Penn Presbyterian Medical Center’s Grand Rounds program welcomed W. Clark Hargrove, III, MD, a Clinical Professor of Surgery at the University of Pennsylvania. Dr. Hargrove discussed the major milestones and advancements in cardiovascular surgery.
there. Dr Abraham and Hey, dr Hargrove. I was worried about you for a minute there. You're muted right now. I just need you to UNm mute. You're still muted. Dr Hargrove. And then now is your we can hear your audio now. Just um thank you. Just need you to share your story. Okay? You may need to turn up the volume on this off way. Yeah, I'm going to do that now. I didn't want to do it while he was setting everything up. Um All right, find the ice, that free throw shooter here, you know, now is he mixed up or he's running and going through my computer so they can hear me as well. You would have to be closing up here. Good morning everybody. Um We'll get started shortly. I hope you guys can hear me. Okay? I'm Wilson Zito cardiac surgery here at penn presbyterian. It's certainly a pleasure to see everybody here in person. It's been a few years, a long, two years. So it's been very nice bill. Get everybody together for surgical grand rounds. Um Today, um we are honored to have dr hard growth. Um He does not need any need any introduction. All of you know who he is. Uh Park here has been a very special individual. Um and and he asked me to keep this introduction. So I fail. Finally gonna listen to me, but I'm gonna, but I'm going to keep it very, very short and just want to take the opportunity to recognize all the great work that he has done what he's meant to penn presbyterian and to all the, you know, individuals in this group. And I just want to say thank you for what you've meant to me personally, I trained here and I grew up here and I learned a lot from you and as you said, you know, you taught me everything I know, but you haven't taught me everything, you know? So I'm really looking forward to this talk and uh thank you. Thank you, Wilson, mm hmm. My my my my ninth grade english teacher, mrs Ruffin made us memorize a number of passages from Shakespeare Milton chaucer. And this one is kind of stuck with me over the years. I think it kind of defines the essence of man's existence. Um we all strut in front of our upon some stage my stage has been presbyterian for the last 40 years. So it's been great to be here. It's been a great run as I was cleaning my desk out of of, you know, 30 years worth of papers in there. Um I came across this paper from the, from the texas Heart Institute and I thought it's maybe a good place to jump off for my, my talk here today. And as often point out these are topics that are personal choices for them, but I think in general reflect what's happened in the last century of of, of advancement. Um and here are their their choices. I'll spend a little just a little time on the, on to echocardiography. I didn't obviously didn't have much to do with it. Market capitalization. So I called josephina yesterday morning and I said joe when did we start doing T. E. At penn in the operating room? And he said well when I when he finished his actually it's interesting that that right shot used to come to the O. R. When I was a fellow in 1982 and bring the eco pro. But these were epic cardinal echoes. But we started doing extra cardio echo in the O. R. When joe finished his residency, they were looking for somebody to do T. E. And so not write checks, started coming to the O. R. And joe would do the teas and teach not Radchenko about cardiac surgery. And um and that would teach joe about about echocardiography. So that's how it started basically. Back in 1990. I told when joe yesterday was home recuperating from covid. So if he's on this zoom call today, I hope he's feeling better. Obviously I didn't have anything to do with cardiac catheterization for which um Andre cornered and Dickinson richards and burn enforcement won the Nobel prize but had not been for Carney R angiography introduced by mason silence at the Cleveland clinic. There probably wouldn't have been much in the way of cardiac surgery because there wouldn't be any cases to do. So this cardiac surgery took off with coronary surgery. Uh more and more people became interested in the field. Okay, maybe I can get a big bottle of water Michelle course. This one didn't come up anyway. Oh, here we go. So I've been titled milestones and cardiac surgery slash cardiology. Cardiologist should really probably be the big, the big letters and cardiac surgery. The small letters, but at any rate, it's a personal perspective. Um and this disclosure. So I'll try not to make this death by power point. This is the americans, the pentagon strategy for stabilization in Afghanistan. Of course, we all know how that worked out. In fact, Stanley McChrystal said when we understand the slide will have won the war. So obviously nobody ever figured out the slide. Uh huh secondly, this is for the most part of probably a tropical trivial um talk might be able to get published in the annals of improbable research, which comes out I think two or three times a year and they actually dickens Okay. This new laptop sometimes doesn't work right. Anyway, they give annual ignoble prizes for the 10 most celebrated unusual and trivial achievements of the year. So maybe this will fit into that category. And if we look at history, we have divergent points of view from George Santayana to Henry, ford, predicting the future is not much easier tom Watson was not the golfer, but the chairman of IBM uh and you can see how right he was. Of course, nobody everybody knows who Bill Gates was. Mike was just commenting on my new laptop has 32 gigs of ram memory here. Uh, So at any rate. Um, so these are my surgical surgical mentors at 10. I know that most of you you wouldn't know Jack Matthew, but Jack was a north Carolinian and he gave me my job at penn on sight unseen after telephone call. It was that Jack, I wouldn't be here today. And doc fits many of you know him. The fits surgical library pen. This is doc fits in his army uniform. The pen surgical service ran the he ran the 20th general hospital in Burma china china china burma India theater in the Second World War. And that's actually where hank shea operating on Lord Mountbatten and Lord Mountbatten came over for the dedication of the shape building when it was when it was built. Anyway. Dr fitz became this Yeah. Period. And he actually was one of the founders of the american Association of trauma surgery. There's a electric in his honor named and this is a picture. It's actually spine you can't see because I didn't take it out of the frame but that he gave me after when I was finishing because I was Clive barker's first hire when he was the john Ray Barton professor and Jonathan Rhodes was one of the great surgical scientists of the 20th century. He along with Stanley Diedrich um, developed what we now call. Uh call the hyper implementation back then. It's totally peripheral nutrition now. Dr Rose at one time was provost of the university Chairman of the department of surgery, President american college of surgeons. And he was so busy during the week. And you love us all the surgery on saturday. So they started seven o'clock, saturday morning clips Wagman and Jack Mackie opened and closed for him and he operated until midnight. So anyway but he was he was a grand old man. He was also a Quaker. So he stayed in philadelphia during when all the rest of them or in the war. He was also a Quaker when he died because he made them keep him alive until june january one the following year for tax purposes. And then he told him to turn the I. V. S off. So that and that's true that's job Rivera he was taken care of because dr roberts was some of my mentor in vascular surgery. I can still hear him saying, put the needle in at right angle sports as I've said to you guys a few times of course, hank Edwards was the principal investigator of the national original ECMO study in the United States. And if you think there's sickness and suffering and death now associated with that procedure should have been around then. Ah Anyway um My my other on the shoulders of giants as they say and I'll talk more about these as we go. So um okay so uh this is a villain. Eindhoven in his lab in Leiden in the Netherlands. And this is a patient undergoing an electrocardiogram, The so called stream Galvin on a tree. And the guy is surely, thank you to himself. I don't care about that Nobel prize you won. There's gotta be a better way than this. Of course he was right. It only took 110 years and you can weigh 80 kg on your wrist now. So anyway, the next historical figure I'll talk about is the as George minds. George was an englishman born in Bath, educated at Sidney Sussex College Cambridge, I'm sure Michael tell us where that is. At any rate. He was a brilliant young physiologist, graduated from Cambridge when he was 19 years old. And in 2000 and 1913 published this paper called dynamic keeping on dynamic equilibrium of the heart, where he defined the requirements for re entry, which is the basis for all uh most. I was as far as we know, all surgery, cardiac surgery or arrhythmias by the time he was 28 he was the professor and chairman of the department of physiology at McGill University in Canada. And he, when he was that that year, he was found unconscious on the floor of his lab early one morning. I thought it was probably a victim of self experimentation in any way the neck was skipped forward in 1930. And and then the american heart journal. These gentlemen published this paper which now carries the demonic wolf Parkinson and white paul Dudley White is cardiologist from the M. Th on the right and it was entitled bundle branch block with short pr interval in healthy young people prone to para accessible, attack the cardio. And of course it was a case report 11 patients all young. There was a mechanism that was a lot of speculation quite frankly if you go back and read the paper and it took this this paper by Charles Wolf fourth and and Fran would at penn to define the mechanism of the E. K. G. And the and the super ventricular tachycardia charlie Wilford junior was actually at one time here the Chief of surgery Presby and Hahnemann uh and uh dr Woods was pinned for quite a while. Um And they use this they use deductive reasoning and physical exam to conclude that it could not be bundle branch block. The the mechanism obviously here the pre excitation council in the down the bundle of kim and then the the SPT slowing through the aveeno. So you so slowing conduction and unit directional block via the bypass track. Here's doctor Doctor would teaching opinion in the sixties. Um I would he was around I think he only retired in 1984. So I actually have seen walking back and forth to the V. A. When I was going over there as a general surgery resident. He was he was quite a today quite a gentleman usually had a bow tie on. Although they obviously didn't in this picture. Um But anyway a lovely person. Um And obviously repository of knowledge. I'm sure Harvey knew him I doubt. I don't know. What did you know him? Bill Martha? Harvey. Yeah. Yeah. Yeah. I'm sure you knew him anyway. Quite a quite a gentleman. He actually had a tree in his backyard and have it for he had gotten seeds from Hippocrates Tree on the isle of coast, you know what I mean? Triple us. But anyway that one of those in his backyard the next is john madden john was actually an interesting gentleman. This is me as a chief resident in surgery 1979. And dr martin I think was doing some of rectal fall durations for for rectal cancer. And so I went up to visit him one day and this is the examining the patient and I'm I'm sure he thought to himself, this guy, I never learned to be a rectal exam. I think he should be a heart surgeon. But my demand was quite a prolific publisher. He would two or three atlases. And while in private practice and he also contributed to to our knowledge of uh ligation and left Philip image for a current block. This was two sisters. A case report. Obviously 1948 I believe it is. Yeah. At any rate there were two patients, both with rheumatic heart disease, atrial fibrillation and recurrent peripheral imbalance. So he says that the knowledge that then was in probably today's these emblems were coming from the left actually depending so he took him to the operating room and litigated the appendage. The results weren't so hard. Obviously one had a major stroke in the yard and the other one died suddenly on post op day nine. I don't know what the sts court would say about that. But at any rate we certainly would probably never see this report in the literature today. But anyway Dot man was a wonderful guy uh and uh and he obviously made a nice contribution and now management of the what we call management of the left dependence is a key part of the management of patients with atrial fibrillation. So Doctor Will Seeley was most people consider the father of arrhythmia services. The paper written by randy Chitwood. This is Dr Seeley and this is his up first patient. The patient was what was from the outer banks of north Carolina what we call a high tide er And anyway he'd been in S. V. T. For six months and so he came to do and obviously heart failure because going to heart beating 100 and 50 times a minute for six months and put you in the heart failure and they obviously had a burgeoning ep group it do and they took him to the operator and this is the report from their first successful a delegation of what they call a bundle of Kent and especially left of work Parkinson white syndrome. And unfortunately for dr sealy and the patient, it was the right free wall bypass tract which are the easiest ones to treat because they didn't have to go on the heart lung machine. And so here's the ep studies, intra operative ep studies and you can see on the right the I guess you're left the the pre the when the before they they're section to bypass track and the one on the right is after they were successful in and closing it. Um and dr Cecily of course said he was a very humble man said, I can call from these from certainty that this work uh that both of us with the fishermen who were in the right place at the right time. So the next significant um contribution in the world of electrophysiology, I'll get around and why it's important to me in a minute was by the actually interesting U. S. Public health service in Staten Island. And the guy responsible or ran the service was Tony d'Amato. And it's interesting the people that he trained included ken Rosen, Mark johnson, jeremy Ruskin and john Gallagher. So these were the who's who of VP when it and when it started. Um and they all made significant contributions to the field, the next one which came from the Netherlands hein Wellens and dark dura, you know, keeping up the long tradition of electro cardiogram fee in the in in the in the Netherlands. And they showed that you could induce VT and a patient not kill the patient. What? Huh. Okay. Anyway, so these two gentlemen were friends and mentors. They were both had a sense of arrogance about them, but they were both very sharing of that harvey will tell you to that. They were both sharing of their knowledge and we're loving in a sense, lovely people. But as of saturday then behind died two years ago, they used to run a cardio E. K. G course in europe was I think medtronic sponsored and then I went two or three times because it was a free trip to europe. Those were the days, my friend, they could tell you, I'm telling you who your great grand, what your great grandfather did by looking at you kg. It's the most incredible thing I've ever seen. I don't know how they did it, but it was it was quite a quite a meeting of course. Uh Alden Harken was also at the right place at the right time by hooking up with Mark johnson and Lynn Horowitz too reported he was the surgeon who did the surgery for their for the malignant arrhythmias and described uh the treatment of of uh reproducible district called to the speed Point and left and went to Denver when he didn't get the chairman of surgery pen. And I think he runs the program in um in uh in Berkeley. Now I'll speak a little bit more about when I talk about that. And finally Gerard Gerard don't help me do four or five W. P. W. He was a Frenchman but ultimately end up in London. Ontario did a number of contributions to ep surgery. This is a drawing he did. He helped me do a post here septal a bypass track and I saved it. And and here you see uh he was he was an artist. And finally jimmy cox was a great mentor of mine. He sometimes this laptop. Anyway there's a picture jimmy here somewhere. There we go. Anyway. Anyway obviously he developed the maze procedure. Always kidding him. He was on uh iteration three or four before he got 25 patients. But it's certainly a significant contribution to the field of cardiac surgery. And we use it today. Uh Still left of april fibrillation. Still being a black box. Anyway here's the here's our experience, his my my personal experience with arrhythmia surgery ah from 1984 to 1988. We obviously did a number of WP W patients with excellent results. And then also did a V. Node. The reentry. Obviously this all disappeared when you got caster ablation. And here's the the s the V. T. Uh ah um experience. I think this is probably where I started getting gray hair. As you can see there was a high risk procedure right? Yes. Uh And I paid a dear price for it at any rate. It was a terrific experience for me is how I started my academic career between all of them myself. We had the largest indoor cardio reception series in the world. Uh And we'll see the help me do some operations as did uh jim cox and Gerard so I laugh. There we go. VT surgeon dug feeder just went the way of surgical aortic valve replacement. And I think the reasons were multiple. One there was a high operative mortality for VT operations. T. P. A. Probably kept people from getting large ventricular aneurysms. Best I can tell ai C. D. Which I comment on the minute and then obviously the capital bless. You took away completely away the the S. V. T. Operations and a lot of the HVT operations. So this is a Michelle Morawski and his co inventor who I actually hadn't realized that until the other day working in the basement of Mount Sinai Hospital in Baltimore developed this defibrillator. It was controversial. Burnett Bernie Lion Bernard loud thought that it would be it would they would electrocute patients but unfortunately wound was wrong and they were right because um and this is uh it became obviously the mainstay of therapy for VT now. And this is actually the last sunday's Wall Street Journal. This is dr mauer's obituary. And there's another obituary for him yesterday in the new york times. So he just recently died I guess he had as much to do with it as Michelle Marasco. But anyway it's certainly one of the great advances. And initially initially I put a lot of money because you had to put two patches on the heart. And so we did a lot of those usually through a sub constantly decision but sometimes to the economy. But those days are gone. The cardiologist stole online pacemakers, defibrillators, everything now A V. A. V. R. So it's it's a never ending battle. Yeah at any rate there was an inter but when I came back from the army I was dr roberts vascular fellow thinking I couldn't do two more years of surgical training store. Instead of doing two years I did ended up doing 2.5 after spending six months in baskets surgery inside I couldn't stand to watch toes drop off for the rest of my life. And anyway this is a paper that we published, it was actually at the beginning of the crumble icis era. And we did we you know these patients with them pops come in with with cold legs and you either take him to the operating and usually would you know be fem pop chop chop. But anyway we were able to get a large number of successes with the using streptococcus tonight nace. Ah And here is obviously another picture dr robert. So no ship. So given the state of a fashion or in this surgery pursued another surgical endeavor, which I had absolutely no preparation. Having done zero micro operations when I was a surgery. Right. So I really hope, at any rate, I'm not sure whether it's louis Pasteur. Well, Winston Churchill, probably Winston Churchill. And I just didn't have anywhere else to go. So I just kept stumbling along at any rate, that there used to be a board out here in the PHR. And I'm sure many of you saw before pin put up their propaganda board. Uh and uh it was the the war in surgery and actually robert glover was the chief of of surgery. Here. He was Episcopal Hospital. And he gave charlie bailey permission to do like his fifth micro commissioner autonomy after the first four had died. And uh anyway, the next one was a success. And as they say, the rest is history. You know, Don Law showed a little bit about him. It's actually given credit by, by Carpentier for developing the first Michelangelo plastic. But here's two gentlemen who kind of actually all the micro surgery had been done in boston by Cutler convened by Henry suitor in London. The cardiologist of the day said Michael stenosis is a disease of the Maya cardi. Um just like gary vigilante say don't treat them. Don't treat them no treatment. Anyway, but eventually they came around to the fact that it was obviously a valvular lesion. And so the race was only after the Second World War about during the Micro Commission. Right. And charlie bailey was working at Hahnemann a number of hospitals in philadelphia area. And Dwight Harkin who had done him and was Alden's dad had done a number of missile removal from the chest during the Second World War. And anyway, charlie was published his 1st 1st case successful case in the Distinguished Medical Journal of philadelphia Inquirer. And Dr Harkin was a little more traditional and published kids in the new England Journal. So charlie actually beat him to the punch here. Charlie eventually left surgery, became a lawyer and practiced law in northern jude Jersey for the last 20 years of his life, but he was quite a flamboyant character. It took him forever. I'm not sure he ever got in the philadelphia Academy of Surgery. That's how controversial. So, here's a picture of from, from Dave Adams and Carpentier is reconstructed valve surgery book and it shows travelers uh circling uh annual plastic still not sure exactly how he did it. And this is a picture said his wife was kind enough to send me back in 2000 and 12 and this is at that time, I'm sure he must be dead now. I haven't seen his obituary, but this is this is he carrying the needle with which they did the Mic, the Michael Michael Annual Plasticky. And as they say Tempus fugit. This is a paper they presented at the american Association thoracic surgery in 1955 what's going on here. Uh Anyway, um and actually presented by bob trout. Uh and this is the pictures from that paper. These are these are what dr Donovan's life sent me a picture of all his gadgets. And remember there were no decent heart valves at that time. And we have talked about donald ross in a minute but there were nobody, nobody had a decent heart valve and that's why they had to develop these other procedures. I can remember Bernie Siegel because he'd been through so many of these things. Wanted you to put a ST jude valve in an 88 year old because he knew ST jude valve was never gonna fail and he could figure he could manage Janet coagulation but in any rate we have moved on from there. Um So so anyway, in 1970 dr uh Professor Alan Carpentier percentages paper at the American Association of Plastic Surgery. And he was, it's basically the beginning of remodeling annular plastic. And this is the picture from his um from his paper. And he basically said he did two things you develop the aortic lee. This is the type one mike not the elephant leaf. And then you put multiple sutures around the post here annually. And you remodeled the committee during the post, your ambulance interesting. He said that rita, that reconstructive operations rally possible and type two Michael insufficiencies, which is basically all we treat today. But he changed that and 10 years later he gave the the honored guest lecture at the 80 S again and he basically codified surgery for michael insufficiency here. He is working on the his mitral, his aortic valve. His Ponty ed was found. He actually, he and his wife had an apartment on the top of the Bruce a in paris. So he didn't have far to go up and down the elevator to get to the operating room boys laboratory. And his wife Sophie actually was a real contributor. She has a PhD in biochemistry to this valve. So at any rate this is the codification of of micro valve repair first defining what what type of micro insufficiency you have. It fits into all categories. And then the principles of repair basically an accurate analysis, reestablished surface of co optation and then do a remodeling annual plastic and restore the relief mobility. Which was for the most part, patients from the french colonies in North africa that where they have a large number of of rheumatic patients. At any rate that was the night necessarily just shows what happened and force you can't see it very well. But they went from doing mostly star in new york valves to almost all by the prosthesis and repairs by 1980. So of course there uh there was a company in America that wanted to monetize this. So they had they formed what they called the club, the trial. I went over there four or five times in the mid to late eighties. And it was a great trip because you've watched carpaccio and do a couple of cases in the morning, you go out and have a big boozy lunch and come back and sleep during his cases in the afternoon. But and then have a nice dinner that night. But at any rate, it was a great trip basically where I learned how to do microsurgery. Um and he also did uh like some courses in this country. Um, so we we went from rash from uh from rationality due to irrationality, going from the screen autonomy to a right to our economy. Uh and anyway, so it had long access actually. And and you can see here, I think first of all, first coast life stop coast segments in 1985. And when I was a resident, we did this great big write up quadri decision. I can't imagine that's quite ever done now. And the porch access was first done by the group at stanford when they developed the hard court system. Um, Toby Cosgrove did too video conferences. That was before their of zoom in the 1996. And he did. Mhm. Anyway, so he did the micro stool, right? Para median decision, which is a great exposure to violent, but he took to cost a Condra junk comes out to cost a condo uh out and um, pieces out and every patient got a chest wall hernia. I mean it all comes back. You know billowing out like this when I operate on a a pastor's wife from some Bucks County. She said, I can't stand this, I can't sing in church, you know. So at any rate we stopped doing that and went to the rights of economy. And of course this paper from the Harvard business review on, you know, team learning. One of the surgeons said porter access surgery is transferring the pain from the patient to the surgeon, which is in a sense true. Uh and of course my friend Dr Bannerman was was was shared all his knowledge with me, had a meetings in in in in and the and Belgium and invited me over every, I'm actually going to new york and having dinner with him tonight. I haven't seen him in almost three years. So it would be a great reunion. Ah So Desmond Julian was the first person to develop the coronary care unit. And I think the main reason uh huh inertia for certain anybody that does 10 or 12 years of surgical training, it's going to be very reluctant to try to change what they do. I mean you've been, you've been beat on for so long and said yes sir, Yes sir. Yes sir. You're elected to change your your your way of doing things. We always consider the report access surgery a team sport. This is a funny, I'm not sure you could get away with this in today's world because lucy says to charlie called you. Yeah, you got it up with my help. But at any rate um you can see what happens when it when it falls. Uh and they they don't know you. So but anyway, cardiology has been unbelievably supportive around here. This has anesthesia and profusion in nursing and the whole surgery. So this this is our experience. We started doing court access in 1998 And throughout the that that the early two thousand's it's interesting. Pen did not become part of the sts database until 2002. I'm not sure why whether tim Gardner didn't want anybody to know what the results were. But anyway, we had the STS database here back when jim sink was the chief back in the nineties. Anyway, Jeannie Fox actually did the kept the database for most of the early uh, airport access cases. So anyway, and I stopped doing it in 2000 and 16. Pavin took over the database. And this is a that what they saw that he and Mark helmer sent me about my personal experience with with Michael and whatnot. It's a little bit confused and I'm not sure I understand it myself. But anyway. Um so in that period of time from 2000 and 2 to 2000 and 19. I personally did uh 500 some open Michaels and 1200 many mike 25% yeah, not 25% also got amazed receivers. So anyway, I'll end with four serendipitous encounters to all related to going to medical meetings, but to wear nonmedical and to, so the first one happened in the at the 80 s meeting in 1991 I was inducted into the meeting into the society that year and the president's and new member reception was at the Supreme Court and our host was Justice Harry Blackmun who's obviously been in the news quite a bit later lately because he wrote the the opinion for roe v wade and at any rate I'll stand in line and this gentleman, I was standing in line right behind me. I never met him before. Obviously he was world famous. I can't figure out how we got into the society the same year except for the fact it was difficult for non americans to get into society at that time. So we chatted it up until we went into, I don't know what the room was. I think that the Chief Justice's reception room and at any rate we had a nice chat and so on and so forth. Uh And at the end of the evening just there were maybe 20 people left Justice Blackmun took us in the Supreme Court chamber. We all sat down on the first two rows and he gave us the word how the court works, who wrote the opinions, how they decided it's one of the great physics questions I've never had. So anyway, the socket serendipitous account account occurred and the uh, Kaz Mahal Palace Hotel, nothing to do with the Charge Mahal, but it's actually, and now what they call the moon by back then we call it Bombay. And the meeting was supposed to be in the, I think the spring of 1991. But that was when the first gulf war started. So they postponed it to the fall anyway. Um and this gentleman, I was sitting out by the pool drinking scotch because you couldn't drink the water or anything else. This gentleman just sat down beside me, started chatting it up. And of course this is this is Donald ross as uh mike, his lovely, lovely guy. We talked about two hours and probably got pretty well sauced. And anyway, this was his paper, he remembered there were no heart, there were no heart files. I mean they were using fashion Lotte this, that and the other and charley Hoffman Eagle had put some about some ball and cage vowels in the descending in order. But they had no treatment for aortic stenosis. So this was really one of the first treatments I had for aortic stenosis. And this is the paper from the lancet, there's a case report 19 92. And he said, here are these prosthetic valves and reconstructions placing the normal custom position i below the carny offices. And this is his graph his his his picture from that paper. He used it as a free graph. He did not use it as a route because I think mental and DiBona reported that their roots and I think 1968 something like that get it right uh at any rate. So but we that was my encounter with john ross. And of course later he he reported his his ross procedure where he used the pulmonary autograph. And this is from that interesting. He also did not do that as a route. He did the pulmonary valve as a free graft also. And this is the illustration from that proceed. The next occurred I was went to a I think of E. P. Meeting in the Netherlands and I was flying first class courtesy of the dutch government. So I flew over first class on british airways and coming back. I was lucky enough to be able to get on the concorde. And and mr pai was they're dedicating the pyramid at the louver. And he was actually sitting here and his wife was sitting in row one seats one and two. But the french minister got on the planet the last minute and wanted that front row seat. So mr pai was my seat mate for that flight. Anyway we chatted up for a bit. And then the lunch came along with all these wines and I probably got pretty well sauced. And I don't remember much more about the conversation and finally time with the gun. So this was it the sts in 1995 1003. You figure whose job it is. One more parking and to your left. Save you a lot more to your left, right there. Perfect. Talk to your left. Okay, good. Right there. 1,003,003. Very good. Okay. So obviously the road has never the dream to warn. Uh and I probably was like a 58 75. I'll never be doing cardiac surgery. But here I am. So anyway, uh I think the future is right. This is a slide of my Francesca. And I was on occasion. But remember the cardiac the cardiologists pretty close. And then you think so anyway, thank you, appreciate it.