So, in the previous lecture we gave a convenient, we gave a criterion for a metric space of when a metric space is compact. So, this lecture we will begin with a lemma which is very useful and it is called the Lebesgue number lemma. But before that we need some preliminaries, so x be a metric space, z contain x be a subset. So, given the subset z we can define. So, we define function dz from x to r by dz of x is defined to be infimum of z in z distance of x from z. So, what does this mean? So, these are x and this is my z let us say. So, this is x. So, we take the distance of x from all points in z and take the infimum right. So, the infimum may or may not be attained at a point. For instance, if we take the real line and we take the open interval 0 1, we take this to be z right and we take x to be minus 1. So, then the infimum, so the distance between d of x comma a is equal to a plus 1 right. If a is a point here, then this distance is a plus 1 right. So, the infimum is never attained because so the infimum I am sorry. So, the infimum is 1, but it is not attained for any a in the subset z right. So, the infimum may or may not be attained. So, this is a function which we define on x. Next let us check that this is continuous. So, we claim that d z is a continuous function. So, for this note that if distance between x and y is strictly less than delta, then for any z in z, we have the distance of x from z is less than equal to x and y and z which is strictly less than delta plus distance of y from z. So, when we take infimum this implies taking infimum d z of x is less than equal to delta plus d z of y which implies d z x minus d z y is less than equal to delta right. So, similarly replacing switching the roles of x and y, x and y we get d z y minus d z x is less than equal to delta which implies the absolute value of d z x minus d z y is less than equal to delta right. So, thus for any epsilon positive we let delta to be equal to epsilon by 2 right. So, then d of x comma y is less than equal to delta will imply that d z is strictly less than d z x. So, this shows that d z is continuous. So, using this distance function let us prove this Lebesgue number lemma. So, let x be a compact matrix space suppose we have given an open cover u i's. So, then there exists delta positive such that for any for every x p delta x is contained in u i for some i. So, now this is something which we have already proved while we are proving a previous theorem because since x is compact every sequence has a convergent subsequence and this is precisely the claim one which we proved in the while we are proving the previous theorem. However, using the this distance function we let us see a clean proof of this nice proof of this. So, proof. So, as x is compact there is a finite sub cover and we may assume x is equal to union i equal to 1 to n u i's. So, let us see i be x minus u i these are close of spaces. So, define f from x to reals greater than equal to 0 by f of x is defined to be summation i equal to 1 to n d c i of x. So, given any point x we take the distance of x from each d c i and we just add all these ok. So, then f is continuous as all the d c i are continuous right. We are simply taking a finite sum of continuous functions and that is going to be continuous ok. So, if this function takes the value 0 then we have summation d c i of x is equal to 0 yeah, but each of these d c i's is greater than equal to 0 this implies d c i x is equal to 0 for all i, but what does that mean? So, note that recall that d c i x is equal to infimum of z in c i distance of x from z right and this is equal to 0 ok. So, this implies that there is a sequence z n in c i such that the distance of x from z n is tending to 0, but this implies that z n is converging to x right. However, we also know that c i is closed right as c i is closed in x this implies that x belongs to c i which implies that the distance of c ok. This implies that x belongs to c i that is all that we need sorry for all i. This implies that x belongs to intersection of c i intersection of c i is equal to intersection of x minus u i which is equal to x minus union u i, but this is the empty set as the union is equal to x right. So, thus we get a contribution. So, thus f of x is always positive ok. So, as x is compact this implies f of x is compact. This implies f of x is closed as 0 does not belong to f of x. So, since f of x is closed and 0 is not in is in the complement of f of x which is open this means there is a neighborhood 0 delta or delta neighborhood of 0 which does not meet f of x. This implies that f of x is greater than equal to delta for all x in x. So, this implies that the summation i equal to 1 to n d c i x is greater than equal to delta by n for at least right because if it was strictly less than delta by n for all i that would mean that the sum would be strictly less than delta ok, but this the. So, what does this mean? So, we have our c i is this and our x is this. So, distance of x from c i is greater than equal to. So, this distance is greater than equal to delta by n right, but then the complement of c i is u i. So, this implies that delta by n x is containing u i. So, this proves. So, we will end this lecture here.


Okay guys, welcome back to figure fantasy. So today we're going to be summoning for Ayane Okada. So I have a few lucky blind box cards left over for, you know, for not for, but from the previous event with that Sunimiko. And I have 17,000, uh, what do you call, diamonds here. Okay, but before we go into summoning for Ayane Okada, I'd like to go here first with Kau Kau. So I'm gonna be, um, consuming 30 fully wishes for him. Okay, so I'm just gonna, you know, try to get him with 30 summon, so let's start this out. Okay, I wanted to do a, a video on Kau Kau, uh, featuring him. That is why I'm summoning for him. So first pull, nada, nothing. Second pull, ooh, better, it's Zhu Liang for this one. So I'm not really sad about this pull, but, um, I want to get him on the last pull. Hopefully I could get him and we could feature him in a build for his kit. Okay, so last one, let us see none. Another purple filled pull. So that's it for Kau Kau. So sorry I didn't get him, but happy with Zhu Liang. So again, let's move on to Ayane Okada. So first pull, um, gonna be getting, I think a few rewards up to here. I'm going to be getting 120 pulls initially, then this is the 130th. So those are a lot. Hopefully I could get her at least two copies of her. So let's try this out now. Okay, okay, okay, okay. I'm there. All purple. So so far, first pull, not good. Go to the second one. There you go. Hopefully it's her. Skip, skip, skip. So I think it was the eighth box. It's Aoi. It's okay, I get a copy of her. Let's move on to the next one. Hopefully she is here. Not this one. Let's skip this. So another box. So this is, I think I'm just going to clear my bag first. Clearing bag, clearing bag. One, seven, seven. Let's go back to, again, 30. This is my 40th. So let's go 40. Okay. So that's the ninth one. Three, two, three, four, five, six, seven, eight, nine. Yes. First one. First one is here. So happy that she's here, that I could make a guide for you later. So let's just skip this out and put out another box. Nothing but purples galore. So this is, I think, my sixth box already. Nothing as well. So we're going to go to the diamonds already. So six pulls as well. Six, 10 pulls. So clear bag first. Clearing bag is what I hate. Confirm. And let's go back. Okay. So again, let's just get this one. Okay. So let's use that. The 10. Oh, I got her in red, red, red, red. I'm happy with this red one. So she's at pink one star ready. Nice. Let's skip this one. Yes. Okay. Let's proceed. Let's proceed to another yellow, the sixth box in this big box. Five, six. It's okay. It's Zephyr. I need copies of Zephyr anyway. So so far, good pulls. So clearing bag. Every time I clear bag, something good happens. Did you guys notice it? Let's go back to... Okay. Let's claim these gifts and let's do more pulls. Oh, not this time. So okay. So I need one more, at least one more. Clearing bag again. Why am I keeping on clearing bag? Okay. Sorry. I have to promote. I forgot. I forgot. Let's confirm these. Okay. Two star red ready for Zephyr. Okay. Auto promote. What we have here is good. Good. Do it manually. Let's just do this quick, guys. I'm sorry to take more time than expected, but I don't have a choice. I have to clear this out for me to summon more. Nearing, nearing, nearing. Let's do quick promote and see if... Okay. A quick promote. Hi. Sometimes I don't do auto promote because the pairings are off with what I have. So so far. No, no, not you. There you go. She's gonna be... Okay. So we're going back. Sorry for the delay. Let's go back to another. Ten pools. I need one more copy of her. Nada. Another one. Oh, another red one. Two reds. Two reds. Gonna skip this one. Yeah, because I know it's her. Let's skip. So let's do another one. Oh no. Okay. I think this is my last pool for this one. Let's make this count, guys. One more. One more copy of her. So none. Got three copies. Two red. Two pink. One yellow. And I'm already happy with that. Okay, let's promote her to... Oh, I cannot promote her. So I need more Galatea units. Oh, I have. I have. Let's confirm this one. I hope I couldn't promote that girl into... Okay, okay. I can promote her. No, no, no, no, no, no. Not you. Not you. You and you. Okay, we're at two star. Then three star. Three star. That quick, eh? That quick. So right now... Nah, I'm gonna leave her at three star as of the moment. I'm gonna build her later. Anyway, guys, I've taken much of your time already. So those are my summons. Two pink. One yellow. And hopefully you guys have the same luck as I have for these summons. And take care, guys. Stay safe. This is The Warden and I'm out of here.


The open data charter has been working to build open up guides to identify high-value data sets to make it open on a particular area of policy. We have built another one on anti-corruption, on climate action, and on agriculture. And this will be the fourth one. So we really think that land issues are particularly susceptible to corruption, according to Transparency International, one on over five people have been paying bribes to access to land services. Land ownership and tenure are pretty much related to this. There are, in some cases, exclusion to communities from participating in land deals between private investors and local authorities.  So we really believe this guide can help address that issue and take action accordingly. So as this open up guide identify high-value data sets that should be made open on a particular area of policy in this case in land governance and administration. It includes standards, examples, use cases, and the specific description of each data set. So we believe that by identifying all these information can help government and reformers from the land sector and data sector, particularly in countries from the global south, to collect, share, and publish more and better data on how land is governed so that it responds to local needs and puts vulnerable communities and marginalized groups at the center of the policymaking. And we expect that by working with the governments from the particular sector these data sets can be adapted and fit to the local needs in a particular context. In this process we're really looking forward to hearing from anyone interested or involved in land policies either from the public sector, from private companies, or from the social sector of the academia. We are aiming to reaching to a particular and a variety of stakeholders that can help us build a strong guide for opening up land governance data. We are keeping public comments open for almost two months because we acknowledge it's a long document with a lot of information and really detailed and we want people to take the time to have the time and to take it to really read through it thoroughly as well as reaching a global community and we know that communication efforts take time. You can read the guide in the land portal website as well as on our different Twitter accounts and social media accounts. We expect public comments to be submitted in writing either in the shared document in the suggested mode with comments or with the specific wording that you would suggest that phrase should look like. We are looking for specific comments that can help us build this guide and really sound for the land community. You can share with us links or resources that we have not mapped or that should be made more specific. In case the shared document is not enough we are providing an email where you can submit specific longer feedback or other resources that cannot be linked. We are really looking forward for comments and feedback from all stakeholders that would want to work on land governance policies and want to increase land data that's available for better and inclusive policymaking.


Box 13 with the star of Paramount Pictures, Alan Ladd, as Dan Holiday. To Box 13, care of star times. Dear Dan, if this is the way you want it, okay. If a pal and buddy has to reach you the hard way, alright. Enclosed is a ticket to my fight with Brennan tomorrow night. I'd like to see your mug at ringside. If I don't, I'll make it a point to mess it up for you. If I don't, I'll make it a point to mess it up for you. Johnny Capelli. Johnny Capelli, a kid when I first met him fighting in a different way at Anzio. And maybe, just maybe, Anzio wasn't as hard for him to take as what happened right here. Now back to Box 13, and Dan Holiday's newest adventure, Double Right Cross. Johnny Capelli. Contender for the middleweight crowd.  Johnny Capelli? I never heard of him, Mr. Holiday. Well, you don't read the sport pages, Susie. But you know him, huh? Uh-huh. We played duck on a rock on the beach at Anzio for keeps. I saw him a little while ago. Told him my Box 13 idea, and I guess he saw the ad in the start time. And you're going to fight, huh? Yes, that's it, Susie. Did he send you a bedside seat? Ah, yeah. There's nothing I can do with that one. So long, Susie. In the driving rain, I headed for the stadium, and my cab ran fenders first into a traffic jam. There was no use trying to get through, so I paid off the cabbie and started to plow the rest of the way to the stadium. I looked at my watch two minutes after 10. First round of the fight was underway. By the time I hit ringside, people were already on their feet leaving. And there was booing. And talk. Capelli knocked out. Capelli acted like a fourth raider. Johnny Capelli laid down. I pushed my way back to the dressing rooms of the little knot of people around one door, and the girl was rattling the knob and calling, Johnny, Johnny, please open the door. Johnny. What's the matter? What's going on? Huh? How are you? We pulled up beat it. No, I'm a friend of Johnny's. Who are you? His manager. I mean, I was, but not after tonight. He loses one fight and you're quitting. Yeah, like he did. When he comes out of there, tell him he can take this contract and tell him. You're Helen, aren't you? Yes. Please go away. Johnny can't see any reporters now. Please go, will you? I looked at it. So this was Helen.  All the while he and I were trying to miss the casualty list in Italy. The girl he sent a diamond brooch bought with a year's pay he hoarded like a miser. Well, if looks counted, she was worth it. She rattled the knob again and... Please, Johnny, it's Helen. Johnny. May I try? Johnny. Johnny, this is Dan. Dan Holiday. Dan Holiday. Oh, yes, you recognize the name? Oh, yes. Johnny spoke of you. He... What's the matter with Johnny? He won't come out, Holiday. Oh, who are you? Helen's brother. You see if you can get Johnny out of there, Holiday. Johnny. Johnny. Johnny Capelli. It's Dan, Johnny. Is there any other way out of this dressing room? Yeah, the window. This is the ground floor. He could have got out of the window. Look, both of you, Helen and... Name's Eddie. Yeah, all right, Eddie. Get somebody with the key to open this door. Go ahead, Eddie. Step on it. Okay, be back in a minute. Now, what's all this about, Helen? I don't know. Soon the fight was over. It came... He was conscious? Yes, he walked, but we got the door here. He broke ahead of me and ran in and locked the door, and I don't... All right, Helen. All right. Now, take it easy. We'll find out what's happened. When we got into the dressing room, Johnny was gone, and Eddie was right. The window was open. I couldn't figure it. Johnny Capelli, a kid whose courage was A-plus. A kid who went through Anzio's Salerno Casino. Sure, he was scared, just like the rest of us. But he didn't whimper, and he didn't run out ever. He just didn't figure it, and Helen didn't make it any more clear. No, I don't know. I don't know why he ran away. Take it easy, sis. Johnny must have had a reason. Yes, he must have. Now, listen, where'd he go? Well, if he's not at his hotel, I don't know. Well, he called there. That's no good. Any other place, think. I don't know of any. All right. Where can I get in touch with you later? 387 Christopher Place. Good. You wait there. I'll find Johnny. It was tough, but I finally tracked on a cab driver, and remembered picking up a man back at the stadium. Seemed, well, drunk, he said. Took him to a little hotel on the other side of town. It could be Johnny, so I went there and... Go away. Johnny. Get out. Listen to me, Johnny. This is Dan. Dan Holiday. Dan? Yeah, let me in, Johnny. No, go away. Just go away, will you? What are you trying to do, Johnny? Nothing. Please, will you go away? Look, kid, let me in, or I'll break in. Johnny. How are you, Dan? Where's the light? Don't turn it on. Don't, Dan. Okay, Johnny. No light. Close the door. Why'd you come? Why do you think... Listen, nobody else knows where I am, do they? No, nobody. Helen? No. Where is she? Home, waiting. Waiting for me to call her. But you're not going to. What's the matter, Johnny? Dan, I... I'm sick. What do you mean? I don't know. Look, Dan, it was swell of you to come. There's nobody I'd want to see any more than you, but not now, Dan. Some other time, but not tonight. You gotta tell me what's wrong, Johnny. All right. Turn on the light and take a look. Johnny. Yeah. Better with the light off, isn't it?  Hurt badly, I've got to get a doctor. No. I said yes. No, you get a doctor and so help me, Dan.  I'll... Johnny. Hello, desk clerk. Listen, get a doctor to room 10 right away. And that means right now. All right, Mr. Holliday. He'll sleep for a while now. How long before he wakes up, doctor? Five, six hours, maybe longer. How badly is he hurt? Well, it's hard to tell. He took quite a beating. Who is he? A friend of mine. I see. Fight? Yes, sort of. Well, I... Look, doctor, as long as there's no gunshot wound, you don't have to report this to you. No, but... Well, let's leave it that way then, huh? You'll be back in the morning? Yes. I'll make a more thorough examination then. He was too hysterical to do much with tonight. But I think it'll be calmer when he awakens. Then there's nothing... nothing too bad. I don't think so. Bruises, contusions, and his eyes. I... What's wrong with his eyes? I'll see you in the morning. Good night, Mr. Holliday. Good night. Thanks, doctor. I sat by Johnny's bed and watched him. I didn't call Helen because... Well, for some reason, Johnny didn't want anybody to know. To know what? Maybe I'd find out when Johnny came too. Maybe he wouldn't tell me. But I just couldn't see Johnny running out on anything. There had to be something wrong. Something big. I sat in a chair alongside the bed and thought about it. I guess I fell asleep because the next thing I knew, I... Huh? Oh, oh, just a minute. Good morning. Good morning, doctor. Is he still sleeping? Yeah. Maybe for another hour or so. But I'll wait. Thanks. You'll be all right? Well, I'd like to ask him a few questions when he awakens. I don't think there's anything seriously wrong, but, uh... Well, I'll wait. What are you getting at? I don't know. You'll have to wait, too. Okay. Meanwhile, I'll go and get some coffee. You can use some, too, can't you? Yes, thanks. I'll be right back. I thought I'd be right back. But when I got down to the street, something changed my plans. There was a newsstand, and the first thing that hit my eye was a sub-headline. It said Boxing Commission holds up Capelli Purse. Capelli disappears after a fight fiasco. I hurried to a phone, called the Star Times, got a few strings pulled, and a half hour later, I was sitting across from the commissioner at his home. Just exactly what interest do you have in this, Mr. Holiday? I'm a friend of Johnny's. I see. You must have something important to tell me, this early in the morning. I want you to tell me something, commissioner. What? Why is the commission holding up Johnny's purse? Because we believe the fight was not quite on the level. Meaning you think Johnny threw it? We don't know. We're going to look at the movies this morning. Johnny didn't throw that fight. Did you see it? No, I didn't, but I... Then how do you know? Well, because I know Johnny. That's your only reason? I think it's enough, commissioner. Look, Mr. Holiday, we have one job to do. Keep the boxing game fair and square as a service to the fans who pay their money to see good, clean sport. Capelle was a ten-to-one favorite last night. A big bet placed on Brennan would bring a lot of money to anyone. Meaning Johnny might have bet on Brennan? It's been done. And the commission is in business to see that it doesn't happen anymore. Until Capelle proves otherwise, we'll say he threw that fight. I didn't believe it. But Johnny lost. He lost badly. And he did run out and he wouldn't tell why. I went back to the little hotel and ran into the doctor who was just leaving. Oh, Mr. Holiday, that cup of coffee took a long time. It wasn't coffee. How's Johnny? He'll be all right. At all? No. Last night when I examined him, something puzzled me. What? His eyes. Pupils dilated. And? This morning when I examined him again, I asked a few questions. What about? Your friend had every symptom of Bellamine poisoning. Last night the pupils of his eyes were dilated and... Wait a minute, wait a minute. That would affect his sight, wouldn't it? Yes. Taken internally, Bellamine is poisonous. Quarter grain and up his fetal. And less than that? Dryness of throat, nervousness. In other words, if someone gave him Bellamine, he'd have a hard time seeing. Very difficult. And if he were a boxer? If he were a boxer and went in the ring with his eyes in that condition, he wouldn't be able to see his opponent. Now back to box 13 and double right cross with Alan Ladd as Dan Holiday. So Johnny lost the fight because he couldn't see Brennan. But why did he run out? Why didn't he want anyone to see him? I thought I was going blind, Dan. Brennan was just a shadow that was beating me. Why didn't you quit? Why didn't you say something? Because I didn't want anybody to know. If it was going to be that way, I'd take it alone. Noble, huh? Look, Dan, I waited a long time for that fight. You meant to crack at the title. Helen waited with me. If I was going blind, I wasn't going to let her know and stick with me. Sure, sure, a kid like you would think that way. Now listen to me, Johnny. Somebody fed you the stuff to impair your sight. Somebody wanted you to lose that fight. Who? You're crazy, Dan. What did you eat yesterday? Eat. The day of the fight? Nothing. Just a little breakfast. And the rest of the day? Nothing. Liquids? Water? Milk? Of course not. No fighter fills himself up with liquids. Makes him logy, heavy on his feet. But Johnny, the bell of Maine had to be given to you just before you went into the ring. Any earlier in the day, the effect would have worn off before the fight.  I'm telling you, I didn't eat anything or drink anything, not for hours before the fight. But you had to. No, no, no. I know what I did. Look, maybe it was my eyes. Maybe it is what I thought. I got hit in Italy, Dan. Maybe... It's not that. The doctor knows what he's talking about, Johnny. Somebody fed you that stuff. Who? You tell me. No, buddy. I didn't eat, drink. Do I have to go over all that again? No. But I am. You wait here, Johnny. Johnny was a ten-to-one favorite over Brennan. And somebody played that for all it was worth. And it looked like it was worth a lot of money if the bet was big enough. A little while later, I was talking to Brennan. You're crazy, Holliday. Maybe the guy wasn't in shape. Look, Brennan, Johnny was in condition. So you're telling me that somebody doped him, meaning me? No, no, no. I'm just asking. And I'm telling. I got 120 fights on a clean sheet. None of them were shady. I don't play that way. I'm not saying that. I'm only trying to find out who could have given Johnny that drug. Well, I wasn't near his dressing room. I didn't even see him after we waited in that afternoon. All right. It had to be in his food. Food? No fighter's gonna eat right before a match. Or drink water? He just rinses his mouth. That's all. What else, Brennan? If he's training right, nothing else. But if he gets thirsty...  He drinks water, makes him heavy. That's why a fighter chews gum all day. It gives him a more... Gum? Yeah, gum. Why? Gum. That's it, Brennan. That's it. Sure, I chewed gum all day. Before the fight in your dressing room? I must have been chewing gum. I remember the... Go ahead, Johnny. What were you gonna say? Nothing. Yes, you were. No, I wasn't. Look, there's only one way the drug could have been given to you. Now, you've got to think. Who gave you gum just before you went into that ring? I didn't have any. Johnny, what are you hiding? Nothing. You were going to say something a second ago. Did Baker your manager give you... No. Who else was with you? Just Baker. Where was Helen?  Did she give you any gum? Forget the whole thing. I'm going blind, that's all. Oh, yeah, not. Beat it. Helen gave you that gum. She was in your dressing room before the fight, wasn't she? Cut it out, Dan.  And the chewing gum was the only way the drug could be given to you.  But maybe 15 minutes before, Helen handed you the gum. Didn't...   Come on, Johnny. She gave you the gum. Didn't she? Didn't she? You... You still got a good right, Johnny. I'm sorry, Dan. Sure. Sure, let's forget it. But I didn't want to forget it. I left Johnny and went to see Baker, his manager. I didn't tell him what I'd found out. I just listened. Sure, I brought the kid up from the Ham and Egg Palms. But after last night, we washed up. Johnny was a tender one-favorite, wasn't he? Yeah, a match with the champ next. Did you bet on Johnny? I never bet. Even if you thought Johnny was going to win? What are you driving at? At somebody who stood to make a killing if Johnny lost. You're asking for a cloud holiday? I just had one. What about Helen? What about her? All right, Baker, here are the cards. Johnny went in the ring last night. I sure bet to lose. What? Yeah, that's right. He was drugged. He couldn't see Brennan from the first bell until he was counted out. He was fighting on instinct and courage. Listen, what are you giving me? There was nobody in his dressing room but me and... And Helen? Yeah. Now, what about her? Nothing. Except once I walked in on the tour, and, well, there was heaven to fight. What about her? They clammed up when I walked in, but I heard something about a brooch. Brooch? Diamond brooch? The one Johnny sent her from Italy? Maybe. All I know is what I said. That's enough. Thanks, Baker. Maybe you'll have a champ on your hands yet. The next stop was to see Helen. I wasn't sure how to handle this. And all I had to go on was the fact that Johnny was covering for her. Why? And they'd had a fight over that brooch. Again, why? So, the big question was, did she or did she not double-cross Johnny? Her first words to me were... Dan, you found Johnny. Maybe. Maybe, but what do you mean? Sit down, Helen. What's the matter? Is he all right? He'll be all right. He's in a little hotel. Well, then take me there. I want to see him, Dan. Maybe he doesn't want to see you. What? Johnny... Did he say that? No. What are you doing? Why don't you take me to him? Why talking like this, Dan? How much did he win on the fight, Helen? What do you mean? I watched her face closely after I asked her. Either she was the new Sarah Bernhard or she was in the clear. For a couple of seconds, she stared at me and then... That's a filthy thing to say. Yes, I know, but I've got something to find out. What a joke to find out by asking me that. I hoped to find out who made a killing on the fight by making Johnny a setup for Brennan. He was ten to one good odds for somebody who'd lay a good-sized bet on Brennan. You mean you... You think I'd bet against Johnny? Did you? That's not worth answering. All right, look. Johnny was knocked out because he was drugged. He couldn't see. And he was drugged only a few minutes before he went into the ring. Baker? No, a manager who's bringing up a champion doesn't sell him out. And that leaves only me. Is that it? Maybe. And I bet everything I had on Brennan. Is that your story? What's yours, Helen? I have none. If that's what you believe, believe it. But tell me where Johnny is. I promised I wouldn't. You promised... Oh, no, Johnny can't believe I... Where's that brooch he sent you? Brooch. Yeah, that's right. The one he sent from Italy. A $3,000 brooch that bring about 1,500 in a pawn shop. And 1,500 at ten to one... Seems to be my day for taking it. I'm sorry. Didn't you give Johnny chewing gum just before he went into the ring? What did you say? Chewing gum. Johnny wouldn't tell me, but I know you gave it to him. I... Yes. You... You admit it? Yes. Huh. That was the only way he could have been drugged. And you admit it? Yes, I admit it. It doesn't make sense. All right, it doesn't make sense. You're so right, Mr. Holiday. Nothing makes sense. Nothing. Now go back and tell Johnny. Tell everybody, go on. Well, this I couldn't get. Two of them. Johnny and Helen knowing it must have been the gum and Johnny not wanting to tell me. Then Helen coming right out and saying she gave it to him. Okay, there was one answer and I hunted for it in the shape of that brooch. I called Lieutenant Kling at headquarters and got him to do me a favor. It took almost the rest of the day, but late that afternoon. Brooch? Yes, yes, the police. But I assure you, I did not receive stolen goods in my shop. The police know that I don't handle it. So you're in the clear now, don't worry. Has the brooch been redeemed yet? No, no. Look, all I want to see is a slip and who signed the brooch in. Well, here, I have it ready. I thought it would be the police who would come. It's right here. Here. You are... There's no mistake about this. Oh, no, no, I let him have a thousand dollars on it. A thousand? And you're sure? Yes, yes, yes, there. There's where he signed his name. John... John Cappelli. No, that couldn't be right. Unless... Unless Johnny was afraid he couldn't make a fake fight look good and wanted to make sure. But where did Helen figure? And why? Why? Then it hit me. Johnny protects Helen. Helen admits she did it. It made so little sense it began to clear. I checked with betting agents and found one who took a bet on Brennan, a bet of a thousand dollars, a ten to one. He remembered who placed the bet, so... Well, I gave me one more call to make. Back I went to Helen's apartment. Hello? Yes. Oh, hi, holiday. Come on in. Oh, thanks, Eddie. Is sister home? No. Grab a chair. Haven't you seen her? Oh, yes, yes, earlier. Aren't you gonna ask me about Johnny? Oh, sure, sure. Where is he? I know. Well, what about him?  Yeah, yeah, he's okay. Oh, that's swell. You know, holiday, I couldn't figure a guy like Johnny doing something like that. No, neither could I, Eddie. That's why I knew he didn't. What? Here, Eddie, have a stick of gum. Oh, no, I never use it. Good for the nerves. Yeah, that's what they say. Well, that's what you come to see me about, huh? Maybe. You like to gamble, don't you, Eddie? Gamble? Oh, sometimes, why? Ever get in so deep you had to, uh, steal to make yourself even? What kind of a crack is that? Oh, a nasty one. Just as nasty as stealing your sister's brooch? What did she tell you? Nothing. She had a fight with Johnny. Maybe he noticed she didn't have the brooch. Asked her about it. Maybe she had her ideas about where it was. Yeah? So what? So she knew and gave you a break. But you had different ideas, Eddie. You pawned the brooch, signed Johnny's name with a slip, then bet a thousand against Johnny.  Tell you what, Eddie, if you and I take a trip to the pawnbroker, then we'll go to the betting agent where you placed the bet.  All right. So what? I got a break. I'll redeem the brooch and... What... What are you looking at me like that for? I took two on the chin today. Maybe it's my turn now to give, Eddie. You lay off now. Sis won't prosecute and Johnny won't neither. She won't marry him if he didn't. It's not the brooch, Eddie. It's the chewing gum. The gum you gave your sister to give Johnny, the drug gum to ensure your bet. You can't prove nothing, you can't. Eddie, you and I are going to the boxing commission and you're going to talk. No, I ain't.  Oh, uh, Eddie, get your top coat too. It's kind of chilly outside. Well, Susie, as they say in the books, all's well that ends well. Gee, it's so romantic. Johnny and Helen getting married, Johnny getting another crack at the championship, and I... What's the matter? What's the matter, Mr. Holiday? Oh, Susie, my jaw is really sore. Johnny hung a nice right cross on me. What's a right cross? Huh? Well, it's, um...  This way? Yeah. Now, look, I, uh, I leave it in my left like this and you... Like that? I... Oh, I'm sorry. Mr. Holiday? Mr. Holiday? I... Oh, good night, Mr. Holiday. Next week, same time, Alan Ladd stars as Dan Holiday in Box 13. Alan Ladd appears through the courtesy of Paramount Pictures.  Box 13 is directed by Richard Sanville with an original story by E. Jack Newman and Russell Hughes. Original music is composed and conducted by Rudy Schrager. Susie is played by Sylvia Picker and the part of Johnny Capelli was played by John Beale. Production is supervised by Vern Carstensen. This is a Mayfair production from Hollywood.


MSNBC's coverage of Bernie Sanders' victory in Nevada on Saturday was so biased, so laughably hysterical that it wasn't just the online Bernie bros who were complaining about it this time. Everyone saw through it, even if you don't like Bernie Sanders, even if you hate him. You couldn't not see just how much contempt MSNBC's pundits had for Bernie Sanders because even Brian Fallon, who worked with Hillary Clinton in 2016, he was literally her national press secretary commented about just how bad it was. So for example, he tweeted out, MSNBC sure has a lot of commentators who hate Sanders. I know, right? If you're from Team Hillary, if you're anyone who is part of Team Hillary and you can recognize that there is a really strong anti-Bernie bias, that's how you know that MSNBC has gone too far. And for those of you who missed it, here's just the taste of what we saw when we tuned in to MSNBC on Saturday. The happiest person right now, it's about 115 Moscow time. This thing is going very well for Vladimir Putin. I promise you. He's probably staying up watching us right now. How you doing, Vlad? These again are people who work on the strip within two and a half miles of the Bellagio, largely people of color. Of those, the majority are Latino, and they are clearly, at least from eyeballing it, strongly in favor of Bernie Sanders with Joe Biden coming in. I'm reading last night about the fall of France in the summer of 1940, and the general Renaud calls up Churchill and says, it's over. And Churchill says, how can it be? You got the greatest army in Europe. How can it be over? He said it's over. So I had that suppressed feeling I can't be as wild as Carville, but he is damn smart. And I think he's damn right on this one. No one else is as hungry, angry, enraged and determined as Sanders voters. Democrats need to sober up and figure out what the hell they're going to do about that. They were genuinely unhinged, genuinely unhinged. And they were criticized so widely, so loudly that the president of MSNBC, Phil Griffin, was forced to respond and basically said, we'll do better. And you know, they were forced to kind of address these recent controversies with Chris Matthews comparing Bernie's rise to, you know, the fall of France during World War II. And it was so bad that even Fox News made fun of them for being so historical. Fox News. Fox News. Listen, when your coverage becomes so biased that Fox News can make fun of you and be correct, I mean, it's time to really look in the mirror and try to figure out what you want your news network to be going forward. But nonetheless, look at what even Fox News said about MSNBC's bias against Bernie Sanders. James Carville is only James Carville can say it. Well, some in the media are wasting no time blasting Bernie Sanders as the Democratic Socialist reinforces his front-runner status here to react media reporter for the Hill Joe Concha. Joe, you watch this stuff for a living. What's your take on it so far? Oh, boy, yesterday was like my Super Bowl. As far as some of the reactions there, Chris Matthews, he's the most senior personality at MSNBC actually compared Bernie Sanders winning to the rise of the Third Reich. In other words, the Jewish presidential candidate whose family was wiped out in the Holocaust, he's comparing to the Nazis taking Paris in 1940. Let me go through a couple, actually. Nicole Wallace used to be a Republican, or I guess still is on some level, was communications director for Bush, right? She says, Bernie hasn't been vetted by either the press or the other candidates if only someone gave her a show for an hour on national TV five times a week. She also says the press does not have as much power as they had when I was young. Boy, that's true. The Hill back in 2016, Jason, we did a compilation of 59 newspapers. And who they were endorsing right before that election, 57 for Hillary Clinton, two for Donald Trump. What did that get Hillary Clinton? A concession speech and a set of steak knives. The impact of media and people being told what to think and who to vote for does not have remotely the impact or influence like it used to even 20, 30 years ago. But how can the media complain? I mean, they kind of missed this whole story. I mean, Bernie Sanders is leading and leading strongly. And you have some others that are not even close. And they act shocked when he wins, right? And again, it's like 2016. How did Trump take Michigan, Wisconsin, Pennsylvania, and Ohio? I don't know if you left New York and Washington once in a while and got to the grassroots and see what people are thinking that that would be telling. But here, look, this is a hilarious scenario that we have shaping up. If Bernie Sanders captures a nomination, many in media, as we're seeing, are petrified or downright low the Bernie Sanders candidacy because they think he's going to lose. Then on the other side, you have Donald Trump and they don't like him either. And the press is very good at picking aside. Who are they going to pick here? And more importantly, they go after Sanders, his supporters. Just like Donald Trump in 2016, the deplorables. Don't go after people's supporters. You know, the worst part about that is they're right. And if you just tune in to like any show on Fox News on Saturday, even Judge Jeanine Pirro, she just reported the fact that Bernie Sanders won.   I think MSNBC objectively is better than Fox News. Now that the bar is that high, I'm not telling you this so that why you view Fox News as a legitimate news organization. But I'm showing this to you because MSNBC is doing real damage to the country. Fox News is strategically capitalizing on their incompetence. They're not necessarily trying to poach MSNBC's viewers because I think anyone who watches MSNBC regularly isn't going to jump ship for Fox News, but they're just going to get people to stop watching MSNBC. And they want that to happen because MSNBC is their competitor. So I mean, when you become such a joke that even Fox News has a point about your bias, it's time to do better. And look, I'm not going to suggest that Fox News's coverage of Bernie Sanders was fair because, of course, even they compared Bernie Sanders to Nazis, he's promised most recently free preschool, free health care, free tuition and, of course, legalized pot. Well, if you look at what he's promising, it's the same thing that the Soviets did in Russia, the Germans did in 33, the Cubans did in 59 and even Venezuela on a day. It's a lie. And so what we're talking about here, Bernie is promising all this free stuff, Steve, but the very people who he's promising to will be the ultimate payer. Yeah. So Fox News is bad, too. But here's what I'm trying to say. MSNBC should be nowhere near the level of Fox News. Fox News should never ever be able to say, look at how bad and laughable and biased MSNBC is and be correct because Fox News is the propaganda arm of the Republican Party. They are literally a fake news outlet. They just lie. They make up facts. So for MSNBC to become as bad as Fox News when it comes to the issue of Bernie Sanders, they've got a choice to make, right? They have got to face the noise. Bernie Sanders is the frontrunner by Super Tuesday. He may be the presumptive nominee if he's not already.  Because look, they have a serious question to ask themselves. Are they going to try to be fair to Bernie Sanders, even minimally?  It's a serious question. It's a serious question.   If they went away, I think it'd be better for the country. But when they can plausibly say that MSNBC is laughably biased, that's when you know MSNBC has got to change directions. They've got to really, really do some soul searching. Their pundits have got to look in the mirror and realize, do you care about this country or do you not care about this country? Bernie Sanders is likely going to be the Democratic Party's nominee. So are you going to continue to hurt him? After years of screeching at the top of your lungs about Donald Trump because corporate money is just that important to you? Or are you going to do what's best for the country? It's a question that is rhetorical because I already know the answer to it. This is a business. MSNBC is not interested in producing news. They're not interested in being objective or even neutral. They are all about maintaining the status quo because if Bernie Sanders becomes president, then they know that he's going after their advertisers directly. He's taking on Big Pharma and the health insurance industry, right? He's going to take on the military industrial complex. So they're fighting to keep the gravy train flowing and they don't want to stop. So they're not going to change unless they have no choice but to change. Now, we're already, again, seeing signs that they're starting to crack. But regardless, it shouldn't have got to this point. Like it shouldn't have come to this. You shouldn't have been so shamed into, you know, doing at least a little bit better to where even Fox News is making fun of you. You should have been able to predict the rise of Bernie Sanders by having enough competent people on your on your programming. And you should have just at least been fair to him and not lied about his policies, but you couldn't help yourself. All of the people on MSNBC are just craven hacks and they only care about themselves. So they've got to change. And over the course of the next couple of months, we're really going to see whether or not they do change and they do better. If they want to survive, they're going to have to, but we'll see if they adapt quick enough. That really is the question and something that we should all watch for.


Well, first let me welcome all of you spellers to the White House and let me compliment you, and that's compliment with an I, not compliment with an E. I want to compliment you with an I on your accomplishments. You are the 137 finalists out of eight to nine million students who participated in this national spelling bee. That's quite an honor and you should be very proud. You know, because of this event I learned that the study of spelling is called orthography. Orthography. That's O-R-T-H-O-G-R-A-P-H-Y. No, I'm sure you already knew that. You were just proving it, but I thought I'd give you that just in case they asked for it on Wednesday.  I wish all American students were as interested in their studies as you evidently are and have been. And I wish all teachers and parents took an interest in their children's educational development as your parents and teachers have taken in yours. Now on Wednesday you're going to be feeling the pressure of the competition, but I want you to know that you're already, all of you, winners in my book and in the hearts of your hometowns. So enjoy the competition and enjoy your trip to Washington. I hope you've been having some fun and seeing some of the sights here. I'm told you're on your way to a barbecue. That sounds like fun, so I don't want to hold you up. But again let me wish you all the best of luck on Wednesday. And remember, I before E, except after C. That ought to help a little.  People can get so sure of themselves. I know you must have heard or read in your studies about the author of many years ago, Mark Twain. And Mark Twain was on a ship going across to Europe. And in the dining salon that night at dinner, someone wanting to impress him at the table, asked him to pass the sugar and then said, Mr. Twain, don't you think it's unusual that sugar is the only word in our language in which SU has the sh sound? And Mark Twain said, are you sure? Well, good luck to all of you. And as I say, you're all winners. And you all have every reason to be proud.  And I maybe have time to just come down and say hello to a few of you here. And I'm going to do that. Is it any more likely that you want to tax cut for the rich and that it won't hurt for those over 50 miles to give it up?  Well, thank you very much. We're having a meeting on that.


Thank you for the kind invitation. Let me share my screen and it's a pleasure to be here with you. I feel like I'm with friends and family and many of THI achievements and outstanding work is familiar with me. I'm very familiar with. So a lot of what I'm going to be discussing some of that she may be bread and butter for many of your outstanding interventional cardiologist. But this topic or this lecture I'm going to gear it towards the clinical cardiologist, as well as the interventional cardiologist. I have no relations with industry or conflict of interest related to this topic. I was a member of the writing group of the guidelines a CCH a viral heart disease guideline. And this topic will cover the issues related to aortic stenosis as well as TAV versus server. So that's my focus for the current grand rounds. I also was a member of the 2017 focused update on the viral heart disease guideline. And I was a member of the team that performed the initial TAV in the whole VA healthcare in 2011, a few weeks after the FDA approval. And just I was a member of the team that we just started at Harris Health at Bantob also the first TAV program this year. So TAV and I think valve is on the core of my interest and I would love to share with you some intricacies related to our viral heart disease guideline, as well as contrast some of our guideline recommendations with the recommendations from our European colleagues. So you're all familiar with the guideline recommendations by ECC and HA class one recommendation and these classes of recommendations are based predominantly on the ratio of benefit to risk. This is obviously separate from the level of evidence. So class one recommendation is a strong condition to do or implement a strategy because the benefit to way outweigh the risk. Obviously, as you may know, there's either no benefit or even there's harm. That's why it should not be done as class three recommendation either for no benefit, or because there's actual harm class to a and to be recommendations are really a borderline So there may be there is benefits that outweigh the risk but the magnitude of benefits is not the same as any class one with a class to be there may be benefits so it's maybe reasonable to implement the strategy. So let me start with a clinical case of a 66 year old man. He's been having progressive this one exertion for the BNP 310 known to have fully controlled hypertension to prior surgeries one cabbage and one other prior medecine surgery. STS prom score isn't the intermediate range 6.5% and echo cardogram showed a normal LV function mild LVH and all three measures indicative of severe aortic stenosis. So the intensity across the valve, more than 4.1 meter per second mean gradients, more than 42 millimeter, and I wrote it well, area of 0.9 millimeters square. This is a still images of the cats kind of this patient to the left panel, you see this calcific tricuspid iodic valve. And to the right, you see a cross section across the left ventricle. It's not an image but a hint of my or not going to go hypertrophy and I want you to focus on the apex and think what's happening at the apex of the left ventricle of this patients, and I'm going to go back to this patient at the end of my talk. So let us start with a simple. That's a really more detail of the cardiology fellows and the clinical cardiologist, according to the vital heart disease guideline. We publish in late 2020 December 2020 by a CCH what should this patient have. Should he undergo an exercise stress test. Should he have optimized blood pressure before treating his AS. Should he have aortic valve calcium score measured receive a follow up echo in six months or undergo aortic valve intervention. In stages of our heart disease at risk valve disease would be a patient like having my cuspid I think valve, who's at risk of progressing to do more significant out above stenosis and disease, progressive I think valve disease would be somebody with mild or mild aortic stenosis. Then you have a stage C which is asymptomatic severe aortic stenosis, and we divide those patients into asymptomatic with no LV or RV decompensation. So the normal structure of the function and RV function. So you have usually more than 50% C2 is asymptomatic severe aortic stenosis. But with decompensated LV or RV, usually with EF less than 50%. And we have obviously the stages D, which are the severe symptomatic. And in the case of aortic stenosis, we classify them into D1, D2 and D3. So D1 is symptomatic severe high gradient aortic stenosis, these patients are able to mount a velocity more than four meter per second and the many gradients above 40 millimeter. So we have an aortic valve area typically less than one centimeter square or index aortic valve area, less than 0.6 centimeter square per meter square. There are symptoms are anywhere between heart failure exertional angina or exertional syncope or presyncope, but really the most common symptoms in these patients are exertional this is not exertion and exertional fatigue and progressive decline in their functional activity. So D1 severe symptomatic aortic stenosis very easy to diagnose that challenge is with stages D2 and D3. So D2 is also severe aortic stenosis but these patients have compromised RV ejection fraction doesn't 50% that unable to mount a gradient or velocity more than 40 millimeter or four meter per second. And you would want to perform the middle mean stress echo up to 20 mic per kilo and try to elicit if they have a contract I'll reserve and increase gradient and velocity across the aortic valve and discern through aortic stenosis from pseudo stenosis. Stage D3 patients is even trickier to diagnose because this patient do not have low EF. These are severe aortic stenosis with paradoxically low for low gradients, because the EF is above 50%. However, they have paradoxically low stroke volume index defined as strong volume index less than 35 CC per meter square. And that's not appropriate or adequate gradient or velocity, and it's trickier to diagnose these patients, you may need to resort to a junctive diagnostic modality, like aortic valve calcium score. You will need also to optimize their afterloads and there is just their blood pressure to increase their stroke volume to be able to better assess the severity of their aortic valve. So let's go back to this patient should we perform an exercise stress test on as patients and when. So in asymptomatic patients truly asymptomatic patients who have no decompensated as we function. So normal EF above 50% exercise testing is reasonable to assess physiologic changes with exercise and to confirm absence of symptoms. And in the guidelines we say if you have symptoms on exercise. You're asymptomatic without exercise. I mean symptoms on exercise stress test are symptoms. Even if in routine daily life activities that patients asymptomatic, once you have symptoms on stress test, then you'd consider this patient as a symptomatic patient who needs aortic valve intervention. Obviously, if the patient is severe symptomatic with stage D one with high velocity high gradients, then you should not perform an exercise stress test, because of the risk of sudden cardiac deaths and ventricular arrhythmia. So in this patient absolutely no stress test. Now what about the role of medical therapy in this patients. Now, blood pressure control in patients with the stages B and C is appropriate as long as it's done very carefully, cautiously and careful titration. To use on to represent therapy, the guidelines really do not indicate preference for one versus the other, but there are some retrospective data showing that blocking the running and you test a system system with a single ARB may impart a benefit. And in retrospective studies, there are some benefit in on all cause mortality probably because of the beneficial effects of ACE inhibitors on limiting fibrosis and led ventricular hypertrophy in these patients. And that in therapy, obviously, is shown in multiple in at least three randomized control trials that it does not impact the progression of Ayurvedic stenosis. And it does not reduce other valid related events. Now, in the clinical studies of as patients, it does reduce by around 20% or so is chemical disease events in patients with Ayurvedic stenosis. In the as patients are older, they have a high atrocious risk risk, and they need to start in anyway, but it's not recommended for the lack of benefit to give it to prevent the progression of as that signal of benefit was evident in early observational retrospective analysis but did not pan out in randomized control trials. We're measuring calcium score in this particular patient remember this particular patient was a stage D one straight diagnosis of high flow high gradient as was symptoms. So really adding Ayurvedic cancer score does not help much, because you already get your diagnosis. Now, adjunctive diagnostic modalities, such as a Ayurvedic cancer score may help in those with diagnostic dilemmas, like those with stage D two. Let's say you did a DSC on them and you're unable to elicit a contractile reserve or increase their gradients, because it's not increased their cardiac output by more than 20% or in stage D three with a low stroke volume index and you're not sure whether the symptoms are this is true severe as or not, then you could measure an Ayurvedic blood calcium score. And there's such specific agates and scores. So for women we go with a threshold of 1300 for men we go with a threshold of 2000 remember in the woman there. So they may have severe aerotics noses with less calcification, because they're more prone to fibrosis of their erotic valve, while in man, there's more predominant calcification as contributing to the pathophysiology of their senior Now what about following this patient with echocardiogram and this patient had severe symptomatic stage D one, he needs to have aortic valve intervention, but let's say if he was asymptomatic or stage B, then the recommendations are as follows for those with mild hyaluronic steels as you would want to follow was a trans-rosic echocardiogram every three to five years, moderate, I would say was every one to two years with a true stage true severe asymptomatic with compensated alve function more than 50% I E stay C one, you want to follow every six to 12 months. Now if they have severe asymptomatic stage C two, then even if they're asymptomatic, because of the structural deterioration in their alve function, they would need to go towards I or take value intervention. So this patients should go undergo an aortic valve intervention. So that was a simple question just to start the discussion. Now, in our guidelines we publish a little bit more than a year ago now, we have five class one recommendation to treat symptomatic and asymptomatic and asymptomatic severe aortic stenosis. So for symptomatic severe as patients. So class one recommendation with the highest level of evidence for those with the stage D one, who have symptoms of exertional dyspnea heart failure and general syncope or presyncope I or take valve intervention is indicated. So the symptoms are symptomatic or stage D two or D three. So low low low gradients with reduce EF or preserve the F, then it's recommended also to proceed with an aortic valve intervention. But here you may face some diagnostic challenges to really ascertain this is a true aortic stenosis. And also to ascertain at least in stage D three that the symptoms are related to the aerotic stenosis and not related to something else. Now for asymptomatic patients we have to class one recommendations. The first recommendation is to perform aortic valve intervention in asymptomatic stage C to patient with severe as so those with severe as even the asymptomatic but have an LV function less than 50% already had the structural heart disease or deterioration of the LV function they need to go with an intervention. Those asymptomatic with severe as who are already undergoing cardiac surgery makes sense to go with surgery concomitant server, in addition to their cabbage for example, and that's a class one recommendation based on non randomized data. So if it's an asymptomatic of intervention, it all depends on the symptoms. So, if the patients have symptoms, and they have stage D one. Then you go for aortic valve intervention with cyber or Davi. If the patient have symptoms, but they're unable to mounts a velocity more than four meter per second, and that there was an equivocal then you go to assess the LV function. If you have EF less than 50%. These could be stage D to or could be a pseudo aortic stenosis pseudo severe as it is then DSE to try to elicit an increase grain it would make sense. And if there's contractile reserve and the gradient above 40 or V max above four is elicited then you go with aortic valve intervention. Now, if the EF is a preserved, and you would calculate the stroke volume index, if it's compromised, then you want to control the blood pressure, and you look for other etiologies, these patients, often they are women, older, and have restricted cardiac filling. If you use what's causing their stroke volume index to be compromised, you would want to measure this when their blood pressure is well optimized, at least to remove the afterload mismatch from the high blood pressure. And that will give you a better indication about the severity and you need also at the junctive modalities such aortic valve calcium score DVI and other modalities. So what if the patient is asymptomatic. Then, if they have severe as, but they're asymptomatic but have compromised at the function isn't 50% that stays to, they need to go for aortic valve intervention. If they're undergoing cardiac surgery need to go for several concomitant. These are both class one. Now what if the patient is truly asymptomatic with normal at the function. And then, if they're truly asymptomatic severe see one stage, you can put them on a treadmill and see if you can elicit symptoms, or examine the hemodynamic and physiologic response. We have limited functional capacity to sex age adjust, adjusted functional capacity, or they drop their blood pressure by more than 10 to 20 millimeter. And then there's an indication for aortic valve intervention, and usually here it's server, because of the positive of evidence for TV in severe asymptomatic patients. Now, if the patients is severe truly severe asymptomatic, and have a preserved at the function, but have very severe or critical as defined as V max more than five meter per second or meter gradient, more than 60. They're asymptomatic but have evidence of subclinical heart failure as evidence by BMP more than three times normal, or they showed rapid disease progression and we find that us on the European guidelines as more than 0.3 meter per second velocity increase per year. And then progression is average is 0.3 meter per second velocity, seven to eight millimeter gradients, and 0.15 centimeters square reduction area, anything more than that, mostly more than 0.3 meter per second with indicate rapid disease progression. So if the patient is severe at the faster rate than this per year, provided these patients are low surgical risk. These patients can undergo a cyber. So critical asymptomatic as some clinical heart failure, rapid progression, it's reasonable to go for cyber, if the surgical risk is low. The patient had moderate as undergoing other cardiac surgery. It's a class to be maybe reasonable to undergo a cyber, and also it may be reasonable to undergo a cyber, if they have progressive reduction and I'll be function, despite severe asymptomatic aerotextenosis, and you need to do three serial studies to ascertain there's no error in readings, even if the reduction happens and the patient is still within a normal range of the function, but it went let's say from 65 to 55% on three serial testing, it's maybe reasonable to proceed with surgical as well replacements. So these are the recommendations for doing at the interventions. Now, what about that choice of server versus study in these patients, and let's go back to that particular patients. So the ATCHA guidelines, the best therapeutic strategy of this 66 year old man with severe symptomatic as his choice of therapeutic strategy is dictated solely by the surgical risk, as assessed by the surgeon and interventionist, but in vital capacity for palliative reasons, several mechanical procedures, Tavi or server with bioprocesses. Let's dissect those. So first, the first answers, obviously wrong. You need to invoke the multidisciplinary heart valve team when intervention is considered. So cardiac surgeons interventional cardiologist, possibly the primary care physician of the patient, noninvasive cardiologists. You need a physician if needed. And you need in a multidisciplinary heart valve team fashion to determine the risk benefit on alternatives that you think are reasonable for this patients. And then very importantly, obviously, that choice of a prosthetic valve and the choice of the therapeutic strategy should be done in a shared decision making process with the patients. So what are the values of the patient? Do they want to open heart surgery, or they would want a periquitinous procedure? Do they want a prolonged hospital stay or an average of a two to three day mean length of stay with Tavi? We also want to understand their preferences. Are they okay with getting anti-coagulation? As such, they would be okay with the mechanical processes.  And then we need to also discuss the risk and indication for anti-coagulation therapy, as well as very important that durability of the valve. Mechanical processes can last forever technically conceptually while bioprocessors have more limited durability. And data for TAVR bioprocessors is even limited to five years of echocardiographic adjudicated data, and maybe eight plus years of clinical data, while we have way more experience showing the durability of the surgical bioprocessors exceed 15, 20 years. Of course, it goes down with younger Asian groups and we'll talk more about this. Evaluating with a hard valve team, share the same thing with a patient, and objective risk scores are all class one indications, by the way, in our guidelines. Now what about vivaloplast? Only in a critically ill patients based on expert opinion, it may be reasonable to do aortic periquitinous aortic balloon dilatation as a bridge to aortic valve intervention, definitive intervention, like SAVR or TAVI. There's not much data. Alan Kribi, I put this picture because Alan Kribi in 1986 was the first to describe balloon aortic vivaloplastia, and he came back along with Dr. Panagua, my colleague at Baylor and the VA. They both did the first retrograde and ontigrade periquitinous aortic valve implantation, but I like to be even before the 2003 did the first balloon aortic vivaloplastia. At that time, it was deemed a miraculous treatment, but we realized shortly after that there is no survival benefits. And the reason behind this, and also the symptoms improvement are only short lived. And the reason behind this can be really summarizing this meta analysis done by Dr. Kumar and Dr. Panagua and Dr. Phyretas and myself a few years back. We looked at all the literature published in balloon aortic vivaloplastia in the TAVI era, and we confirmed what has been known before, is that you improve severe AS from very severe to moderate to severe or the last severe. And the improvement in mean gradients is really marginal goes from 50 to 25, and they improve an aortic valve area goes from 0.6 to still less than one centimeter square. And the hemodynamic improvements because of the nature of the senile catastrophic stenosis, unlike mitral stenosis, rheumatic mitral stenosis, where it's commissural disease is diffused fibrosis and calcification of the aortic valve. But it's a mechanism, which splits the commissure does not act very well on aortic stenosis. That's different than congenital aortic stenosis in the young, obviously. So, these valves can restynaus, and the symptoms recur within a few weeks to up to three months. That's why I ordered by velocity is not a definitive treatment for severe catastrophic aortic stenosis. Now, whenever you consider the choice of TAVI versus cyber, you want to factor many things. One is the age slash life expectancy. So you want to balance the patient longevity against the durability of the prosthetic valve. So for example, the very young patients. There's a signal survival benefits when you use a very durable durable mechanical aortic valve with surgery, because these can actually last for a long time. And you don't need re-operation and you're not subject to the risk of structural valve deterioration the way you have with bioprostatic aortic valve. Patient risk and comorbids are very important, obviously, you would want to assess the risk score and we have objective risk scores. We use mostly SDS risk scores to assess the surgical risk. TAVI risk score we don't use as much because TAVI risks are really very low. But with SDS risk score, you differentiate into low, intermediate and high risk and even extreme risk which is inoperable patients. And in those with who are at high risk or inoperable risk, it does make sense to proceed with a less invasive approach like TAVI. You don't have to deal with any of the indices you have. You want to also assess other comorbidities that may not be incorporated into the risk score. For example, with SDS does not account for medicinal radiation. And this patient in particular had medicinal radiation in the past. And that accounted for in the SDS risk score and both of those, for example, are increased the risk of surgical risk and make surgery possibly prohibitive and make TAVI more attractive. You want to also account for anatomical and technical issues and procedure specific impediments. So anatomical consideration by Caspid aortic valve are less well studied in clinical trials, and they are at higher risk of complications with TAVI. They're more calcified, more eccentric, so IE, more PVL, although this has been going down with a newer generation TAVI platforms. And oftentimes they may have an aortic aneurysm, a scenic aortic aneurysm or abnormalities. So that makes TAVI more problematic and more tricky and sovereign these patients is preferable. Procedural consideration. If you've got peripheral disease, unable to perform transformable approach TAVI, then it's preferable to go with sovereign. Remember most of the endocrine clinical trials, and our guidelines are really based on data from RCT for the SEMRA TAVI. Alternate access TAVI has been shown promise and effectiveness and safety in multiple non randomized trials, but did not make it yet to the guidelines. The European guidelines have a soft indication for performing alternate access TAVI, but not the American guidelines. Another procedural consideration, for example, low coriosteia distance from the aortic analyst of let's say, six or seven millimeter may subject these patients to occlusion of the coriosteia during a TAVI when you do the implant of the valve, and as such, the valve would be preferable in these patients. You also want to account for the goals of care and the patient preferences and values, including the preferences and values for prosthesis and for onticoagulation. And finally, indications for aortic valve intervention. Remember, the randomized control trials for TAVI, and most of the evidence is derived, or based on patient with severe symptomatic aortic stenosis. And also asymptomatic aortic stenosis, there's a positive evidence supporting the use of TAVI. Now it does make sense that maybe beneficial, but we're waiting for the evidence. While we have decades of experience with a server for symptomatic and asymptomatic aortic stenosis, such as those going for cardiac surgery. So there's some data showing that it's reasonable to proceed with the server, even with severe asymptomatic, at least two surgical products showing benefit, small scale studies but showing benefit. So that's why an asymptomatic patient with severe as server may be the way to go for the time being. Obviously, this is a very dynamic field, and we are waiting for more evidence and more data. So let's go for the crux of the, of the topic, or the most important part of the grand runs. And this is good towards the clinical kind of what also the interventional kind of just so for severe as when to choose TAVI versus server, but the way you see me using interchangibly as of December 2020 our guidelines we are catching up with our European colleagues, and we're now phasing out the TAVI term and we're using TAVI. It's trans-cancer aortic valve implantation. So whenever you have an indication for aortic valve intervention, you want to invoke the patient in a shared decision making, as well as the hot valve team, you want to determine the surgical risk. And according to the surgical rules, you want to dichotomize these patients into either high or prohibitive risk defined by an STS more than 8%, frailty, and multi-organ dysfunction, or if they have procedural impediments like medicinal radiation, or portion higher. So these high or prohibitive risk are one category. And then the other category are not high or prohibitive risk, i.e. low or moderate risk. So if the patient have an indication for aortic valve replacement, and after shared decision making with the patients and deliberation by the heart valve team, if the patient is low to moderate risk, you would want to ask this important question. Is the patient is amenable for vitamin K antagonist, anti-calculation. Can he or she take Coumadin or Warfarin? If the answer is yes, then you would want to see what's the age of this patients. If the patient is below 50 years of age, several with a mechanical processes is the way to go because of the durability of the mechanical processes with several. In very comprehensive valve centers, in patient caretik, anti-calculation, you can entertain RAS procedure, although durability and the IOTIC accreditation with the new IOTIC valve, and complexity of the procedure may make it's really only limited to certain processes. It may be a reasonable approach, but mostly mechanical IOTIC valve. Some meta-analysis show that there may be survival benefits from using mechanical processes with several and younger patients. These patients can take anti-calculation with minimal risk, and this patient needs the long-term durability of a mechanical process. Above 65 years of age, bioprocese is the way to go because with bioproceses, it's likely that the patients will outlive the bioproceses so that durability is not an issue. And also at above age 65, the risk of bleeding with anti-calculation becomes more bigger and bigger and more problematic. At 65 and 50, mechanical or bioprostatic valve with several is the way to go because even bioprostatic several has more data for durability compared to a TAVI bioproceses. Now, what if the patient is not amenable to vitamin K anti-calculations, i.e., this patient will be destined for a bioprostatic IOTIC valve, or if the patient is above 65 and already destined to bioproceses, or patient is younger but really doesn't want to take a mechanical valve, so bioproceses. Once you have a bioproceses determined as a treatment strategy, the next question is, what stage of IOTIC systems does this patient have? If the patient have a stage C2, so anything outside D1, D2, D3, or C2, they would go for SAVR, so stage C1 they go for SAVR, but stage D1, D2, D3, or C2. So the majority of severe symptomatic AS were getting bioproceses could go the route of either TAVR or SAVR depending again on age. So, if they're above 80 of age, the American guidelines say transformable TAVI provided they're suitable for transformable TAVI is recommended as a Class 1 indication. Because the durability of the bioprocese with TAVI is long enough to likely outlive the age of the patients. And the risk of SAVR in this age group is much more pronounced than the risk of TF TAVI. So Class 1 recommendation for transformable TAVI, it's reasonable to do SAVR in lower risk patients, but in general above 80 of age transformable TAVI is recommended. Now below 65 year of age, SAVR is recommended with bioproceses. So between 65 and 80 years of age, this is where you need really a good discussion with the patients and understand the value and the preference of the patients, and you could go either with SAVR or TF TAVI. Now this is the American guidelines and these are quite different than the European guidelines. So our European colleagues and I will go over this in a minute, instead of going with this granularity of age cutoffs 65, 80, and 65 to 80, they went with a dichotomy of 75 above and below, in addition to risk. So we are factoring that I'll take a regulation, the surgical risk, and the age of the patient. So we believe we have a little bit more granularity in our decision making for TAVI versus SAVR. Now what about these patients in the American guidelines who have indication for erotic valve intervention, and have a surgical risk that's high or prohibited. So the question is, do they have a life expectancy? That's more than one quality of life here. And if the answer is yes, and they have suitable valve anatomy, and suitable peripheral anatomy for transphemeral approach, then they should go with TAVI. So we have limited quality of life, as in a year, quality of life expectancy, if they're not suitable for transphemeral TAVI, or have very, very specific, like aspirin, severe erotic stenosis, that make it very high risk, then maybe palliative care is the way to go. So that's the guidelines, because remember we do not have alternate access in the guideline as a therapeutic approach. Our European colleagues do say that you may consider doing alternate access in selected patients. And if you have poor life expectancy, obviously palliative care is the way to go. In the American guidelines, the choices of intervention start initially with determining and a shared decision making with the patient, whether the patient should receive mechanical versus bioprostatic erotic valve. Below 50 years of age, mechanical, erotic valve is the way to go, above 65 years of age, you can use bioprocesses better. You can reasonably use bioprocesses in preference to a mechanical valve between 50 and 65 either way, depending on the patient's anticoagulation risk and preference and values.  Between 65 years of age, or a life expectancy more than 20 years, several of the bioprocesses the way to go because of its durability. Above 80 years of age, or a life expectancy less than 10 years, then transformable type is the way to go, because of its safety, and because the patient is likely to outlive the Tavi by processes between 65 and 80 years of age, either or transformable Tavi is recommended. Now I can remember that there are procedure specific risk factors that are not factored in in the Tavi risk scores and in the STS scores, such as medicinal radiation, erotic classification, the extent of severity of COPD, RV dysfunction, hepatic dysfunction, all these are not factored in the STS scores and they need to be added on in your risk assessment. So these objective scores are not really, are not gospel, you need to add the clinical good stat to it. And also remember that most of these randomized clinical trials were really based on clinical efficacy studies based on the very well appropriately selected patients. Now patients with end-station disease with COPD with hepatic, adverse hepatic disease were excluded in these trials, but we have retrospective analysis and observation data showing that Tavi may be an acceptable alternative in these patients. This is one such analysis from administrative data that Dr. El-Badawi, one of our interventional fellows along with Dr. Cappadia, chair of the clinical clinic, did with myself and many of my colleagues at Baylor. What we showed is patients with a prior medicinal radiation, there's an increase in the use of Tavi over time, while the use of cyber plateaued, and even after multi-variable adjustment, of course these are confounded data because of the administrative data. But with the best multi-variable adjustment models, we showed that there's a signal of mortality benefits doing Tavi over cyber, although these are non-randomized studies. This is just one example of these observational studies that showed the benefit of Tavi in patients, especially the patient population that were not included in the guidelines. This is an example of patients with a prior medicinal radiation, but we have data in anesthesia disease, in patients with liver dysfunction, probably not adverse liver dysfunction, and patients with even by caspered aortic valve, some retrospective and observational analysis showing the benefits and the merits of Tavi in these patients. Now, I want to remind you, I want to remind you of the current outcomes, contemporary outcomes of Tavi. So in the discussion with the patients, when you want to invoke the patients, they share the decision making, you want to tell the patients that 30-day mortality in Tavi has come along quite a bit from 5% to 6% at 30 days in the early expedients to now 2.3%. So the rate of 2% mortality, and it's even lower in the clinical trials, stroke rates coming down in hospital from 2.2% to 1.6%, and 2.8% to 2.3% at 30 days. The pacemaker rates as well coming down to nearly the single digit, now 8% to 10% in hospital versus 30 days. So, and depending obviously on the Tavi platform, but outcomes are improving over time, part of it because of technical improvements because of Tavi platform improvements, but also importantly, because now we're doing more and more low risk patients. Remember the initial approval in 2011 in November, when we started the first Tavi was for inoperable patients based on partner B, a cohort of 300 patients showing survival benefit of 20% of Tavi over medical therapy. Then we had the high risk indication a year after in 2016 when the intermediate risk indication and low risk in patients in the low 70, 72, 73, showing low risk benefits with Tavi compared to saver in 2019. And this is when the low risk FDA label came in. And based on this also we enlarge extends updated the guideline. So we're doing more and more Tavi procedures in low risk patients. And the contemporary data for IOT isolated IOT valve surgery showed a more tight rate of operative of 2.2%, but you had cabbage with the cost of 4%, you had double valve replacements when it's nearly 10%. So part of our leak after Tavi remains a limitation of Tavi but it's less so with the current generation Tavi platforms. Dr. Dhruv Mata, one of our cardiology fellows wrote this editorial and emphasize that really PVL now with the newer platforms, when it's approaching zero for moderate or severe PVL. Part of our leak limitation is being overcome with a better platforms. And also, there's always this question is, when you go for surgery can fix both valve there's a matter of disease, but if you go with Tavi, you're only limited to the robotic but you may need to go for a second approach. There's some data to show that this may be the case in a fraction of the patient but a lot of these patients, if they have concomitant severe AS and severe MR once you fix their IOT valve with a Tavi, what you do is you decrease their LV and systolic pressure and you decrease their pressure and with the help of guideline directed medical optimization therapy, you do not need a subsequent as catheter, I think, my intervention. So that's why in the guideline we shed away from stating that you should do concomitant percutaneous valve procedures to fix the Tavi, the IOT valve for the Tavi, and then you reassess and optimize and reassess the need for it's ER a later on. And there's something we outlined in a nice editorial with your own doctor plan and our brilliant fellow Dr. Jean Souffredi in this editorial. There are no randomized controlled beta there's good retrospective observational analysis showing that it's effective and safe and selected patient to do Tavi however you would want to do them really in a comprehensive valve center. And it's maybe reasonable to do them, preferably it's always preferable to proceed with SAVR as a first option, one these patients are young, they may need anyway mechanical procedures to they have high calcium score, they may be more prone small signal they may have anabolic stroke. They have eccentric aniline, they may have more peripheral leak, although admittedly this may be slightly overcome in the current era with a better Tavi platforms, but there's certainly more risk in these patients. So I think SAVR is preferable and maybe reasonable and selected centers, comprehensive centers to do a bicuspid optic valve Tavi's and Dr. Cayani, one of our faculty members wrote a very nice editorial at the clinical journal on this regard. Let's go back to the case of the patients. I just presented to you. Remember, I told you he had two surgeries. So one of the surgeries was cabbage, and you could see that he has a Rima, a particular Rima to the ADD, and this Rima is adherent to the Mediastinum and you call from this in our lateral view. So doing the open heart surgery may risk injuring this Rima. So that's one that's why surgery is prohibitive. And again, this is not accounted for in the STS core. In addition to that this gentleman had Mediastinum radiation. And I counted for risk. Despite his young age, this guy is at a very high surgical risk for redo, redo surgery. Now what I want you to pay attention to is this ring over here. Remember the apex of the left ventricle. This is a patient we performed a Tavi on in 2012, our early experience. This is a pigtail in the left ventricle. We're doing an LV gram injecting a radio aerated radio contrast material in the LV gram and you see the opacification of this conduit that's going from the left ventricle all the way to the Iota to decompress the severe AS in this patients. So this patients had earlier cabbage and Mediastinum radiation. He had a progression of his aortic stenosis. He's no longer eligible for saver. Tavi was not an option at that time. So he had one of the infrequent surgeries to decomp to relieve the aortic valve obstruction, which is a conduit evolved conduit from the left ventricle to the Iota and there was a valve here. That's a metronic valve. Now this patient few years afterwards came in with symptoms of aortic stenosis again. And the question is, what happened to this conduit, does he have obstruction or stenosis of the valve inside the conduit or there's any conduit problem. We're injecting dye to assess this conduit. We don't see any layering thrombus. This usually don't really form layering thrombus, but we don't see anything gross with this injection. After that, we went through the Iota retrogradually, and took us some time to find the osteum of the anastomosis of the Iota with the conduit. We catheterized it after we found it. We put a wire there and over the wire, we advanced our catheter. We injected dye to check for any obstruction at the level of the conduit. And also beforehand, we did a gradient between the left ventricle and the conduit distilled to the valve and there was no gradient at this level. So really, the valve inside the conduit was not the stenotic culprit. We did a pullback. And you could see that there's a hint of anastomosis problem at the most between the conduit and the Iota. So the conduit was non functional or the conduit is imparting a functional Iota stenosis, but it was at the level of the anastomosis. So here was the choice, should we balloon risky balloon, the anastomosis the static anastomosis between the Iota and the conduit. Or should we proceed with the newly available trans-fameral TAVI and that's what we did at that time in 2012, mid 2012. This is the early generation Edward Sapien TAVI platform. I forgot whether it was 26 or 20, 26 millimeter probably valve. There wasn't 29 at that time, if I recollect.  And this was done obviously under RBP basing with double base maker, nicely deployed Edward Sapien valve. I continue to follow this patient to now and he's doing very, very well. And then later, by the way, with the non-STMMI, and I had to interview on his vein grafts, and I was so happy that I put a short TAVI platform, the balloon expanded platform, because that allowed me easier access to his coriosteum. Actually, it was a vein graft intervention. So coriosteum access was not an issue with this patient. This is his hemodynamics before the TAVI, you see the delayed and diminished Iotic, systolic Iotic pressure, this coincide with his parvus etardus carotid pulse, large gradients, elevated LVDP as well. And then post-transfameral TAVI, you see now your appearance of the dichotic notch, and there's no diminished or delayed pulse and nearly superimposable curves with a very, very minimally gradient of two to three millimeter. Before I finish the topic, I just want to tell you that the European guidelines were published probably three months, two to three months ago. For the most part, they have similar guidelines recommendations to us, with the exception, instead of using the cutoffs of 65 and 83 groups, they use the cutoff of 75, one cutoff. So above 75 or higher risk, patient would go with transformer TAVI, according to the ESC European guidelines. Below 75 and low risk, you go for server. Now, any other patients would go to either server or TAVI. For example, patient below 75, but our moderate risk, they could go either TAVI or server. Above 75, it's strong preference class one for TAVI and high risk or above class one for TAVI. To go for server, you need below 75 years range and low risk to go automatically for server. So really, the European guidelines lower the threshold for the utilization or implementation of TAVI in AS patients. So the reason we did not do that, and we went with the more we think our approach is more granular, because it's, it's basically more granular it allows more choices for the practicing physicians. That's one and remember these are only guiding documents. And with the low risk patients, we really have one to two year data fall out now actually we have more data accumulating intermediate term data but still we're lacking the long term data for the durability of the TAVI by procedure, especially in younger patients, and the partner three trials are really mandated to continue for to report their 10 year outcomes. So we will know in many years from now, what's the long term outcomes of TAVI in low risk patients. So I want to end by reminding you that our team approach objective risk assessment of server risk and TAVI risk, as well as shared decision making with the patient are key. So the guideline, and you want to factor everything in your assessment of the patient treatments and the choice of treatment, including age, comorbidities, freight lead life expectancy, as well as anatomical and procedural considerations. With this I want to end and thank you all for your attention, and I'm happy to take any questions you have.