Hey, what's up YouTube? A.J. here with my good friend Gia Helena and today we're gonna be talking about how to overcome social anxiety to have great conversations with strangers. Now if you get a little nervous talking to strangers, maybe you run out of things to say or you feel awkward, then you're gonna want to stay tuned because we're gonna talk all about overcoming social anxiety, how to be more vulnerable, and we're gonna give you six quick tips to strike up conversations with anyone. We all know how difficult it can really be to talk to strangers and at times it could be not even scary but even nerve-wracking. Absolutely, whether you're extroverted or introverted, sometimes our social anxiety trips us up and we run out of things to say. Social anxiety is the fear that most of us have of being judged negatively or even rejected in some social or performance situations and this could be actually one of the biggest reasons why it might be very hard for some of us to start conversations with strangers. And listen, we get it. You're behind your phone screen on a daily basis and because of that we're feeling more and more disconnected and unfortunately we're losing some of our social skills. But here's the great news. These are muscles that you can train. You can get better at growing and strengthening your social skills so that you can find a great relationship, you can get that job offer or even make a great friend and here's the best part. We all struggle with social anxiety. I remember myself back in the day when I was getting started trying to learn how to be more social and going to events feeling nervous, feeling awkward and of course it was a self-fulfilling prophecy. I'd get in a conversation, I'd freeze up, I'd feel awkward and then I'd struggle. Now there is power in talking to strangers. In fact, if you think about it, every single person in your life at one point was a stranger outside of your family. So your ability to strike up a conversation waiting for coffee at the bus stop or at a friend's get-together is incredibly powerful for you to grow that social circle. It's so true. Being able to strike a conversation out of the blue opens yourself to a lot of possibilities and also your social network. People that are much more restrained and maybe even a little bit afraid to do that or to start a conversation might be limiting themselves also to stay in their normal network and very limited to getting to know different kind of people and other opportunities as such. Now, how do we do this? Well, it starts with being vulnerable. We understand it's a little scary to walk up to people and strike up a conversation but if we lead with vulnerability, you're gonna find conversation happens a lot easier. So when we talk about vulnerability, we're not talking about spilling it all out in front of other people or maybe showing some sort of weakness. Leading with vulnerability, we're talking about connecting with people at a deeper level from you being yourself. Vulnerability is not disclosure as such and it's important for us to leave from that perspective. Absolutely. Being vulnerable is about being open to meeting new people, not closing yourself off or being stuck in your head. We don't have to spill everything about ourselves to be vulnerable but we should at least go out with an openness to getting to know other people. You being vulnerable is the permission that you are giving yourself to be yourself and be perfectly okay with that and at the same time giving the other person in that conversation the same permission to feel comfortable and safe around you. And we get it. It's scary but guess what? Rejection doesn't have to be scary because the people that we're talking about, strangers, they don't know you on a deep level. All they're rejecting is your approach. So fixing your body language, changing your posture a little bit can have a drastically different result and you don't have to hold on to that negative rejection. Now we are vulnerable and we can speak about our emotions and there's nothing wrong with being a little honest and saying I'm a little bit nervous to be here today but I'm so excited to meet new people. Believe it or not, it's far more easy to be vulnerable with strangers than at times it would be to be vulnerable with our friends or people that really know us due to the fact that there's no expectations and sometimes, you know, we might not even see that people again. And their judgments really don't matter. I can't stress that enough. As you get better with this stuff and strengthen these skills, you'll find that those rejections are not nearly as scary as you think. Practicing confidence is about you going through that fear and being able to continuously show up as to strengthen that muscle of starting and sparking conversations with strangers out of the blue. Now let's give you six quick tips to help you start striking up more conversations with strangers. And the first is smile. When we smile, we open ourselves up to conversation. And I can't tell you here in our bootcamp how many of our clients, when they are on film, when we're interacting with one another, they lose that smile and immediately the energy is set from the interaction. So smiling and being open to conversation is our first tip. What's the second one? Saying hello is our next tip.  Exactly. If they hold eye contact for a few seconds, that's a welcome opportunity to walk over and say hello.  Now the third tip we have for you is lead with a simple compliment. Let people know what you like about them, something they're wearing or even better, something about their personality. One of AJ's favorites always to open up a conversation is asking somebody, Hey, what are you excited about? The reason I love this is because it gives them the freedom to pick something maybe professionally that they're excited about or something personally they're excited about. So it doesn't force them to talk about things that are boring or uninteresting. Also psychologically, you are kind of inviting the person to have a positive thought and to find somebody, something also that they're proud about. In that direction, they will be happy to share it with you. And then already there, you're leaning with some positive emotions. Small talk can go a long way.  Often here in LA for what I know is the traffic topic. It's always a topic, perhaps the weather or maybe one of those situations you're currently going through at the moment wherever it is that you're hanging out, anything that might be relatable to each other. It's always a good place to start. So let's not underestimate also the power of small talk that might lead you to great deep talk. Now, number six, we have to be open to share. That means coming a little prepared with something to talk about yourself. What are you excited about? What's going on in your life that you're looking forward to? Adding that to the conversation allows the other person to get to know you and we're off to a great start. Because how often we have seen conversations falling short or abruptly ending due to the fact that the other person has nothing, nothing much to share. Sometimes they end up with somebody saying, awesome, cool. But we need to follow up in that conversation. I think that what you're saying is very interesting because and also giving something a little bit about yourself. That's the key word because whenever you feel yourself saying cool, awesome, agreeing with someone, add a because statement at the end of it so they get to know a little bit more about you. Now, to recap, we talked all about social anxiety and how we've even struggled with it in the past and it's totally normal, but it's something that we need to work through and our devices may be causing it. And what about that power of vulnerability? Vulnerability, please remember, is not exposing yourself and giving out all the way. It's allowing yourself to be who you are and giving permission also to the other person to feel very comfortable being themselves. And of course, six quick tips to strike up that conversation because we know that almost everyone in our life started as a stranger.  Open your circle, open your network and prepare yourself to be amazed of what the power of supporting conversations with strangers can do for you. And if this sounds overwhelming to you or you want to take your conversations to the next level, then check out our communication accelerator where in 30 days or less, we're going to get you walking up to people, having great conversations and welcoming them into your life. You can click the link below to join now and get that experience. If you like this video, then you're going to love our podcast, The Art of Talking to Strangers, where we go even deeper. So if you're interested in learning more of the science behind talking to strangers, check out the podcast link below, like, comment. Let us know what your favorite tips are or strategies for striking up conversations with strangers. We'd love to hear that.


In this video we are going to compare the arithmetic and geometric growth in plants. So let's see what the differences are. Let's say here we have the tip of a plant and at the top of the tip there are these two yellow cells which are meristematic cells and as you know meristematic cells are cells that can divide. So these cells divide and each of these cells produced two cells in turn in let's say one hour. So in one hour each cell is dividing to form two cells. So then we have a total of four cells. Now only the top two cells will divide in the next hour and the bottom two cells won't. So again we will have an addition of two cells and then again an addition of two cells. So in arithmetic growth this is what happens every time a cell divides or let's say in a given amount of time the number of cells added the number of new cells added remains constant. In this case two cells are being added every hour. In geometric growth it's a little bit different. How is it different? We can see this with bacteria as well as plants so let's look at bacteria. So let's say we start with two bacteria in geometric growth what happens is both of the cells will divide and let's say in this case each cell will divide to form two cells. So each of the cells give rise to two more cells so two cells are added right so initially we had two cells and then two cells give rise to four cells. So each time the number of cells double because each cell can give rise to two cells every time they divide. So let's say in one hour every cell doubles. So in the first hour two cells form four cells and then in the second hour what will happen is four cells will form eight cells. So notice what's happening to the number of new cells being added. In the first instance we had two cells added in the second instance we had four cells that were added and then next we will have eight cells that are added. So each time the number of new cells that are added is doubling whereas in case of arithmetic growth each time the number of cells that were added was constant two. In this case it started with two then it became four then it became eight. So that is a fundamental difference between arithmetic growth and geometric growth. The number of new cells added in arithmetic growth per unit time remains the same whereas in geometric growth it increases. Now let's take a look at the formulas representing the two growths. In arithmetic growth the formula is nt is equal to n0 plus rt. So what are these different things? nt is the number of cells at a given time. So let's say number of cells at time t. This is nt and what is n0? n0 is the number of cells at time 0. Then what is r? r is the growth rate constant. This is a constant for the type of growth that we are looking at and where we are looking at. Let's say in this particular case this plant it is some value in some other plant it will be some other value. So r differs from plant to plant or organism to organism and then t is time. Now let's take a look at geometric growth formula. So in geometric growth we have nt is equal to n0 times e to the power rt. nt and n0 are the same. nt is the number of cells at time t. n0 is the number of cells at the beginning. r is again the growth rate constant and t is the time. e is something that is not there in arithmetic growth formula. e is an irrational constant or irrational number which is a constant and this is a very important number in mathematics and it's used in a number of calculations and its value is 2.718 and it goes on like this. So since we have an exponent this is an exponent that is why geometric growth is also called exponential growth. Now let's take a look at the graphs of the different types of growth. So what we'll do is we will plot nt versus time. In arithmetic growth we see a straight line and hence since it's a line a straight line this type of growth is also called linear growth and in geometric growth what do we see? We see this type of a graph. So you see the difference in linear growth the slope of the line remains constant whereas in geometric growth the slope of the curve keeps changing in fact it starts off at a low slope where the graph is rising slowly and then it rises faster and faster which means the slope keeps increasing. So we've seen that in arithmetic growth the number of cells that are added per unit time is constant whereas in geometric growth the number of cells that are added per unit time increases with time. The formula of arithmetic growth is given by nt is equal to n0 plus rt whereas the formula for geometry growth is given by nt is equal to n0 e to the power rt and because there is an exponent involved geometric growth is also called exponential growth and in arithmetic growth the graph is a straight line hence it's also called linear growth and in geometric growth the graph looks like this where the slope keeps increasing with time.


Tom here from Orange Systems, and we're going to talk about Cloudflare Tunnels. Now this is a free offering from Cloudflare that enters no need to open ports. It does not expose your public IP address. It works behind NAT. It works behind CG NAT. And you're probably thinking, well, how do they offer that for free? And is it too good to be true? Is this really that easy to host my servers without exposing any of those things and creating those extra complexities of having to deal with certificates? Yeah, it's actually free. Now, why is it free? Best speculation is Cloudflare wants you signing up for services, so they hope to upsell you on more services. Now, there's a couple prerequisites here. You do need a domain. Now, you don't have to transfer your domain to Cloudflare, although that is an option. They will handle domain registration. You can register domains to Cloudflare. I simply took my name servers for one of my domains. The one we're using in this demo is going to be Lawrence.video. And I just swapped over the DNS settings for it. Pretty simple to do.  Next, you need to have a server that can run the Cloudflare tunnel server or a tunnel client. This client can run as a Docker, can run on Mac, Windows, Linux. It can run as a standalone daemon in Debbie and Linux. So there's a lot of different options that we'll talk about when we're using the Docker one specifically. And you need to have wherever that server is, the ability to talk to the other servers or the servers on that system, that you want to talk to, to broker that connection. Now, what I mean by that, and I'll have a layout that we'll be covering of how that works, the server that you load this on, I have Docker on it and I have a few other Docker containers, you can talk directly to those other Docker containers, but it can also reach out laterally and move to the other servers that it has access to. And that's something that matters a lot for this final prerequisite and that is trusting Cloudflare. The Cloudflare dashboard talks to the Cloudflare server to say which ports seem to be open and which services should be exposed. If someone else were to take control over that dashboard, it would be able to send down commands and say expose things that maybe you didn't want exposed. That's just something you should keep in mind when you're thinking about how the security works. It's not a reason not to do it. It's just understanding who's in those trust boundaries when you set up services. Final note is about how the encryption works in terms of the data that may pass through a local service back out to the Cloudflare cloud because Cloudflare is working as a reverse proxy. Any data that goes through that reverse proxy could be seen. So whatever is sent over those connections, because they're terminating the SSL for you via their tool, there's a way to pick that data out of it via that tool itself. Now the tool being open source means we should be able to see how they're doing it and look at it. But it's just one more thing to put in consideration and why trust Cloudflare is part of the final prerequisite because they're all in your trust circle and so is any data that will be traversing it. The consideration you may want is to limit where these servers live and what else is on there. So if you have something that absolutely should never be public exposed, you may not want to have it within reach of where this Cloudflare service runs. I just want to throw this out there. There's not any reason I have not to trust Cloudflare, not that I don't think they've done good job security. It's just always being aware of who you have in your circles of trust when you're building out technology. Now before we get started with this tutorial, let's first are you an individual or company looking for support on a network engineering storage or virtualization project? Is your company or internal IT team looking for someone to proactively monitor your system security or offer strategic guidance to keep your IT systems operating smoothly? Not only would we love to help consulting your project, we also offer fully managed or co-managed IT service plans for businesses in need of IT administration or IT teams in need of additional support. With our expert install team, we can also assist you with all of your structured cabling and Wi-Fi planning projects. If any of this piques your interest, fill out our Hire Us form at laurancesystems.com so we can start crafting a solution that works for you. If you're not interested in hiring us but you're looking for other ways you want to support this channel, there's affiliate links down below to get your deals and discounts on products and services we talk about on this channel. And now back to our content. All right, let's start by covering some of the basics of how this lab is set up and the layout and the goals. So we want some service.laurance.video to be accessible publicly with a certificate. The way you would do that with, for example, HA proxy would be to load HA proxy on a PF sense firewall. I've got a whole video on that, set it up and then point it to the services that are running over here on this Ubuntu server that's at <IP_ADDRESS> and it's running Docker with a few different containers on it. The other option might be to run a reverse proxy in Docker as well and then have certificates that then go through here and you port forward so you can expose the service. You have to make sure the DNS for that service is pointing there. All of this though comes with the, well, problem of it's going right through your firewall and you're exposing your public IP address. You're wondering why that is bad. Well, generally, if you're a home user building your home lab, you may not have a very robust ISP that can deal with any type of DDoSing that may occur. This is a problem that you can ask Jeff Geerling about. He has videos about DDoSing and his setup and mitigations he's done about it. Back to the topic here though, let's talk about a simpler way of handling this in a simpler way of handling the certificates. So here is the same idea, some service.laurance.video reaching out to the cloudflare edge. The cloudflare edge sits between you and the services. So the tool is going to run and we're going to run this in Docker, but it can run as a daemon. It can run as a service in Windows. It can run on Mac. The cloudflare connecting tool is going to be running on this Ubuntu server at that same IP address of <IP_ADDRESS>. It's just going to pass you to firewall like any other service reaching out to the internet. So there's nothing we have to do the firewall to configure it. If the firewall IP address changes, or if it's behind CG NAT or double NAT, doesn't really matter as long as it can reach the cloudflare servers publicly. From there, anything that this particular server has lateral access to. So if it is able to reach out to, and we'll do this in a demo here, this Synology server at <IP_ADDRESS>, then no problem. It's going to be able to reach out to that server and broker the connection back out to the cloudflare edge. And then any client trying to access it are always accessing via the cloudflare edge and not exposing your public IP address. And it doesn't matter if your firewall IP address changes, this can change dynamically and it resynchronizes quite fast because the cloudflare tool is always reaching out to their servers to let it know where it's at and it can broker those new connections. So it's not a big deal if your IP address changes. Now let's talk about functionally how to get this set up. Now for simplicity, we're only going to be talking about using HTTP and HTTPS, but there are actually more services this cloudflare tunnel can support and there's a lot more it can do. But this will get you started with the common things of just exposing things that you maybe want to sell posts that are web based services. So this is the documentation, plenty of it, lots to read. We're going to be using the documentation as a reference, but I'm not going to go through every detail in here, but they have plenty of use cases and lots of details. The other thing you're going to need to set up is the cloudflare zero trust dashboard. I'm going to skip setting that up. It's really easy. You just go through the basics of registering an account with cloudflare for that. And also as I said in the beginning of the video, there's an assumption that the DNS has already been done for whatever domain you have. In this case, Lawrence dot video. Now we're over here in the cloudflare zero trust dashboard. It's your first time signing up for it. Just scroll down to the bottom and always look for the free option that they have. We're going to be here to access, we're going to over here to tunnels, and we're going to create our first tunnel, Tom's tunnel for YouTube. Sounds like a great name for this. Save tunnel. And don't worry, this will be deleted by the time I post this publicly. Therefore, anything that you see in here, I'm aware of could cause a security risk as in for you because if you add your service to my dashboard, that would be really interesting because I'd be able to map things in here to whatever services you may have. But here, store your token carefully as command includes a server token, a lot of the connector at anyone, anyone access token will be able to run the tunnel. That's the point that they're making here. We have a Debian option, 64 bit, 32 bit arm options. I've tried it with the Debian Damon works perfectly fine. Didn't have any problems with it. Because we're running portainer and a few other things in Docker, I thought, Hey, why not do it in Docker? A lot of you do run Docker images in the home lab because well, they kind of make things easy. I'll admit. So we have Docker run cloudflare latest tunnel. No auto update run in here's the token. We're going to go here and copy this, but we're going to add a couple things before we paste it into the server. Let's go ahead and paste it in and add those extra parameters. So right after Docker run, we're going to add dash D dash dash name cloudflare tunnel give it a nice name dash dash restart unless stopped and then the rest. That's a really simple add. But what this does is runs it Damon road names a cloudflare tunnel and says restart unless stopped. This means it will automatically restart or start whenever you restart the server that is running this. And let's go over here and see if it's up and running.  If we click on the logs icon on portainer. There we go. We can see it. We can see the logs makes it really easy. If you're not familiar with portainer, check it out. It's free. It's also a Docker image itself. It does making managing Docker images really easy. All right, let's go back over here and hit next. Now let's create the different domains that we want the subdomains if we will. So I have uptime kuma running and I have it running right here. If we click on uptime kuma and the port we see it's running at one nine two one six eight one dot four colon three thousand ones. It's on the same server that this is running at. So we know it has access to it. Let's go back over here and we'll call it uptime kuma demo YT or YouTube. Now you could not put the subdomain and just have it right there where it would be Lawrence that video, but we're going to have several services. So I'm going to create a series of subdomains. So Lawrence that video, the type is HTTP because this is a not secure standard HTTP not HTTPS connection. So go over here, paste in the IP address. We don't want HTTP in front of it. So it's one nine two one six eight one dot four colon three thousand one. Nothing else we really have to get this working. Save Tom's tunnel. Now we see that the tunnel status is healthy because it's up and running in Docker. There's the origin IP of this tunnel. Now this is what's kind of cool is you can see this public IP. Don't worry it's not my public IP. It's just one of them I have sit up here. But if your IP changes where this is coming from this updates really fast matter of fact if we go over here to the portainer and we're going to hit stop on this one. So we'll take down the cloudflare tunnel. It's exited. We click here and click back we can see this tunnel is down. We go back over here and we'll restart that tunnel. So hit start. It started look at the logs. It's already registered with it. So if we go here real quick just click off it and click on it again healthy. It's right back up and running. So the restart times on it is really fast. Now let's see how I do is go in and check to see if the system we set up with this public host name this uptime kuma demo is working. So we're taking this public IP address which is going to wrap over to this particular instance of uptime kuma. So we'll go ahead and click on it brings us right back up to the dashboard here and now we can log into my uptime kuma by the way if we click here and we say connection is secure certificate is valid. It gave us a wildcard certificate here. So now I didn't have to do anything and it's brokering the connection of note as I mentioned earlier because this is not secure but the security is being added by the cloudflare tool the communication that's going from this painter instance which also runs on the same cloudflare server at 192 168 1.4 it's brokering the connection. So any visibility for plain text traffic is going to be occurring within this particular system not over the public internet from the connection from this server outgoing once it reaches in the cloudflare tool it's encrypted all the way through to the endpoint where we have it right here but we can also add trust for things that are internally using HTTPS so let's go ahead and do that let's go ahead and add another public host name and we're going to do this one with the Synology Surveillance Station and this is my Synology Surveillance Station model dba so we'll give it that same name this does have an HTTPS connection so this has got a self sign certificate and we'll pull it up real quick to show you what it looks like here says not secure but we're at the 192 168 60 dot 15 dot 5001 and yes this server does have access to that go back over here so we'll go ahead and put that IP address in here HTTPS one more thing because it's a self sign certificate we're going to go here to additional application settings tls and we want to skip verification if you don't do this you let up a little bit ahead trying to figure out why it won't connect in what you're doing is skipping validating whether or not that self sign certificate is valid because it's not that way when it talks to it we can just skip that verification save host name so now we have an HTTPS connection which means the connection from this server at 192 168 1.4 to 192 168 60 dot 15 5001 that connection across my local network is encrypted then it's encrypted again and that information is passed along to cloudflare via their edge and we should be able to click on this and log into the analogy dva so i can do my full login login with my username my password view my cameras everything else on here and i've not done any public exposing of any of my systems and it's easy enough for me to you know quickly changed that dns setting and if you looked up the dns for any of these let's do that real quick when we ran as a dig command surveillance station dva dot launch that video and the public IP addresses it shows are the 104 21 72 and the 172 67 187 because it actually registers with redundant servers with 2a records over in cloudflare so these are both cloudflare owned servers that are handling the proxying of this so nothing is exposed in terms of my system itself other than what i showed you in the control panel now let's talk about adding an extra layer of security that they have in here this is just really amazing they added this and offer it for free i really recommend doing this if you have a service that you don't quite want publicly exposed but you want it publicly exposed for certain people and let's talk about how you can do restrictions on that let's go ahead and add another one such as our uptime kuma but let's make it different you can add more than one even if they point to the same thing so we'll edit this one so we can just copy that make it easy so this is uptime kuma demo and let's go ahead and configure public hostname add one and we'll call this one uptime secure kuma same thing here http so all parameters are the same here but we're going to call this one uptime secure because i want to add an extra layer of security so if i click this it's going to look just like the other one but let's go ahead and go to our applications here add application self hosted give it a name the name is going to be uptime secure kuma the domain uptime secure kuma launch that video there's no other path we'll leave all this at default there's a lot of details you can do in here but for now we'll just keep it pretty simple and our policy name let's keep the same name consistent here and then we want to choose how you want to authenticate we can say anyone with an email so they have to provide an email address to make this work or maybe we want to get more specific emails ending in domain but there's actually ip ranges country common name bailout certificate lots of other login methods in here but ending in domain and so the domain would be at laurance systems because i want to share this only with my employees for example so anyone at laurance systems dot com is going to be able to get into this so great we'll see if everything else at default like there's a lot of things you can do in here add application so here's all the details now let's go to the domain and see what happens copy the link here it seems to need a domain so let's type in demo test at laurance systems dot com and send me a code i'm going to wait for an email to come as soon as that email comes i'm going to put that code in cloudflare here's email me a code we're going to go ahead and hit sign in with this code and now it brings me to the secure version of the uptime kuma this is a really nice extra layer that you can put in front of things so they can't just poke at it they being anyone who wants to publicly find these addresses they would need whatever those parameters are that you apply to add that actual layer of security this is a really nice thing that they're doing because you know if there's a problem with one of your publicly hosted servers and you don't get it updated in time this is one more layer in front of it that someone would have to get through in order to get to that server but of course at the added inconvenience that once your session expires you would have to go through the same of inconvenience as well but it's a nice feature that you do have the option of adding my overall feelings are that i like the cloudflare tunnel system there is a bug that i think is a little weird i'm going to do a little testing and maybe report it to cloudflare that i found and that's if you create a tunnel and create a bunch of those different names and then you delete the tunnel but don't delete the names that were created it seems to leave all those dns entries and therefore you can't create a new tunnel like you would in a youtube demo where you want to use the same names again and find out they don't work because it's already has those extra connections in there now if you delete the names in the tunnel prior to deleting the tunnel they delete perfectly fine and it's probably not an issue you may run into unless you are creating tunnels deleting tunnels and not deleting the attached domains you created within that tunnel but i don't think it's too big of a deal it's just something i noticed as someone who's creating demos where i usually test all of this many times to make sure i can do the demo properly before creating content around it but i thought it's worth mentioning if someone from cloudflare sees this and tells me what it is that'd be great or if you have seen this problem you know it's a known bug or if those domains expire after a day of not having a tunnel attached to them that would be interesting as well that's the part i'm going to be testing leave your thoughts in your comments down below let me know how you like this service or if you've had some problems with it or you just really enjoy it so far all the testing i did i didn't find anything buggy or weird about it it seems to be pretty simple to do it has a lot more than i've covered there's a million other features it can do but i figured for most people this is enough to get them started i did that bit warden video the other day and people said well hey isn't this good for using it for like self-hosted bit warden yes as well as a lot of self-hosted web applications which are pretty popular in a home lab this is a great way to put things in front of it and also a great way to add a little bit of security in front of it as well with that you know registering only a domain or maybe a specific email that requires sending something to authorize it before it's viewable i just like these little extra layers of security they put on there and i think it's a really cool service that cloud flare offers links down below to the documentation lots to read through over there or how to my forums for a more in-depth discussion thank you and thank you for making it all the way to the end of this video if you've enjoyed the content please give us a thumbs up if you would like to see more content from this channel hit the subscribe button and the bell icon if you like to hire a short project head over to laurancesystems.com and click the hires button right at the top to help this channel out in other ways there's a join button here for youtube and a patreon page where your support is greatly appreciated for deals discounts and offers check out our affiliate links in the description of all of our videos including a link to our shirt store where we have a wide variety of shirts that we sell and designs come out well randomly so check back frequently and finally our forums forums.laurancesystems.com is where you can have a more in-depth discussion about this video and other tech topics covered on this channel thanks again for watching and look forward to hearing from you


I'm presenting this, I will confess the idea about the way we treat a orders fits this nice CLE, that's our Cleveland thing. Expeditious probably should go first, but I'm gonna be comprehensive here and I'm gonna move fast and really talk about the way I think about the aorta starting from the left and trick or outflow tract and working all the way through it and just share with you some of the things we're doing now and where I think we're gonna go in the near future, I don't claim to look too far along and I think it's dangerous if we try to get too far ahead of ourselves, so I have to use the arrows. Disclosures are shown here, I do work with a lot of companies and I've learned a lot from their research and development teams and I will talk about some off-label and investigational use of devices. I think it's important when we talk about any sort of intervention or any of the things that we practice that we really bring it back to the base of understanding the disease process. Lars Fensen and Renee Rodriguez pointed this out several years ago that the aortic disease and underappreciated epidemic and there's probably more than 40,000 deaths a year that are attributable to aortic disease. And data in other countries, it's this older but real study from the group in Sweden demonstrated increasing prevalence of aortic disease and increasing number of the operations that they do there and it's no surprise that if you look at the volume of cardiothoracic operations that we perform at the Cleveland Clinic last year over 5,000 operations, a fifth of what we do entails the aorta. It is really a critical part of what we do and as I know it is here and has been for many years of course with Dr. Koselli in the room, of course it always will be but it's really a trend that we're seeing across the whole practice, cardiovascular care. We did 1,441 aortic operations last year and even through the pandemic, we saw our volume rise and I think if what happens in Cleveland and Houston is a barometer of what happens in our fields and I think we have to appreciate the fact that in the near future we definitely will be treating the aorta more commonly at the very least. One of the reasons that we've built or the reasons we're seeing more of this is because of the way we've reorganized ourselves in Cleveland. When Toby Cosgrove took over in 2005, he changed the way the whole enterprise is organized from a conventional organization where we had divisions of surgery and medicine to a more radical disease and organ-based institute model and this quote from Toby really I think sort of characterizes the whole culture that we have there. We need to focus on the convenience of patients and families, not just what we do and that's a forward way of thinking of things because things move fast in medicine faster than ever and this busy slide just is a quick snapshot representation of what happens in our aorta center. It's a lot of different groups that come together around an individual patient with disease looking at it in a lot of different ways. We collaborate clinically, we collaborate in research and we collaborate in education and we have these other centers organized around other organ system or disease states like the aortic valve and adult congenital disease where there's a lot of cross pollination between what we do and this organization really fosters collaboration and allows us to do more. When Lars Fenson took over as the institute leader he gave me the job to be the aorta center head and I quickly realized that what we need to do instead of just having one surgeon at the head of everything is we need to create shared team leadership models. So I changed my title from the director to the surgical director and invited a cardiologist and a vascular surgeon to also be directors within the aorta center so we could really foster these ideals that you see on the right side so we can work together as much as possible. And when we did this, we sort of put our heads together and realized that we need to have a master plan of how we're gonna build our aorta center. It started with really focusing on those acute aortic syndrome patients, the patients that need us the most. We are their last resort, they get here, they get plugged into the system oftentimes in that desperate time of need. But if we really wanna treat that disease we need to understand it across the whole spectrum. And so we thought about how we have these different sort of buckets of where the patients come from. And by doing so, we've invited our cardiologist to sort of embrace this early phase of the disease and learn how to screen and find patients when they're in that sort of moderate phase and they can connect with someone on the medical side that can really teach them about, you know what they need to do looking forward the diagnosis of aneurysm or ectasia or dilatation doesn't have to be something scary and dangerous because they have a plan. And we meet people in the advanced stages who maybe had emergency surgery somewhere else and then were left to their devices or never really got good education about what was going on with them. We bring those patients in because of the broad spectrum of excellence that we can provide them. And we screen their family members. And now more than ever, we're actually finding a lot of people with disease in the early phases so we can get them on board because when you have aortic disease it's a problem for your entire life. And so how are we treating the aorta now? We're treating it together. We're like a special forces unit and we have a whole bunch of people with skill sets that tackle these problems at different phases along the way. We know that aortic disease is life-threatening. When we meet an aneurysm, we want to prevent it from becoming a dissection. However, sometimes it's not an aneurysm and it dissects anyway but the really only treatment that we have right now for this problem is prophylactic replacement. We don't have, I mean, we treat hypertension and that's really critical but we don't have medical therapy to stop the progression of degenerative disease of the aorta. You know, like we need to get better with that. I tell my patients all the time. Really the best time to fix your aorta is the day before it ruptures. And that's where we want to be. We want to be that good. We're not even close. But I think if we all work together and we think about this and we invite our cardiology team and our medical team to work with us on solving these problems. We work in the lab, we can do this because ultimately what we need to do is not provide care with average treatment effect. We need to provide care with precise, tailored, shared decision-making where we think about all these different characteristics that go into the decision. The disease specifics, the other comorbidities that the patient brings to us and then look internally at our own surgical experience and results so that we can really center any kind of decision around that specific patient and also appreciating their own preferences for things like avoiding surgery or anti-coagulation. Right now, we still use a model that's based on size and I always show this curve, which, you know, and I've even said it in front of John Elefteriades. I love the work he did, but this isn't really a curve. Any statistician in the audience would tell you, that's just sort of this jiggy little thing. And that's what we use. We decide to intervene around five and a half centimeters or less based on a feel. And it doesn't work because there's a large number of patients who present with acute aortic syndrome way below that threshold. We need to get better. Well, we've tried to figure out how we can do that by using some indexes, trying to sort of tailor it to a patient's body size. There's something that, you know, we refer to as the aortic area to height ratio. Some people call it the Svensson Index, where our Svensson really did this with a small amount of data. And then it's been explored a couple of times with Mace-Ree's written a couple of papers with Malin Desai and have demonstrated that it actually is a pretty good predictor of risk in our patients. At least we can tailor it a little bit to the individual when we're making these decisions. So we don't look at body surface area because people in Cleveland are heavy. They're heavier probably than even in Houston. So weight, gaining weight doesn't reduce your risk. It's the height that matters. And actually, interestingly in this, you can see that when we look at the diameter of the aortic root, the curve has probably shifted left a little bit. So now we're starting to gain an appreciation. It's sort of soft evidence, but we're gaining appreciation that the pattern of aneurysm probably makes a difference. So when the roots more dilated, we also tend to be a little more aggressive about repairing it. And even Dr. Elefteriati's team has looked at this and they've demonstrated in this paper that they also agree that height alone, better the body surface area is a good way to estimate risk. But really the whole idea size based on no disrespect to Sir Laplace, but based on this law of Laplace and wall stress is oversimplified because we're not dealing with man-made tubes. We're dealing with biologic structures and vascular tissue behaves in an anisotropic way. The characteristics of it change along the length of it. It deforms differently under the stresses. It is a very dynamic structure. And the forces upon that aorta also are dependent upon the disease states, not only how the heart functions, how the valve functions in the shape of the valve. You see these really fantastic looking MRI images that demonstrate normal laminar flow and how the stress is on the wall change depending on what type of bicuspid valve the patient has. And on the right, you add stenosis to the mix. It even gets more complicated. So we need to understand these details because what's happening in any individual patient is Sir Scott LaMarina's team can tell you is a whole lot of complex things at a microscopic level that are affected by the forces on the wall of that aorta and what's happening at a microbiologic level. And there's a strong interplay between those two. And we're trying to understand that better. My lab isn't as cool as the one that Scott showed me today, but we have a biomechanics lab and started this, what we call the Matador study, multi-disciplinary study, based on two characteristics and hemodynamics for development of non-hilarid sten grafts. Matador is much better. Where we use the standards of care for our patients with aortic disease, we enroll them prospectively. We do echocardiography as well as our cross-sectional imaging and all the clinical data. We get this specimen out, we test it in the lab, both in uniaxial and biaxial load, and we do a histologic assessment. We're also approved to look at other factors like blood, proteomics, genetics, and the entire thing. And you can see that with our partners from the imaging team and the anesthesiology imaging team, we can gather quite a bit of data, just again, using standard of care at the aortic ultrasound in the operating room in TEE to try and understand what happens to this tissue. And then we take those segments of the aortic tissue directly from the location where we've imaged it and we put it through load testing. And this is sort of the protocol we developed for tissue harvest. So this is a patient of mine with a root aneurysm. And I'm careful when I excise this aorta to keep it all intact. It takes a couple of extra minutes instead of just slicing it down the middle. I'm trying to take it out as a tube. And here you can see I'm taking out the non-pornary sinus down along the right side of this patient. So we maintain that within the specimen. This is a patient who's going to get a valve-sparing root replacement. About half of the patients in our protocol have bicuspid valves and about 15% have known connected tissue disorder, or genetic issues that are known, that are mapped. And then we take the specimen. I showed you some of the uniaxial load, but then we put these specimens on the different lengths of the aorta. You can see a couple of those specimens in the image in the corner. And we do this biaxial load testing where we look at speckle displacement. And this way we can gather a lot of information about tissue stress and strain from this experience. And then we look to correlate it with our clinical factors and we look to correlate it with the other information. And some of the things that we've learned is that the age and sort of the region of the aorta that's involved has a much bigger predictor of how much elastic energy is maintained in that structure. So again, lend some credence to our idea that a root aneurysm maybe is worse than an aneurysm along a different length of that zone zero. And also I think a little bit differently when I see an older patient with an aneurysm then I do a younger one because I know they don't have the same elastin structure in their aortic wall. They might be at risk for failure a little bit sooner. So I may be more aggressive about it. And we're certainly learning every day that thoracic aortic disease is familial. Not only these clinical syndromes that we've known about for a while because these patients look different on the outside, but a whole bunch of these other genetically triggered associations that we're just starting to learn about really quickly. 10 years ago, if I wanted to do a genetic screen and maybe screen for three or four or five, now like an inventory panel is up to 37 genetic abnormalities. And yet only about 20% of families where we know it runs in the family do we identify the gene.  The hope is that in the next decade or so we'll be able to tell a specific individual patient what their genetic make up is. Maybe we'll do something like wrapping their aorta like this Paris procedure with a robotic approach.  We're not there yet, but we're gonna give them a better understanding of the genetics of what's going on with them. The pathophysiology that makes that connection between their extracellular matrix and their smooth muscle cells. And hopefully we're gonna discover some therapeutic targets. So maybe we can treat them with medical therapy before they need to go to the operating room with us. One of the things that we've learned is some discovery in our lab. We did mass spectroscopy to try to describe what's in that space where you see this degeneration. And we identified massive amounts of something called agri-can and Versa-can in the thoracic aorticanders and dissections and no one had ever defined that before. Agri-cans really common. They study it in cartilage and orthopedics forever. So there's simple assays that are out there that nobody uses because it's not that important for the cartilage. But we found was really interesting and we validated a data this in a mouse model where there was also some reduced Adam T.S. activity. The point is that there's probably many, many, many diseases that all filter down to this common fate of an aneurysm and dissection. Aneurysm and dissection are probably not unique disease states as much as they are complications of things that we're learning more about the causes of. And as we become more knowledgeable about it, we'll be able to tailor our therapy for patients. We certainly, again, going back to this idea that Laplace law of Laplace isn't so good. We actually found that thicker tissue did worse, had worse biomechanics than thinner tissue. So Laplace is kind of out of the water yet we're still using size. But maybe what we learned in some of this experience will help us create other ways to diagnose our patients. This group in Germany took our experience, I put it in the red box as they quoted our paper about the massive agri-can collection in that study that we wrote, and they actually used those commercially available assays and found that agri-can might be a new biomarker for acute type A aortic dissection in a small series of patients. We're looking at this in our own lab and we're trying to understand if we can maybe understand this better. It might really help us in the ICU. You've got someone that comes in with an IMH and you're wondering how important it is to treat it. Potentially you could use a biomarker to guide you. So when will we be treating they or in the near future? Definitely more sooner along the path of disease and more precisely to every individual. But for now, the treatment still is complex repair and reconstruction. I'm a surgeon, I'm gonna start talking about surgeon for a little bit this afternoon. We know that the more disease is involved in the aorta, the more complex the repair is, and then you add aortic dissection to the mix and it adds a whole nother level of complexity with what you deliver. We're able to still do this really well with our team. This is data from just this last year. Our ODE ratio is a third, it consistently has been and it's because we have this multidisciplinary team where we provide a lot of different modes of therapy. Acenaeortic replacement is still sort of the gold standard for acenaeortic disease. We've demonstrated before that we can do that well, even in multi-component operations and the paper on the right, we matched a bunch of patients undergoing cardiac plus aortic surgery with patients undergoing just cardiac surgery and found that you can add an acenaeortic replacement without any added risk in most of those patients. And so we're pretty aggressive about treating that aorta. And we'll do it minimally and basically as long as we think we can provide that same kind of outcome in this series where we demonstrated that we're able to do a lot of things including root replacement and acening plus valve or even hemiarchs through those many incisions and that still represents a portion of what we do. But we need to also understand that a lot of proximal aortic disease that involves the acening aorta also may involve the aortic root. And in fact, the bulk of the proximal aortic surgery that we're doing these days does involve the aortic root. It's typically for kind of operations that will do a mechanical and biological, dental procedure, homeograph or some form of valve-preserving root replacement. Most commonly is a re-implantation procedure. And it's important in an aortic center that you do it well. And I tell residents and fellows in training all the time no matter where you go, aortic root replacement can't be some sort of select operation. Everybody needs to know how to do this nowadays because that's what we're treating with surgery. Aortic valve disease is going towards TAVR. Aortic root disease needs to be really appreciated and it needs to be done really safely. This study from a few years ago showed that 25% of these operations on the aortic root or involving the ABR and the acening aorta were done at 3% of centers. I think we need to centralize this kind of care because you could see that volume had a big impact on outcomes going from a low volume center less than six of these cases a year to a high volume center greater than 30 cases a year. And that's not much volume for, you know a guy from Cleveland and talking to a group in Houston that cuts the mortality in half. At our center, we did over 500 room replacements and you can see kind of a good spread across the bentos, homographs, valve spring roots and we've gotten into doing some ROS procedures in young adults again over the last few years. It's not really for root disease but it is a root replacement operation and for elective operations their outcomes are excellent for emergencies. Now there's still emergencies but that represents a large volume of what happens in the country and compares I think excellent compared to the STS database and I do that maybe cause, you know Lars said I should come down here and brag about how we do but more so because I think it's important we understand how well we can do. These are should be our goals. Elective aortic root surgery should be the same kind of outcomes we strive for with isolated valve replacement needs to be done really safely because a lot of the patients that we see are patients with bicuspid valves, they're young. We see in this machine learning we kind of confirm what's sort of been known that a large proportion of patients bicuspid valve disease have root aneurysms that are often young and we need to provide good solutions to these patients because surgery is what they need and catheter advice is not gonna be it. Certainly a catheter device is never gonna fit well into a valve that looks like this, this severely diseased bicuspid valves or one like this that was repaired 18 years earlier I could hardly find the orifice in this thing I don't know how the patient tolerated eventually I scraped away some calcium and there was that little tiny hole in that valve but patients can tolerate a lot but they're not gonna do well over a tabber this patient needs a real operation. And then what do you do with a patient like this? This 40 year old who comes in with a bicuspid aortic valve, severe AI and AS mixed valve disease is common in these younger unicuspid type kind of valve patients and that aorta is dilated clear the ascending needs to be replaced it's over five centimeters but the roots that 4.2 by 4.4 ish kind of thing I don't know, do we replace that? Do we leave it alone? We might have to come back for it now that we have a trans catheter valves as an option we need to understand that even if the patient chooses a biologic prosthesis they might not wanna come back and just have another valve replaced when the bioprosthesis wears out they might wanna have tabbers so we have to think differently about how we managed to say aorta. We saw this data from Toronto that says certainly if you encounter an aorta that's greater than four and a half centimeters you should replace it but what do you do with the ones that are between four and four and a half? We don't have the data, we don't know. The same group from Toronto also told us that it doesn't need to be replaced when you replace bicuspid or tricuspid aortic valve it disagreed with them and let's look at their data and maybe explain why. You can see that their follow up was only, the mean imaging follow up time was only five and a half years you see the blue arrow down there but the patients who did fail and eventually needed to come back they all had that failure happen after about the eight year mark. This is true of almost everything we study in cardiovascular medicine we're getting so good at taking care of all these mechanical problems it's okay for data to share with the FDA to get something approved with five year outcome data but it's not really good enough for us to really understand the fate of what we're doing by following only five or 10 years. Our patients are living into that second decade and more and more surgical patients are young and we expect them to live into that second decade we need data to really understand what's happening in that second decade of follow up and so I would disagree with these guys I think that these patients are gonna come back or at least the significant portion are gonna come back with aortic disease later on we need a better way to determine how to do it maybe it's just imaging the aortic wall with some tool that Dr. Lamar is gonna provide us with to get an understanding of what their future is gonna look like or maybe it's just knowing we can do it safely and being more aggressive about it. Here's a patient that Toby Cosgrove operated on in 2002 he replaced the patient's aortic valve and left one of those kind of smallest roots alone and did it through a mini and it was great a mechanical valve the guy was doing fine. 17 years later he had this five and a half centimeter of aorta so we re-operated on it and we replaced his aorta should it have been done at the same time? I don't know it was a mechanical valve. This is a 46 year old who had an AVR in 2004 then came back eight years later now 55 years old had a moderately dilated aortic root that was left alone and replaced at a nearby hospital with a stentive prosthesis and thinking that that aortic root would be okay and then I saw the patient just about five years later and the root looks like this now 55 millimeters. So I think we have to appreciate that the size it's not a great predictor we have to look at that tissue probably a lot better and really appreciate the fact that the root will also grow and a lot of these patients are gonna live 10 or 20 years after an AVR. So that guy that I showed you earlier the 40 year old with the bicuspid valve and the small root, I replaced this guy's root he was bipolar and there was no way he was gonna take any coagulation when I got in there you can see down on the bottom right certainly half of this aortic root looked really thin walled I didn't trust it so I went ahead and did a lot of that on him. I think that's the right choice we'll see what happens down the road if it gets infected we have to re-operate on it's gonna be a little bit more difficult I suppose but we have to think about the choices as being informed choices that we should do with our patients and appreciate the fact that most patients don't want mechanical valve and a coagulation most of them want a minimally invasive approach. And if we can save that living valve and a lot of this root disease and get better at that then we'll be even better at providing what our patients need and providing some long-term solutions. So Lars Fenson taught me about this sort of class schema as the way to think about aortic valve function it's not just the cusps or it's really the commissures the leaflets, the annulus, the sinuses and the sinus tubular junction that all play an interactive role in the way that aortic valve functions. You see that cool 40 CT scan you can see how the LVOT expands in that patient as well as the other changes in the aorta when that valve opens and closes. And we know how to do these operations. We've demonstrated certainly in patients with connective tissue disorders like Marfan syndrome that those repairs can be done really safely and they're very durable. And as we've gained experience with that our number of these operations performed has grown exponentially over the last 20 years where we now kind of appreciate the fact that while when I look at somebody like this 21 year old with really severe AI and a tricuspid aortic valve and a dilated left ventricle and I want to save his valve if I'm going to do a repair I got to do more than just something to the cusps of that valve I've got to address that dilated annulus even though he doesn't have a typical root aneurysm he's got really severe annular aortic contagion. And in this guy when we got in there that the sinuses weren't normal as well. And so we did a David re-implantation procedure in him even though it wasn't a typical patient that's part of the reason why the volume has increased. But you can see now I feel confident that we've stabilized that entire root and hopefully this repair will be as durable as possible for this young man. And then we've also expanded this sort of knowledge about how the root all interacts and has allowed us to use this operation expanded to patients with bicuspid valves that we want to save. So this is the typical way that I will do one of these operations in someone with a root phenotype aorticopathy and a severely leaking bicuspid aortic valve. We debride this fibrosis across this con joint cusp and clean that up. And you can see that there's a lot of good healthy valve tissue. And just to look at it, we see that eventually we can get that to come together in a nice way. That's a 30 millimeter hangar dilator just demonstrating this patient does have that annular aortic aphasia upper lumbar normals only 25. If we just did a leaflet repair that patient would be in trouble. This patient also had a dilated root. So we do this re-implantation procedure by securing that annulus with these interrupted sutures underneath after we've dissected everything out around that aortic root. And then I kind of can make a couple additional markings on my graph because I want to resuspend these two good commensures in this patient in 180 degree orientation so we can get real symmetry between this two bicuspid leaflets. And I spend a little bit of time sort of making sure that I'm going to be happy with how this thing looks. And then when we put those stitches under the annulus I'll often put more stitches in those patients as well to secure it more. And then we re-implant this valving and see when we're sewing this commissure in it's at that purple line kind of in between the two black marks because we want to get those posts lined up 180 degrees. And then after I get the valve re-implanted into this new root then we go ahead and do the cusp repair. And so we'll take that con joint cusp which has got that long free edge and we'll go ahead and pli-kate that valve and we'll close that with a running suture so that we have equal edges to those two cusps and I'll often carry that closure across the belly of that valve as well so that it doesn't prolapse or balloon out into left ventricular alfotrack and we get something that looks like this. And we've had good results with this of course they don't necessarily last as long as a normal tricuspid aortic valve but they seem to be pretty good option for a young patient with a living valve that we can keep it. And we've even used some of these principles about stabilizing that entire root to how we apply the ROS operation in adults. So some of our ROS patients might have a moderately dilated aortic annulus if it's really dilated we don't push it but a moderately dilated annulus we want to secure that and I'll put an annuloplasty band this is a mitral annuloplasty band around that ROS procedure to help stabilize that. And then we've also learned something else as we've looked closer at the imaging and the anatomy here here's a 29 year old with one of these root phenotype aneurysms is dilated annulus and learning what we've learned from the imaging aspects of looking at the mitral valve we've recognized what I call aortic annular disjunction. So we've heard about mitral annular disjunction or dislocation and we've recognized this process in our aortic patients and we have paper coming out soon about this but I've also developed a way to address this. So you can see in this video this patient with a bicuspid valve as you see the insertion of where the cusp is is really deep inside the lip ventricle and where the aorta and the ventricle come together is separated from that. So there's this aorta annular disjunction and we repair this by first bringing those two things together with a mattress suture that we run along the areas where there is that broad separation between the insertion of the cusp and the level of the aorta ventricular junction. And by doing that, we lift that leaflet that valve up into a more even plane and then we can go ahead and proceed with our re-implantation procedure, get the valve re-implanted. And when we do so, it comes on plane. You can see there's an application but you don't have the belly of that cusp that inserts really low in the ventricle falling sort of deep under the repair or having to put those sub annular sutures in some way where you're intruding in the right ventricle. This is a post operative assessment of this patient. We've got a few of these where we've been able to now recognize that sort of issue beforehand on the imaging.  This guy with a 41 millimeter annulus just needs a thing replaced. I don't think anything's gonna be durable in that situation. To spread all these attempts to do prophylactic repair, we still see patients who come in with a new dissection even after we've replaced their ascending aorta or that dissect at small sizes when we don't expect it. And a fifth of the aortic operations we do still our emergencies. Some of them are even in patients that we've been following. So, you know, as I said, we're falling short, but we know how to take care of them in these emergency situations. We've seen both in US and UK data that the more experience you have, the better you are at taking care of a patient in an emergency. We've demonstrated this with our own data. You see it next to IRAD with our multidisciplinary team. We've been able to keep the mortality from dissections in the single digits pretty much across the board, whether it's type A's or type B's and whether we're operating on them for type B's or not. And we've learned from that IRAD data that there's a multiple phases of hazard. So we're understanding aortic dissection a little bit better during the hyperacute phase. We get that information now sent to us as a page on our phone. There's an epic connection. One of our cardiovascular imaging specialists will get those images piped over, reviewed, and I can look at it on my phone while I'm laying in bed in the middle of the night if I have to before I go in to determine what my strategy is going to be like so we can mobilize our whole team so that when that patient arrives, we have a very good idea about what we're going to do and everybody's ready on the spot with all the different technology we need, whether it's a hybrid technique, a device, a RAD tech or just to even keep the anesthesia team up to speed and what they're dealing with. The typical repair is a conventional limited reconstruction and we still do a lot of these, certainly for Debakey type twos we do this. For a lot of Debakey type ones, we're doing more extended repairs now because we've learned that presentation predicts mortality. Certainly with really severe ischemia, the mortality is a lot higher, but even with imaging ischemia, those patients are at risk. And this unpublished data on the right shows that when we do an extended repair using a frozen elephant-type technique, which I'm going to show you in a minute how we do it, we've actually reduced kidney injury in these patients because we're getting their true lumen perfused better downstream. We know that a patent false lumen downstream from a repair is predictive of survival and also predict predictive of the need of late re-operation. And so I asked the question, is it enough to fix the ace in the aorta in 2022? Certainly it is if you're saving that patient's life, but if we can do more without compromising any of that early mortality, it sure would be nice. And so we've worked on that and I think there's some new technologies coming out. Dr. Kassellian is the national PI for the device you see in the middle. And I think we're going to hear probably at the ATS that it's going to get launched as a commercially available frozen elephant trunk device. I mean, there are some other devices that have been available in Europe and some graphs that reduce the number of anastomosis. But the problem with all of these devices and their current iterations is that they still require a lot of reconstruction. In an emergency situation, that's a lot to ask of anybody, even the most experienced surgeons. So there's been limited adoption of these techniques. In our center, using commercially available devices that have been modified in a bunch of different ways over the last really 12, 13 years or so, I've been working on changing and improving and evolving this procedure to what we do now is called a B-SAPER, a branched stent and an anastomosis frozen elephant trunk repair. And it's come to a point where that operation is pretty much standardized amongst our team. And we've got at least nine different surgeons that do this operation and it represents about 70 to 80% of the debakie type one repairs that we do in our center. As such, when I published this story of the evolution of this and there's only a handful of patients in that paper that actually got to B-SAPER in March of 2018. And again, it represents a large number of what we do over 130 elephant trunks. Just a little bit after that, maybe about six weeks after that I got this real nice email from the FDA. And they said, you know, we appreciate you looking at this a little bit closer because you're modifying a class three device that you're manufacturing. Well, it's not quite fair because it's still an open operation that we're doing but I got their point and I had talked to them about it and in many times different situations but it came pretty clear that we had to move along this path of developing a physician-sponsored IDE. And that's what we did and it took a couple of years for me to sort of put it together because this physician-sponsored IDE is not just to get something approved for industry where you can have very tight exclusion criteria. It's to study this procedure that we're doing and this device and I wanted it to be as inclusive as possible. So we developed an algorithm where we have sort of three groups of diverse groups of patients, those with aneurysms, those with acute dissections and then within those with aneurysms with or without chronic dissection and then some congenital patients. And it's a diverse group of procedures you can see sometimes we put multiple stents sometimes we'll do multiple and SMOs these but in all of these we're modifying a stent graph when we put it in the patient. And we shared some of this early data we had with the FDA and then on December 31st, 2020 we got approval for the FDA to proceed with this PS IDE. And after putting a few other things together like getting my team together around this and gathering a bunch of my co-surgeon investigators we started rolling in the middle of last year, May 27th, 2022. I'm sorry, that's 2021. We're not at May 27th, 2022 yet. May 27th, 2021, but in several months we've enrolled it was 81 as of March 10th I think we're up to 90 patients now. And you can see we've done them in all these sort of different iterations where we're always using a stent graph in a branch into typically the less of clavian artery but sometimes the carotid or otherwise. And we've had pretty good results in these first annual report analysis the acute mortality was less than 6% stroke rate was less than 10%. Some of these patients went on to have a second stage repair we've had no spinal cord injuries. And the circa rest time has consistently been under 45 minutes for these patients, the average is about 30. In parallel, we developed a device so we don't have to modify a class three device on the table and I was able to do this internally with the assistance of our innovation team. I'm sure that, you know, Billy Cohen was here he probably find a way to have developed this faster and I did, but I did have a good team we went pretty far along we went through multiple prototype designs and then we've got a business partner from industry used to be cryo life is now our TV on is working with us to develop this device. Hopefully we'll have first in man early feasibility studies last summer we did the animal studies I think I was the first person to do arch replacements in sheep that almost killed me but what you can see the fluoroscopic images of that device in a sheep's arch and that proceeded along well and so hopefully we'll keep moving forward with that. And that was all done sort of in this spirit of what I've been really fortunate to be in the right place at the right time at the Cleveland Clinic and with my good friend Roy Greenberg I was looking for I wish I had that picture that Joe shows Roy where the two of them are giving each other a piggyback ride in China, it's a good image but Roy sort of taught me about always finding a better way to do things. We certainly all pay a lot of attention to the great work that's done here and the complex treatment of thoracolabdominal in order to handle this disease and we know that that one will never be duplicated but we follow your lead to make sure that we can do as well as we can when we do these open operations but Roy was able to find another way to take care of patients because you have to be really select when you do thoracolabdominal disease take care of some of these patients who didn't have great options and develop this technology, this branch technology which first started as sort of marrying a branch into an aortic device, something like this and then design these helical branches that come off of it and now there's these devices that have multiple of these branches built in them and now there's a lot of these different devices available from industry partners and a lot of teams out there have physician-sponsored IDEs where they're studying this and this branch endographed technology which certainly plays a role for a subset of patients who aren't great candidates for open surgery has been important but it's also led to the development of a bunch of other technologies there's now this imaging programs that automate the sizing in these devices there's imaging programs that limit the amount of radiation and contrast exposure both to the patient and the operators which is really critical to overall safety and it's also expanded this idea of putting endovascular devices in the more proximal order so we see a lot of these arch branch devices now available that have two or even three branches for treating the aorta and we're involved with several of these trials they've not progressed along super fast because stroke has been a real difficult problem to avoid no matter how you handle it with even these endovascular technologies but what we've learned from that has allowed us to come up with some other innovative approaches and this guy who was on oxygen had this horrible looking aneurysm after someone did a really limited ascending replacement for his acute dissection we de-branched him by making incision in the base of his neck at the top of his manubrium we put all of his head vessels coming off of his very large left of common carotid artery and I thought I was gonna get a branch device for him then the pandemic hit so we sat around trying to figure out what we were gonna do and we decided well, we're just gonna cover that arch with this device and I know this is gonna look really freaky this next image because there's actually no flow going off any branch vessels on this angiogram but we have a pump so we had him on axillary fem bypass that perfuses brain and then I went ahead and punctured his left common carotid artery with a spinal needle and you can see it's sort of pushing on the device and then sort of popping through there and that allowed us to get a wire across that and kind of on the table incite to creation of a branch device for this gentleman we're able to give him a branch device and it's worked really well and I just saw him recently for his one year follow up his lung disease is still horrible what hasn't progressed too bad and we're able to get him through this with this repair and that giant aneurysm is no longer an issue for him so I think we'll kind of continue to see this technology develop we certainly have seen it address some of the unmet need in the ascending award I showed you this curve before but there's these people that are turned down for type A dissections that we studied a few years ago and realized that even in our center where we thought we were aggressive with everything represented about 8% of the acute dissections that we saw they're older most of them weren't prohibitive risk like a person with dementia from a nursing home most of them they just didn't look good when they came in and we were comfortable operating on them but they were in their 80s but maybe they were pretty functional last summer cutting the grass and doing things and if we had an ascending device to treat them we could probably get them through it and we've done this in other situations where we've been desperate for a mechanical solution for a complex problem I have personal experience of over 70 of these T-VAR procedures and we learned a lot of details about what the challenges are from that experience like this guy, this 91-year-old who had a TAVR you can see his TAVR device sitting down there after the TAVR they realized he had this horrible dissection from the procedure his brain was being now perfused they quickly intubated him and called me and then I came in and put a commercially available stent graft in the guy and I thought we had a pretty good seal but realized that we had a ton of AI and I was like, oh man we gotta get that device off the valve so I did this, watch it, here it comes so we pulled the device back with a balloon by letting the heart eject against it and then the AI went away, which is cool but we really need a device that we can be coaxial at the sinus tubular junction with fortunately in this guy I kind of knew this time don't push it so far in and we were able to get this device second device deployed and get his ascending aorta treated and then we had to put some bare stents in his downstream aorta and he did really good I've seen him also a year later the guy looks fantastic and his valves working well, thank God but we thought that this idea of treating the ascending aorta with stent graft really have to think about this zone zero as being way more complex than just sort of zone nebulous zone zero and we've described sort of the difference between zero A, B and C and really need to sort of think about this short segment of the aorta as being really complex if we're gonna develop devices for it we need to understand the nuances of it and I showed you, we'd been looking at the tissue but we also need to know clinically it's important as well the person on the upper right that had this little pseudoanderism that we could sneak a device above some coronary bypass and seal it off is gonna do great based on the bottom right that has a tab or a bunch of other stuff going on we put a bunch of hardware in there they survived that but I don't know how long that's gonna last the cool thing is we got industry partners now that realized there was a place for this technology the gore device, this ASG arise study we enrolled 19 patients in this early feasibility study and this is a device that's steerable so not only do we get it into the ascending aorta and partially deploy it which allows us the ability to mobilize and position it a little bit better after that partial deployment and you can see that sort of on the angiographic image as well we can then go ahead and shape the device so by turning that dial that you see on the bottom right we're turning and shaping and shortening the lesser curve of that device so we can pull the edge away from the left main coronary artery and really get this thing lined up super precisely along the sign of tubular junction for these patients before we fully completely expand it as you see in the images here there's a fluoroscopy image and it pops open completely we do that typically with rapid ventricular pacing and there's an option to then again dial it and scoot it up a little bit more if we find on the angiography it's still too close so we can get precise within a millimeter or two all the coronary arteries of this device and we've had good experience with it so far we're gonna see a pivotal trial coming out and we're learning how this technology interacts with the disease like this is the one case where I thought we had a great result but on the early post op CT you see some flow still there in the false lumen but six months later they're totally resorbed and that's like a real nice 3D image of how we treated that the Bakey type II dissection in this 80 year old lady that was on dialysis but still pretty functional that did great one home after a couple of days this whole idea that of course opens the eyes to the world of maybe adding it to TAVR and doing endo-ventals amazingly this was done in 2020 by this group down in Brazil they were really smart about how they did this to treat this really unique complex patient that they came up with this device for and it worked they spent hours doing it I don't think we're gonna see a lot of this yet because there's a lot of issues to address we have to remember that TAVR valves still have a little bit of leak around them even in the best situation and that's a bad endo-leak if we're treating an aneurysm but and select patients we might see these technologies married together in the future certainly we think about ascending stent graft as part of our treatment paradigm for acute proximal aortic dissection you can see it's not just OR or nothing now we think about whether we have an endo solution if we don't have a broader open solution and we have a much lower threshold to extend the repair with these be safer procedure in our patients we've also learned a couple other things and I'm gonna go kind of fast through these last few slides for the interest of time but I think we have to appreciate that we need lifelong care for these people it used to be again I was talking earlier about this incomplete follow-up we operate on them we hope that like they're gonna do okay now in Stanley Crawford knew at a long time ago these people shouldn't be considered cured of their disease when they have an aortic dissection now we've developed clinics where cardiologists faster surgeons, cardiac surgeons we all see these people we invite them back we all see them we all kind of educate them with our different perspectives about what to do they'll often see multiple of us at one of those visits and the patients welcome that because their doctors at home are scared of aortic disease and what we've seen and this is old data but it's significantly increased the number of office visits so it's good for the business of our cardio aortic cardiology specialists it's a great area to specialize in so these patients will keep coming back to you and they're very grateful our outcomes are a little less than ideal when we get these people through the acute phase the average age is 59 and three or survival 60% that's not nearly good enough so we've been a little more aggressive about treating type B's with T-VAR sooner knowing even knowing that this repairs are incomplete but we developed a whole bunch of these other strategies to try and address these chronic dissections some of them are shown on this slide there's this new technology with some bare stenting to optimize flow and the true lumen and with new problems we find new solutions so we are doing more open repairs in patients that have a previous T-VAR than ever it's about half of our thoracodominals have a T-VAR in place this graft on the right I call it the Roselli-Coselli because the team helped me add a cuff to the Dr. Caselli graft that we use all the time for thoracodominals and all the nurses call it the Roselli-Coselli but anyway we're going to get that soon and this is kind of what we do for a patient this patient had a thoraflex device then came back had a T-VAR and then an open thoracodominal repair we left the iliacs alone because it was kind of a mess down there and then my partner from Vascular Surgery put one of these branch graft devices in and we got this whole aorta treated in multiple stages and got this patient through it safely and this is the kind of crazy schema we have when we see a chronic dissection lots of options so we need lots of people to come together to make these decisions about what to do for our patients because we're going to see more survivors that need late treatment especially after dissection they do better with earlier proactive treatment we know that endovascular solutions can be safe and expand treatment options but we have to understand they have a complementary role to open and hybrid repair we're going to continue to get better devices and we need to understand the natural history of this disease and the causes of it and hopefully in the future when we're treating aortic disease we'll be doing it both collaboratively and more precisely thank you very much


Welcome folks, we are the Dow Industrial Trading down 192, Nasdaq off 59, S&Ps off 19.5, Gold contract up $7.10 trading at 18.52 an ounce, we have Silver up 14 cents, $21.71 an ounce, a light sweet crude, $78.42 a barrel, notes and bonds, you get the 10-year note right now trading down 6 ticks at 111.27, that's yielding 3.84 folks are getting closer to 4% and the 10-year down, 30-year rather down 21 ticks at 125.17 and King dollar, King dollar's down 64 ticks trading 103, 859, Euro 106, Yen 30, Yen 30, Free A4 and the British pound is that 120 to 1 U.S. dollar. We'll go over and take a look at the market folks in the bottom line, can't catch a bid, bottom line I think it's going to be a slow way downtown because what you have here, we're coming into a Friday, bottom line is that what you're seeing out here, yeah the spy rejected the 408.26 but that being said, it's having a tough time getting any traction at all, we are going to have lighter volume, so I suspect as we commit to the close here, you're going to basically try to get down into the lower pot, from this morning that is a high volume low, that's the bottom line at the 408. We're going to the NDX100 that's actually given us a better signal, the reason being is that because the NDX got the volume yesterday and it should have been able to basically go after this high from last week today, well it didn't even go after the high, it's having a hard time even getting the price of yesterday, okay so that's saying guess what man, the bottom line is that there's no buyers up at this level not to get us to a higher price and we take a look at the intraday chart, the bottom line is that you know I have volume down here at 307 or 30630, there's volume and there's still a high volume low coming down to the bottom, so my take that's where we're going, we go take a look at the dollar, the dollar out here today, you know it rejected lower price yesterday, today it's just basically it's down 41 ticks but it's you know it's still over the range, the range is 103.964 and we hit 104 right now 234, right now you're at 103.888, stay right there folks come right back