived. Yeah, uh, one hour ago in the hospital, and you don't have the blood culture. So you still need when you have only one major criteria, you also need free minor criteria. And yeah, actually, in this patient, uh, we can use, for example, the she did have any predisposing art condition, but And she was not, uh, drugs abuser. But she had, uh, Porta cut. And actually, that was the important trend for the end of her diet. She's, uh she also has fever. And she also at the Ulster Notes. So we have one major criteria, which is the, uh, echo and the, uh, free minor criteria. Uh, so that, uh, we we're really dealing with, uh, infective endocarditis. Um, And for the indication of surgery I want you to, um realize that we have free major indication, which is which are the heart failure. So the patient that the cardiogenic shock, the the uncontrolled infection and the prevention of, uh, embolism. So all of them, the only one, uh, indication for emergency surgery, which means bring the patient immediately to the or to the operating theater. Is that, uh, doctor Jenny shock for the rest. When you have a patient. When? When? When you you're, uh every day, Um, practice. You see a patient with the endocrine society's. Of course, you have to call the technologies. Of course, you have to refer to that the patient to the specialist. But, yeah, you have to really run only when the patient has hemodynamically programs of it. The rest are urgent. So the pain you cannot center. Of course, the patient at all. But, um, you have to run to the operating room only in case of cardiac fellow. So we decided to bring the patient to the, uh, the operating theater. And while while we were moving, are we, uh, she developed a stroke. Can someone tell me what to do now? Do we still have to proceed. Proceed with with operation or, uh, yeah, we can wait. Uh, that's why we will use the, uh, machine. So we would use a lot of the aspirin. And with a recent stroke, Yeah. Is there something that you want? What would you do? So someone's mentioned T p A. Yeah, it's quite difficult to to do. That is a good idea. But you can do it. Uh, yeah, he said, Yeah, we did some sometimes, but yeah, uh, but this is, uh, didn't show the city's kind of the right patient, but that was to paramedical to do that. But it's, uh, uh, It's a good, uh, a good option. Yes, but they're not suitable for this patient. So we Fortunately, we have also, uh, guidelines for that. And when you see the guidelines, uh, of course, they say that if you have, uh, the free indication that we already mentioned So the heart failure, uh, the uncontrolled infection and the risk of the embolization. You have to bring the patient to the operating room. Unless what you are going to do? So the operation will yeah, make the patient worth. And if a patient is a coma is, uh, yeah, she has, uh, patient has, uh, severe comorbidities or the stroke left with severe damage. Then you don't do that. And especially when you have, uh, when the patient is bleeding, So they, uh when the stroke is minimal And it's not that the patient is not bleeding you still have any attention to go immediately to the in this case, at least immediately, uh, to the operating room. So stroke is something that we learn. Uh, these guidelines change very recently is not, uh, strong communication anymore for for surgery. This is something that you Yeah, I think it's important for you to realize because yeah, you will see it in your practice. So we decide to go to the operating room. Uh, even if the patient, uh, I developed a stroke and was in very model angulus unstable situation. And when you have such a big, uh, infection on your heart, what you have to do is, uh, big surgery that we described this article, uh, in 2017, and I would like to first present some, uh, some, uh, drawings about it, because then then it's more clear. So you, um you have, uh, the valve, Uh, which is completely infected. So you have to remove the ascending or to remove the at least detach the current buttons and then remove the all the infected tissue. But the problem is, that is not only in the aortic valve, but the infection is Yeah, going down to the metro power to access the matter of all your to Yeah, open the left headroom and remove the tissue as well. Then you remove you open the left side room, we move the partially the infected tissue of the, uh, left and zero, uh, leaflet of the metro behalf, and you can do replacement. But if you want to, to repair the valve. And there's something that we try to systematically to do because the survival is better with that repair than with, uh, replacement. Then you have to choose our ring. And, uh, yeah, here comes the difficult part for the surgeon because usually we measure the size of the ring according to the, uh, the anterior, uh, micro leaflets. And yeah, when you remove, uh, most of it, then yeah, you have, Uh, yeah, very, uh, little to measure. And so here comes that that experience of the surgeon. So it's not something that you can do during your residency, for example, then you have to, uh, future the the ring. You use a Senna pericardial patch to, uh, restore the anterior, uh, matter leaflet. And then you have two options. Yeah, you have to reconstruct reconstruct the left ventricular outfall threat with, uh, ascending aorta, and you have to close the, uh, effect on the, uh, left bedroom. And we started doing this procedure of using two different pages. But, uh, we learned by experience that the chance of, uh, leakage here using two pages was quite high. So we developed this technique, were using a folded badge. So you followed this big patch. You, uh, use the mid part of the page to suture it to the, uh, mitral valve ring and then use the inferior part of the page to close the left edge. Um, and the anterior, uh, patch you will be your New York to where you can, uh, suture your new valve aorta valve. So here is the left atrium is closed and then use the anterior page to reconstruct the, uh, left ventricular out for track and then a singing or to and you can use. Yeah. In this case, we Yeah, we try to to use a normal graft of, uh, stentless, uh, procedure, uh, produces to, uh, restore the arctic valve and a sentence. And then you you attach again the current bottoms. Um, I would like to bring you to the operating room now, So, uh, yeah, we are in the face that we removed all the, uh, infected tissue. So the head of the patient this year on your left, the legs are right. And then you can see you can see the Arctic cannula, the aortic lamp. And this camera is what we used to give the cardioplegia, which because of this clamp when you have, uh, yeah, competent art evolve that, um, cardioplegia can only go to the, uh, coronaries. And then you have, uh, an arrested heart. Here you have the two venous cannulas to the superior, inferior vena cava. And the blood goes, goes to the, uh, heart along machine and then returns back with the oxygen on the aorta behind the plan to perform, uh, the rest of the body. Um, yes. You cannot see that much you can see only the left and the right current buttons. But for the rest, you can. Yeah. Have you don't recognize any structure? Yeah. And this is something that, uh yeah, we, um, see regularly. Um, it's actually, uh, left ventricle. That, uh, the surgeon is pointing out with these forces for Yeah, so we go further. I see that my battery's running out. I have to ask my wife, too, to bring me the recharger. Um, for on in this picture, You see that the, uh, again, the the ring has been Yeah. We are starting to search, uh, search er the ring on the metro back, generals. And this is here. Uh, so you have the left edge, which is open, and the left ventricle is here behind. And then here You can clearly see that the surgeon already attached at Senna Peri cardio patch on the, uh, wondering to reconstruct the mitral valve. Yeah, uh, here, uh, in front of it, you have the outflow check of the, uh, left ventricle. Then the next step is to search for the, uh, folded patch, and you can see here. So you you use this lower part for the left side room and the anterior part for the, uh, sorta and you close it and you'll reconstruct the eleventy Graterol threat and then you can use yeah, whatever you want. But usually the results are better with with, uh, biological valve. Uh, at least this is our believing. And, uh and, uh, so on, um, a graft or, uh, Freestyle. So why we should talk about look at that Because, yeah, it's, uh the incident is increasing. You will see it your everyday life and the, uh, a professional, Uh, timing is crucial because the more you wait, the higher the mortality is. And it's quite expensive. So yeah, it's, uh it's becoming a really, uh, problem for, uh, for the, uh, N h s. As as well as, uh, for the, uh, developed country on the other end. Uh, it's a very procedure. Very nice procedure to see because it's a It's a complex surgery. You need educating the hospital teams. And it's, um, something that you Yeah, you can only manage properly with a big team with the cardiologist cardiac surgeon. Uh, we also work with We are very likely to work with congenital heart uh, surgeons and and cardiologist. Neurologist? Because we'll see a lot of neurological complication urologist and nephrologist. Mm. And, uh, of course, uh, microbiologists. So the time of this kind of surgery is crucial. And this is why, Yeah, The many reasons why you also need, uh, endocarditis team, which are also indicated in the, uh, last European guidelines. Um, it's not a nice disease to have. I mean, the in hospital mortality is 17%. Still, it didn't change. Probably because, uh, we are seeing much more older patient. And the long term survival at five years is, uh, 60 17% which is, uh, in general. Uh, but it's something that you we also saw in our, uh, written down, uh, in our population, which was actually much sicker than than just an all developed endocarditis or single valve. And dermatitis was very This is, uh that's rivaled actuation in, uh, very disease patient with, uh, needed really huge major surgery. And the survival of five years is around 5 50%. And, uh, yeah, some. Yeah, we see also them coming back with recurrence. So, uh, this is what what I wanted to say for this, uh, public. Um, on on regarding, uh, in fact, you end of her dad is I don't know if you have questions. You want to ask me something? Any questions, guys? Yeah. Uh, okay. Um, and, uh, I Any questions, guys? Uh, I think if they have any questions, they'll ask you at the end. Okay, then we do, uh, shall try, uh, should I go straight to the the next presentations? Yes. Okay. And then just option. Let me see if I I figure you're still seen, uh, so it's loading up. I think we just need to wait a few seconds. Yeah, we've got it. We've got it. Mr. Uh, Yeah, Yeah. Okay. Um, so I'm a cardiac surgeon. I'm used to this kind of setting on, uh, with a lot of, uh can you ask coming out there just the patient, a lot of blood and, uh, kind of control chaos. And when we are talking about, uh, Tavis, we are talking about, uh, our stickball, uh, stenosis. And, yeah, the the results that I want to see during the operating room is, uh, more or less this. So, uh, stickball, which, uh, send the order without classification. all, uh, where, Uh, the valve has been removed. And where I can easily plant implant, uh, new pro prosthesis when my professor in Leiden asked me to join join the team. Uh, and you, uh, be more focused on the tab is I felt like, uh told him, uh, felt like, uh oh, Maldini like it was, uh, in my opinion, the greatest defenders in history. And when he was 17, they asked him, Yeah. Would you like to join on? Uh, our 1st, 1st, team. Uh, but yeah, the only place where you can play at the moment is, uh, left back. And it was not a lefty. So of course he said yes. And, yeah, I felt like like him, because I Yeah, my professor asked me to join for the for the time. This is not something you don't become a cardiothoracic surgeon to do tariffs, but if you can join the team, you just do that. So, um, when we talk about article, uh, babies, we talk about our Tybost analysis mainly. Actually, at the moment that we already started doing, uh, implantation on TV for article resuscitation. But it's not the main indication. And yeah, we know that when the patient has symptoms developed symptoms for for our Tybost. Analyst, then you have to hurry because the survival and, uh, yeah, the survival goes, uh, is very bad in a very short time. Until now. Until a couple of years ago, Uh, the only way to resolve to solve this problem was the, uh, operation. So with the Ms Sternotomy, we are now, yeah, we're very good results. Also, with many, uh, thoracotomy. He's also for the Arctic valve replacement. But when we, uh, talking, uh, whatever, I would like to show you how the results about the tabbies, which was the first time, was implanted in 2002. This is the first paper showing, uh, professor, uh, Caribbean, uh, who implanted it in France and that the click in the last 20 years actually didn't change the match. So you have, uh, delivery system, which goes to across the delicious. So in this case, the the Ortho past analysis, and just like you will do it with, uh, stent current extent, we will, uh, yeah, inflate the balloon and really release the stent and solve the stenosis. Um, this was the first about implanted, uh, was a very rudimentary valve, as you can see. And you do, uh, and the patient, uh, in this, uh, this very nice, nice record. Uh, the Doubters reports a survival of two days. So they were Yeah, very enthusiastic about the technique. But at that time, uh, the cleaner results were not that good. Let's say so. In the meanwhile, a lot happens. I go very fast here a lot that we have on the market. A lot of crabs. Uh, valve story. Uh, but what you need to know, uh yeah, is that there are two main, uh, kind of valves, the balloon expandable and the self responsible. And there are two way to implant. It is strong, completely transported, Uh, kind of hybrid approach with surgical access. Um, the most, uh, use accesses the transfemoral with street. About 90% of the procedure nowadays. Um, but yeah, sometimes we are forced to look for other options. And the second, the third access our surgical. So transapical and terms of cloudy in and why we need to go to talk about today is because also Yeah, Yeah. You will see your clinical practice. Uh, some patient with the tabes. Um, and yeah, if, uh, see, that's the or tiba replacement here. And the, uh, combined surgery are kind of steady. Quite numbers or even decline. Uh, amount of time implantation is, um, implementing a lot in the last year. It's exponential. And can someone tell me why we see so many implantation of the tariffs Is, uh, something is Archibald disease? Uh, contentious disease is sort of one pandemic like covid. Uh, there's something else going on. Any suggestion, guys? Well, what would be what we we are seeing now is that, um oh, sorry. Sorry. So we change the indication, actually, So there are. There were a lot of people at the beginning that we're not even candidates to, uh, receive an art ivar replacement, uh, now, because because, uh, with the Irish Patient's in 2011 with a partner, one trial, then we are partnering. 23 so patient that we're not surgical candidate, uh, with, uh, poor prognosis that we're, uh, just kind of, uh, palliative indication. And in this, uh, 10 years, uh, we switched to intermediate risk patient. And nowadays too low risk patient and the results of the last trial. The Parton Freer shows that the the surgery has even worse results than the time it's There is a lot of discussion about it, and they want to bother you about about that. But yeah, we have to know that there is also some Yeah, uh, statistics calculation behind these results and that, uh, the results are they combine um uh, outcomes or death, stroke and rehospitalization, which are strongly in favor of tabbies instead of surgery. So if you look for this kind of results, you get, uh, this kind of curves, Uh, but anyhow, this is important That take home message is that yeah, we are impending. The tab is also for the low risk patient's. Nowadays, uh, this is not the way it should work, of course, but Okay, uh, so if you go, we'll go to the operating room. What we do is, uh, yeah, we will insert, uh, sheet and, uh, delivery system in the descending aorta through the femoral, uh, artery. Then we pull back the vow to the the delivery system. And then we do this because, um, when you do this, the diameter of the delivery system will get bigger. So we we want to do it inside the patient, uh, to have the smaller, uh, French possible to insert in the sort of smaller cuts that are possible to insert in the family. Artie. And then, um, the system that gives you the possibility to, uh, look for the right position, uh, the valve. And then just like you will do, uh, with the current extent political stent, you inflate the balloon and you deliver the vault. The art of all the native or tubal will stay there. Uh, so the results are not comparable to the, uh, surgery, where where we remove all the classification is the main problem of the tally. But then you have, uh, functional al to Bob with very low gradients. Usually, if the patient that doesn't have a good, uh, very, very, uh, access you can do, uh, trans aortic access, which is, actually, um, the principal is certainly the same. Only you need to perform, uh, thoracotomy and function that, uh, left and takura, uh, epics, um, inserts the delivery system to the left ventricular epics. And that's it. Um, what we do in, uh, Laden is um, this is the typical setting of the, uh, room. So you have a skirt? Nerves, Uh, cardiothoracic surgeon, cardiologist, uh, imaging cardiologist. And, uh, this is a picture of, uh, a couple of years ago where all the patient's were, uh, intubated. So we need it also, uh, a sociologist working with us. But now, nowadays, 90% of the procedure are transfemoral, and the patient is awake, and we don't Yeah, we do just need some, uh, local anesthesia, and that's it. I also wanted to show you this picture here on the right, uh, show you that? Actually, the the things that we need to implant, uh, to be are actually, uh, free catheters. This is, uh, what we call the pigtail, which gives us helps us orientated, uh, inside the, uh, article sentence. Uh, then we have a pacemaker on the right, Um, which goes to the Rite Aid room and goes down to the right ventricle. Maybe someone of you can tell me later why we need a pacemaker. I'll show you, but, uh, yeah, it's, uh, would be nice if, uh, you already start thinking about it, and then we have the delivery system of the valve which goes through the Arctic. Uh, so we need three functions. Uh, and that's it. So we need the, uh, delivery system usually on the right femoral artery, because, uh, we work on the right side of the patient, but can can be, uh, both the growing czar, uh, suitable for it. And then we have two categories. Um, so this is the pacemaker, which is more medial, and you can see that it goes to the, uh, than, uh, femoral vein. And, uh, this is the big tail that will help us, Uh, orientate ing, uh, for the orientation. Uh, I'm sorry for the video quality of the video. It's an old video that we did a couple of years ago. And, yeah, you can see the pacemaker, the pigtail and the boat. So we put the pigtail on the non current cusp. So which is the lower cast for the, uh, the rt plane? And then, with, uh, wire, we pass through the rt valve, and then we are inside the ventricle we deliver. This is the develop with the delivery system, which goes through the femoral artery, a celiac artery, uh, abdominal aorta to the, uh, state to the, uh, Ortho bound. And then in this case, we choose to, uh, dilate the article first with a balloon and then you see es, uh, the most the central part of the, uh implementation. And you see that we have, uh, BP was going down, and we do that with high rate of, uh, pacemaker. All right, uh, I write a patient with, uh, pacemaker, which is imprinting the right ventricle. And while the BP goes down so we have no cardiac output, we inflate the balloon. So the balloon will stay in place in this, uh, in this moment because we don't have any cardiac output, and then the frame and the the aortic Well, because of the calcification of the aorta, uh, will stay here in in place, and then we do, uh, check angiographic check. And we see that the coronary, uh, open. And we don't see much vegetation in this case. So the wall was, uh, successfully implanted. The problem is that we, uh the delivery system is still quite big. During the this 20 years, the French, uh, sites have been Yeah, uh, getting small, smaller and smaller. But the smaller that we have is, uh, 60 16 French at the moment, which is, uh, 55 millimeters, 5.3 millimeters. So we cannot at the patient's are, you know, quite old, uh, everyone has, uh, high potential. So closing by compressing, uh, family. Artie, Uh, which has all of five millimeters. Uh, it's not an easy task. So we usually use this system, which is called, uh, Cipro and, uh and yeah, this system goes is, uh, substitution of the surgeon in faith because we What we see is that look, look at the video, shows it properly. So it goes through the, uh, in the vessel. And then thanks to a needle which goes around the hole that you made with, uh, selling a technique, you can put a note in place. And when the procedure is done, you can close the, uh, the whole just by pushing there before not inside the system. So this, uh, something that we use by every single case, we better see problems. You can see it now. Yeah, that that the note has been pushed down with this system. And, uh, and the for morality is closed. Now, um I just wanted to conclude saying that, uh, while yeah, probably the picture. The slide is now too small to to see it, but, um, surgical about replacement still has an important role in art in Boston. OSIs whenever, uh, the patient as, uh needs a concomitant, uh, surgery or is too young or is there is a, uh, high risk of a, uh, pacemaker implantation. Then, uh, we prefer to, uh, yeah, performer. So surgical about replacement. But we are also assisting to, uh, current of, uh, paradigm shift. Because especially, we are now saying everyone is a candidate for to be unless there are some good reason to to do to do otherwise. Um, So concomitant surgery is one of the reasons the most, uh, common reason, but also, uh, yeah, young patient and, uh, fear of, uh, pacemaker and power of, uh uh, the other two main things, Uh, that we have to take in consideration, But in the future, uh, single arctic valve replacement will be, um uh uh, cured by tab implantation. And I'm sure that a lot of, uh, you will see in the future patient's with Daddy. Also in the young age, And, uh, this, uh, short video shows you also another extra reason why? Because in, uh, this was made in 2, 2017 again when the patient's were still intubated and all the patient we're still intubated, and we re perform. Also, some cut down to expose the, uh, former family arteries. And in 67 hours time, we did seven, uh, to bob replacement with Davies, Uh, on the same time in the surgical teeter you can do if you are very fast free. Um, so it's a technique, which is yeah, to stay and that, uh, you will face also in your clinical practice. Um, I would like to finish by saying, Yeah, I was also asking to spend some words about why I choose, uh, surgery. Um, there are, uh, several reasons I don't see the piece, the other two slides. But anyhow, uh, we don't do it for money because, yeah, uh, there is the, uh, cardio, uh, automatic surgeon plus surgeon. They they they gain much more money than the than us. We don't do it for a healthy lifestyle because yeah, over you are doctors. And you know what's, uh uh, night shifts, means. And, uh and, uh, long hour days, Uh, working hours in the operating room over in the hospital means so we don't do it for that. But cardio surgery as the, uh uh, it's quite special on this, because we, uh c measures surgeries like show you with the endo conducted, uh, patient. And also, uh, the future is also there, uh, with minimal invasive surgery and, uh, mini thoracotomy knees. And, uh, so it's a combined, Uh, both of the, uh, special is, um so can be a cardiology and characteristics surgery. And I, like, also work with team with other people. So, yeah, you need You have everyday contact with other, uh, specialist cardiologists and sociologists, intensive care. And, uh, radiologists, you need to know a lot of, uh, radiology neurology. Because if you implant, uh, possible. But you do do your planning. A video case, uh, you have to recognize and something measure. Uh uh. What you are on the CT scans and the pet city. What you are going to do at, uh, the day after interpreting room, but yeah, it's very cool. And I'm sure that my Children, uh, very proud of what We're, uh that is doing as a characteristic surgeon. So this is also a good reason there was, uh, what I want to say about, uh, characterizes surgery tonight. Um, I'll give you the word to you. Hold it. Um, I think it was a very amazing presentation. Mr Can Dura, uh, I thoroughly enjoyed, and I I myself don't know much about cardiothoracic surgery because we didn't I didn't really have much of, uh, you know, much of a placement when I was in medical school, but I thoroughly enjoyed. I think it's a great specialty. Just by listening to you, I can see how passionate you are yourself about cardiothoracic surgery. Uh, and I'm sure a lot of us would feel the same way as well. Um, does anyone have questions to ask Mr Condor about cardiothoracic surgery at all? Mhm. So, um, so someone's asked you to someone's method. Thank you so much for the talk. Um, this This will help someone in their placement over the next two weeks, but someone's asked if it's possible to get Mr Can Duras email for any further questions. Would you be happy to for us to give the email address Mr the Cardura. This trump prevent all? Of course. Of course. So happy to do that. Yeah. So we'll we'll, uh, We'll give you, uh, Mr Condos email for you guys to answer. I'll ask any questions? Um, but and any questions at all? Guys, I put the on the shop. Amazing. Thank you. Um, so one person's asked, um, my question is about the work life balance. Is it much different than general surgery? The thing about general surgery is that at least my experience is that the team is much, much bigger. So, of course, uh, they have, like, us nowadays. Uh, we're super specialities. So, yeah, if you need to do a particular surgery, you know that, uh, everyone is, uh, indispensable. But you we what, we the problem with catheterizing surgery is that even in big universities and academic hospital, uh uh, the group is very bigger than a you know, 56 people. So if you, um, someone get six, or or, uh, the amount of money and the work is you got to do and the, uh, meetings that you have to attend. Um, you are constantly, uh, you constantly don't have enough people to do all the work that you have to do daily. Um, so I think the balance is, uh mm. Uh, it's something that probably I wouldn't, uh, suggest, uh, to my Children out to do, to be honest, so I have to, uh, you have to be very motivated. And, uh, here in the Netherlands, where I live, the work, uh, private life balance is very important. Um, and only the last five years, um, three people, very brilliant related, uh, decided to retire and to switch for another spirituality because, uh, yeah, uh, there is too much work to do, and you are much, much more in the hospital than than outside. That said, um, it's the price that you have to pay for doing the most incredible job in the world. I mean, the feeling that you have by stopping somebody's, uh, heart and having it in your and repair it. And when you are done, uh, making, uh, Byetta gain, it's something that I'm not sure that general surgeon will feel. And, uh, especially on a daily daily base. Uh, so you have to be very passionate. And, uh, if you, uh, have the extra motivation to do. Yeah, the extra mile. Um, my suggestion is, you know, do it because it's the most amazing job in the world. But you have to know that you have two patients sacrifice for that, Um, someone's mentioned. Do you think there'll be a time where cardiac sergeants won't be needed? And healthcare will rely on cardiologists, especially with how procedures are becoming increasingly more minimal, minimally invasive? It's a very good question we are then dealing with it on a daily base. Um, the thing is that what we are seeing is that the quality of their resiliency probably is getting, uh, worse because of the Valium that we, uh, that we are seeing as young surgeons is not already comparable to, uh, what our teachers at, uh, in their period. But yeah, people will still get shot on the street. Uh, there, there, there will always be a patient coming, uh, with, uh, preference lung, Uh, infective endocarditis and those kind of problems. Uh, you cannot really, really complex, complex, uh, surgeries, which are not, uh, still solvable and won't be solvable by cardiologist. You can see also with, uh, procedure like a normal cabbage, which is a procedure that was initiated in the 1960 steal. The results when you use, uh, arterial graphs are not, uh, not comparable with stents. And I mean that the the surgeries as offers much better results than what our, uh, interventional cardiologists can do. So, to answer the question, cardiac surgery is here to stay. It needs to evolve. Uh, but I don't see an ending to it. Um, someone else asked. Do cardiothoracic surgeons have a chance to specialize in lung surgery in particular? Yes. So, uh, it depends on the on the country where you do the residency. I think in England is the same as, uh, here in the in the states. So you get the training as a cardiothoracic surgery. Italy. We do something different. We do cardiovascular. Uh, and we don't do lungs, but at the end, even if you are trained, last has characterized surgery. Um, you get subspecialized in one category. You cannot do even Yeah, even in think this small, uh, field where I work. Um, so characteristic surgery is very specific. Sounds very specific, but there are colleagues who are more specialized in the, uh, valves repair. There are more colleagues that are more specialized in our failures. So, uh, artificial arts and, uh, and some colleagues just do lung surgery. Uh, but, uh, the residency for what I know at least also in England, is, uh, for a character, ask the surgeons. So you first have to do yet to be good enough in both, and then if you want, you can sub specialist. And this is actually the future. This is something that everybody aspect aspect form from from a characteristic surgeon now to be, uh, mini focused in a sub specialisation mhm. And during your presentation, you mentioned that during tabbies the cardiac surgeons are doing the procedure themselves. But are the cardiologists what do the cardiologists do? The reason why there are several hospitals where, uh, the cardiologist do Tavis nowadays alone? Uh, and there's something that we are completely against the concert in, Uh, uh, Biden, because the problem is that when you have a complication, so you have a major bleeding. If you have, uh, pop up pop down on the valves. So the valves instead of staying We didn't mention the complications of these, uh, procedure because that time, But when you have it can happen that evolves doesn't stay in place. Uh, for several reasons, you have, uh, less calcification their fault with than what you thought, or you are over sizing under sizing the valve that you choose. Then you can have a pop up pop down. Then you have, uh, to be prostheses, which is swimming. Uh, either in your sentence or so or in the left ventricle. And yeah, if the cardiologist has some this kind of complication, then it needs to call the surgeon at the very last moment with a patient who doesn't have usually, um, proper functioning Arctic native 40 valve because it's been especially partially destroyed. Uh, destructed by the, uh, the procedure. And then the patient is, uh, two problems. So you have a valve which can give you some amble ization and, uh, native rt valve, which is given causing you, uh, economic, uh, stability of the patient. So the surgeon, without knowing the patient, needs to bring the patient to the operating room. And even without knowing if, uh, male or female, we just open the patient and yeah, you hope that you're doing something? Uh, yeah, correct for the patient But this is not the way we work. We want to know, uh, starting from the planning. Uh, what is the best, uh, for this? That single patient. So we made the decision together, cardiologist and characterized insurgents. We make the measures together, Uh, we choose for the, uh, all together, and then we implant it together so that if we have a problem, the vow that, uh, operating the theater where we work is a hybrid. Uh, it's very It's very new. Uh, since, uh, a couple of months as you work there, it's amazing. You can do whatever you want. The patient doesn't need to move from the table where it is, uh, putting on. And then we jump go on with the surgery instead of, uh, yeah, run after the complication in the very last moment. So the results in our center is, um yeah, we think better than than than than others. Because of this reason we do it together. Uh huh. Uh, and one last question, Mr Khan Dura. Um um, someone mentioned, um, are there any screening tests that you do to detect cardiac amyloidosis in patients with severe aortic stenosis undergoing tabbies? Wow, very good question. Yeah, cardiac, uh, hot topic in the cardiologist, uh, field, I think you can also easily detected, uh, by ICO. I mean, when you Yeah, there are some aspects. Uh, when you do, uh, when you perform a trans of a gel or transit thoracic, you go. You can see the particular peculiar trans, uh, limited insee of the septum and, uh, negative. And yeah, you You can start with that by, uh, suspicious. Um, Trans cirrhotic. Uh, then we then we do. We do also the genetic test immediately. Uh, but all the pensions who, uh, get a to be, uh, by definition will get also a CT scan with contrast. And sometimes you, uh you can use that also for the for the screening. So I have to say, in our practice, uh, we don't see them much, But when you when? When you suspect it. You? Yeah, usually you're on time because, uh, the screen is quite extensive. And even if you don't want to see it at the center point there you will bump into some, uh, peculiar images that will, uh, bring a bell to you and say, Yeah, we have to do that genetic test? Yes. Amazing. Thank you, Mr Condor. A forgiving. An amazing presentation today on cardiothoracic surgery. Um, I already enjoyed it. And a lot of people have personally messaged me saying Thank you for giving this amazing presentation, Mr Khan. Dura. Um, it's been very, uh yeah, it's a great specialty. It's very complex surgery that you've just shown us. And, uh, yeah. Thank you so much, Mr Khan. Dura. Um, guys, I just want to ask you if you can kindly fill up the feedback forms, uh, so that you can get your certificates and like us for us, feedback forms are just as important as, Well, um, so we'll be gratefully be very grateful if you can fill out these feedback forms. Uh, tomorrow, Um, there'll be a teaching webinar session on urology that will be given by Ms Darlene May hasten. Who is a consultant? Neurologist. Abstinence. A Helios hospital. Um, once again, Mr Can Dura Thank you so much for today. Uh, next time. Yeah. Thank you. Till next. Come in and see you tomorrow, guys. If you can make it bye bye.