Kia ora koutou. No mai hai damae ko Erika Austin Tokungiwa. We will open the session today with Akarakiya as we transition the energy of the virtual space into our formal session. Akarakiya is a non-religious blessing and is a practice of the Indigenous peoples of Aotearoa New Zealand, the Māori people. So here we go. E te hui whai te matouronga kia marama, kia whaitake ngā mahi katoa. Tu maia, tu kaha, aroha atu, aroha mai, tātou ia tātou katoa. Greetings to you all. My name is Erika Austin, the community activator at Edmund Hillary Fellowship and the host and tech mission in the background for the session. The Edmund Hillary Fellowship, EHF, is a community of 500-plus innovators, entrepreneurs and investors committed to Aotearoa New Zealand as a base camp for global impact. Our vision is that Aotearoa New Zealand inspires global leadership and solutions for the future generations to come, built on the principles of tangata titi and values of the Edmund Hillary. In the session we will hear from fellows and angel investors Kirsty Reynolds and Sean McGrale on bridging the gender gap, empowering women founders in New Zealand. As advocates for women entrepreneurs, this is a follow-up session after their duo presentation on the mystifying early stage fundraising, which is available on our website. So Kirsty and Sean will be making a compelling case for why investing in women-led businesses is marked. They will also analyse the multi-faceted reasons behind the funding gap from bias to lack of networks and will outline actionable strategies women founders can use to increase their chances of getting funded. So firstly some house key things. So this session is being recorded and will be listed on the EHF website afterwards to share with your peers. Please stay muted but feel free to put your observations, questions, comments in the chat box as we go and hopefully we'll make it an interactive session. And some of you may leave at any time and that is okay and you can catch up with the recording. Before I hand it over to Kirsty and Sean a little bit about them. So Kirsty Reynolds is an EHF fellow angel investor and company director with deep experience investing and start-ups and working with ambitious New Zealand SME businesses that are poised for international expansion. She has been an active angel investor since 2015 and has 25 years of commercial experience developing New Zealand businesses internationally throughout the Asia-Pacific region. These experiences help inform her understanding of the unique challenges faced by business owners in general and are invariably constrained by limited resources, thereby impacting their ability to scale their businesses internationally. Now Sean, Sean McGrale is a committed social entrepreneur and impact investor based in Auckland, New Zealand. As an EHF investor fellow, he propels entrepreneurs to create world-changing businesses with a focus on UN sustainable development goals like gender equality, clean energy and fair work. Prior roles include managing director at Golden Seeds where he supported women-led start-ups and co-founder of Paint Night, an award-winning social impact company that became one of the fastest growing private companies in the US. So, Kirsty and Sean, thank you so much for taking the time today. Over to you. Thanks for having us and we're going to start off sort of defining the problem at a sort of very high level and then get into a little bit more tactics about what women founders can do to tilt the playing field in their favour. Alright, so just at a really high level, why does this matter that to get women on the playing field of entrepreneurship? So, both Kirsty and I believe that some of the world's biggest problems require an all-hands-on-deck approach. And we think entrepreneurship does play a big part in solving a lot of those problems. And without women at the table, it's like trying to run a marathon by hopping on one leg. So, we'll be happy when everybody's participating fully. And the numbers really speak for themselves. Like many of you will have read that there are studies that have been done that actually show that women founders outperform male founders in terms of their metrics. There's often better team dynamics and they're often more capital efficient. So, the news isn't all bad. The trend lines are heading in the right direction. So, there has been a rise in women entrepreneurs in New Zealand and globally. So, currently right now 32% of all New Zealand businesses are owned by women. And women-owned businesses have grown over 114% in the last two decades. And globally, this trend is also true in one-third of all businesses are owned by women. But despite these rising trends, there are some gaps. And these gaps are both in relation to funding as well as in the leadership space. So, women in the US receive about 2.3% of venture funding. In New Zealand, the statistics are a little bit better. We have about 18% of early stage funding going to our women-led businesses. And if we look at this in context of leadership, in the US, about 7.4% of CEOs are women of the Fortune 500 companies. And I looked at the stats for NZ for the NZX 50 and we're at 14%. But in comparison, that's 7 out of 50 CEOs of women in New Zealand. And now we recognize that, you know, women are just sort of one group that it's tougher to raise money. And there's other groups as well that also face challenges. But we think that gender equity is just one step towards equity of all. So, we don't mean to downplay that it's a challenge across the board, but we wanted to sort of start off with 50% of the population being disadvantaged. So, how do we understand what is behind this issue? Well, the problem is multi-faceted. There's human bias. We tend to commune, relate to people that look similar to ourselves. And so, men, you know, and a lot of women-led businesses are actually trying to solve women's issues. And so, men tend not to have an understanding of some of these women-centric businesses. There are outdated cultural norms around family and around responsibilities that still impact the way we do business. There's also bad behaviour, lack of network and know-how in terms of knowing how to access capital. And many people have seen the likes of Shark Tank and are a little bit intimidated with the idea of how to go about raising capital. So, these are sort of some of the multi-faceted reasons. But one of the things that we're going to explore further on in the presentation is this idea that many of the businesses may not actually meet the criteria of an investable business for angel and venture capital. So, we also want to let you know that you're not going it alone. We're not sort of presenting this over on the side that nobody else is aware of. So, within the ecosystem of investors, it's recognized that this is a problem. So, there are VCs and angel groups that do take bias training to make themselves aware of when there's not a completely level playing field. There are also grants and other incubators and accelerators that are specifically for women-led businesses. So, you know, this is a topic that people are trying to address across the board within the investment ecosystem. So, let's kind of bring some reality to this. The fundraising isn't easy for anyone.  It is difficult. So, this idea of being resilient is incredibly important. Rejection is going to be part of the journey. And I remember my mum, she was a schoolteacher, and she said to me one day, Kirsty, I could wallpaper an entire room with the number of rejections that I've had when I've applied for jobs. And I said, well, mum, why do you keep going? Because at the end of the day, you just have to keep going. So, rejection is not the end. Learn from your experience and continue to refine what you're doing. Keep iterating what you're doing. So now, what can women founders do to increase their chances of getting funded? So, first of all, you should be aware of bias. And oftentimes people think of, you know, why they might not be getting funded as straight up sexism or misogyny. So, bias is a little bit more insidious. It's unconscious and it's drilled into people over basically their whole lifetimes and their societal norms and their personal experiences gained over a lifetime. So, and both men and women can exhibit these bias and stereotypes. So, this isn't just sort of men behaving badly or asking, you know, certain questions. But women can also exhibit this as well. You should be able to start to identify what is called a promotion question versus a prevention question and we'll get into that in a little bit. And then if you're asked questions about family or relationship situations of, you know, who's going to look after the kids if you're travelling so much and things like that, that they might not ask a male founder. So, just be aware that's one of the biggest reasons why women tend to get less funding. So, let's just explore a little bit more about what we mean by these promotion questions and prevention questions. So, a promotion question is something which is oriented, is a question which is oriented towards growth, towards expansion. Whereas a prevention question really is all about risk mitigation. How do we prevent something happening? The only thing from an investor founder point of view, from a founder point of view, is you need to be proactive in your responses. You need to actually answer the question in the positive rather than being defensive. So, this idea of flipping it, redirecting it with a promotion answer will actually allow you to raise a lot more capital than if you answer it in the defensive. And the study that was originally demonstrated that the women that did flip those questions towards a promotion answer went on and in 14 times more capital than people that answered in the negative. So, for those of you that might be considering bringing on a co-founder, you know, you may want to think about bringing on a male co-founder.  But if you are considering it, consider that. And then studies have shown too that gender diverse teams are five times more likely to raise money compared to women only founders. So, this could tilt the playing field in your direction. So, now we want you to think around this diversity within your cap table as well. We don't want you wasting time with organisations that haven't necessarily invested in women founders before. So, as a rule of thumb, think about, have they invested in at least five women founders? And I'm sort of talking about venture capital organisations now. Do they have women partners in their organisation? And, you know, below we've listed a few examples of different organisations that are actively in the space trying to support women founders accessing capital. Now, another big thing is alignment with investor appetite. So, this is sort of the hot topics of where money is flowing right now. So, software right now is getting a lot of money, AI, robotics, whereas other sectors such as retail, wholesale and professional services don't typically attract VC funding. So, you might be getting nose from investors that you're talking to just because it doesn't meet with their sort of thesis on the world. So, if that's the case and you've gotten a lot of nose, maybe consider bank loans or tapping into personal networks or alternative funding sources if you're getting lots of nose from the venture world. And then, you know, studies have been done that women led businesses tend to be in low growth industries. So, as mentioned here, you know, bootstrapping friends and family bank loans, there's other ways to raise money and we'll get into that a little bit later too. So, another, so we've kind of wanted to help people also understand why do some businesses just not access funding via angel or VC. And so, if we were categorising them into sort of four categories, a bad business. So, that's a business that unfortunately makes up about 40% of the market where they're just never going to make money and they have a tendency to sort of stop doing business within a couple of years. A side hustle is something that somebody might start on the side of actually working for another company or as an employee for a business. And they might be earning maybe 10,000 or 200 that, you know, up to 200,000 of additional revenue from running that little side hustle. And that could be anything from being a reseller on trade me, running a netsy shop, that kind of thing. When we're talking about lifestyle businesses, this is the majority of businesses in the market today. They generally have revenue of sort of between one and $10 million in annual sales. They've got maybe one to four employees and it throws off enough cash to really support the founder, but not for an investor. And so, it's more of a lifestyle business for that founder. 57% of businesses fall into that category. So, what is important to understand is that we're looking for in the angel space and in the venture capital space. We're looking for investable businesses and I'm going to let Sean talk about this in more detail. But there has to be a clear pathway over $10 million worth of sales. And this really fits less than 5% of startups who begin this journey. Yeah, so if you're getting a nose, you might really fit into the first three categories in the view of investors. So, I know my experience is, I meet a lot of lifestyle businesses where founders have a great business. They should just keep on going with it, but I'm not going to invest in it just because there's sort of a ceiling to how far they can grow that business. So, some basic criteria that almost all investors look for is one which is market size. Are you tackling a problem where currently people are spending over a billion dollars in generating sales from all the companies that are out in the world that are trying to solve this problem? Is it a billion dollar market? In New Zealand, this tends to be one of the biggest killers of why businesses don't get funding. It's a smaller market and if you've kind of said like, I'm only going to be in New Zealand and I don't have any international dreams, it does kind of limit how big you can actually get your business. So, oftentimes you have to look overseas to begin with. Then we also look for, investors look for a profit margin of 20%. Or have a business that might only have one or two percent generally that's going to scare off a fair number of investors because they're comparing your business with say a software company which tends to have high profit margins. Also growth, they want to see that you're growing year over year and at a pretty decent clip. So a 20% year over year growth is sort of a minimum for early stage companies. And then do you have a real competitive advantage? Are you building a better mousetrap or is it really just a better logo? So I run into this a lot with founders who, you know, what they're really proposing is more of a marketing play rather than actually having built a better product. So before you go on and talk to any investors, make sure you do Google search on your competitors and market size and also have an Excel spreadsheet showing how your business functions.  So that'll make you more of an investable business. So we know that gender diverse teams within businesses outperform businesses that don't have that level of diversity. So we want to suggest the same thing when it comes to your cap table. If we think about the fact that women who are writing checks to invest in women-led businesses really only make up 15% of the market. It's really important not to lock out the other 85% of potential male allies that could actually be investing in your business. So you want to make sure that you are pitching to both men and women when you go to raise your capital. And it's really important to have those male investors on board in your first round to increase your likelihood of second round funding. We also recommend that you build strong networks. So there's lots of groups out there. There's meetups and Facebook groups that support women and offer mentorship and are also investor networks. So make sure you tap into those and build out your networks in those areas. So in the same way that I talked about making sure that you identify male allies and you have a diverse cap table, it's really important that you don't just network with women, that you actually engage consistently with a network consistently across a range of vehicles or organisations to help you access and build those relationships. Ask for warm introductions through your contacts. That's really, really important as well. And you can get that either from LinkedIn or approaching directly people in your network. And men should definitely be part of the solution here. This shouldn't just be women solving the problem. Men need to be at the table as well. So ask for mentorship from men. Ask to tap into their networks. Ask them to advocate for you within the investment community. So make sure you're engaging with them and that they're participating as well. And if you haven't built an advisory board, I highly recommend that as well. So another avenue for potential funding is crowdfunding. So in New Zealand, we have snowball effect. And some of the interesting statistics that come out is that women are actually a lot more successful at raising capital via crowdfunding than what their male counterparts are. And it seems to be really good for consumer brands. And I know Anna's on the call today so she might want to share a little bit more about that. But it helps those brands in particular create community support for what they're doing. However, there is something to keep in mind that ultimately if you are looking to raise capital offshore, some businesses have experienced a little bit of pushback when there have been crowdfunding involved in the cap table as well. Yeah, and just to touch on that real quickly, you want to have make sure if you've got 500 small investors that there's a clause in there that, you know, kind of forces them to be dragged along. So you don't have to get approval from all 400 is where it becomes sticky. Also another way to raise funding is non-deluded funding. So there are grants out there specifically to fund women-led businesses. There's also competitions. And then there's also corporate sponsorships. So these are just a few ways that you can raise capital without giving up any equity. Tends to be some of the best money that you can raise. But so consider those and educate yourself if you're not familiar with those areas. So now let's just turn for a moment to when you're pitching for capital.  Be mindful of what you say, your body language, what you're wearing and be confident. What we're wanting to make people aware of is that as women we can have this tendency to say sorry or I think or maybe or it's possible, which actually creates a level of uncertainty for investors because that sort of communication sort of suggests that maybe you don't know. Whereas if you are more confident and you state your case in the same way that we were talking about promotion answers before, if you state your case powerfully and you have good eye contact then you're far more likely to actually raise the capital that you're looking to raise. The other thing is don't downplay your achievements. Own the room. Be the tall poppy in the room. Be authentic and let your passion shine. So another question we thought was going to be good was just is raising capital from angels and VCs right for you.  Figure out not only are you kind of trying to consider if it's right for the business but also is it right for you. Investors can be painful to deal with. There's a lot of governance and reporting that's required and having to report which and a lot of processes have to be put in place which for many founders can make them bristle. And then also you can get fired from your own company by your investors so only 25% of companies that make it to the IPO stage actually have the founder as CEO. So many people think that Elon Musk was a founder of Tesla. In fact, he actually was an investor in Tesla and fired the founders there. Steve Jobs also got fired from Apple so make sure this might not be the right thing for you because investors do have an upper hand and can remove you from the business. And then also, take an honest look, is your business attractive to investors? And then when you do take money, you're somewhat forced or expected to grow your business very, very quickly once you've got that funding injection. So make sure it is right for you. So what are some alternatives to venture capital? Well, sales are actually your best form of capital. And too many businesses come in thinking, well I need investors on board and actually completely lose sight of the fact that actually generating revenue from old fashioned sales is still your best way to grow your company. It provides confidence for investors and also the banks and it demonstrates that you really are building a product or a service that is in demand and that market will pay for. And these are just a few other alternatives to funding your startup. So bootstrapping is, you know, if you happen to have some cash on hand and fund it yourself, that's also great. Friends and family, bank loans, line of credit, supplier financing. So sometimes, you know, there's generous terms where you might not have to pay them for 90 or 120 days. Definitely take advantage of that if you have a physical product. And there's grants, government and also foundations are funding women led businesses. There's incubators and accelerators that often put you through a program and then at the end of it often will invest, you know, $100,000 or so. There's initial coin offerings. And also take somewhat of a risky bed of like leveraging your credit card or home equity loan and things like that. But, you know, you should only do that if you have 100% confidence that you can pay this back in a short amount of time. But it is a way that I've seen some companies get that funding that they need to launch their business. I know we kind of ran through that, but we wanted to leave a lot of room here to open it up to the floor to see what people have. So feel free to ask away. I don't know, Erica, did any questions come in on the chat? Yeah. So Julia has a question. So I have her concerns by female founders that the male co-founders were given excessive power and credit by external people such as investors. Can you address what we might need to know about potential downsides of having a male co-founder? Well, I think in general, co-founders come with pitfalls. So making sure that you are aligned and have open on honest communication. So I think aside from gender, you know, I've seen lots of co-founder arrangements fail. So a co-founder agreement between each other and setting that up first, you know, before you bring somebody on is important. So really define the terms of the roles of who's responsible for what and if someone needs to exit, you know, there's some terms there that are agreed upon before bringing them on. I've also seen situations where just by bringing on an investor in general, employees sometimes take the word of investors. And give it much more weight. So even though the investor might only have, say, 10% of the business, because a lot of employees view them as having money and success, they sometimes outweigh the investor's opinion more so than even the founder's opinion. So I've seen it go other ways. I don't know. Kierce, did you want to jump in there? No, look, I think that the reason why we wanted to bring this to people's attention is that while 2.4%, I think of funding goes to women-led businesses in the US, there's about another 18% or between 14% and 18%, which actually goes to male and female co-founded teams. So we are sharing this in the view that you actually increase your chances of raising capital if you do have a gender-diverse team within your founding team. So just wanted to bring that to your attention more than anything. Right. So we've got a comment and a question from Anna. So just to celebrate, half of the successful campaigns on Pledge Me are led by women and some haven't had any pushback. And her question is one thing I've been wondering is how society makes women more risk aware, which can be off-putting when you're pitching or even put you off from raising investment. Any thoughts on how to address this? Do you want to take that one? Yeah. So I'm just trying to understand the question, how society makes women more risk aware? Anna, do you want to speak to that? What is the particular point that you're wanting us to answer? Yeah. So just in the research that I've done in the past, what I found was women are often seen as risk-averse, but what we saw is actually the risk-aware. And to know how they're going to pay for things and make things happen. And there's just that risk-awareness that means when they're going out to pitch, they're really aware of all the risks.  So just if you have any thoughts on that. Yeah, I think you're right on point there because women are slightly less risk-averse. But they also, statistically, they show that there are actually a lot more capital efficient. They ask for what they want, and they're more capital efficient with it. And so that is something that I think we can be proud of. But I agree with you that we often don't ask for enough. So we really need to be able to look and say, well, actually I need this to provide an 18 month to two year runway, rather than a year because you don't know what's going to happen in that year. You don't know whether there are going to be some circumstances within the market. So actually being able to have the confidence to ask for more is really critical. Does that help answer the question? And if I can jump in here too, I think women also in New Zealand there's a cultural bias to give a realistic view of how much capital they're going to raise and what the company is going to do. I generally tell entrepreneurs to give a best case scenario, not an unrealistic. It still needs to be within that realm of being reasonable, but give a best case scenario because the role of the founder is to be the biggest cheerleader, the most enthusiastic.  And then, you know, hopefully land somewhere in the middle, but I find a lot of founders here in New Zealand tend to aim for that middle from the get go instead of sort of painting an optimistic picture. I don't want to make it, you know, completely unreasonable but sort of promote that sort of the growth opportunity and this is what it could be in the future. So really paint that best case scenario picture. I also think that often businesses will underestimate what it takes to actually develop their markets internationally. So they might be asking for half a million dollars for their business, not be and be talking about opening up in a couple of markets, but not being aware that actually to open up a new international market is going to take half a million dollars just on its own. And so actually having businesses working thinking strategically about getting their sales up locally and then local market is important as well as trying to build an international strategy. So there's, you know, there's an element of sometimes we think we can do more with the little amount of money that we're trying to raise than what we actually can. And so asking questions, talking with experienced people in this space, you know NZTE is a great resource for helping businesses that are wanting to come out and emerge and look at. Export markets in that way as well. So, you know, just thinking about that in terms of their capital raise piece. Anything so Bailey, would you mind taking yourself off me and asking the question or would you rather I read it out for you. Not so good. Okay. Hi Sean. So I'm probably in the weeds, but I'm getting a little bit overwhelmed by the market size is the accountant and me. I'm like, how do I get this accurate enough. So I'm working on a strategic planning and operations software but taking a regenerative approach to it so there's not really an exact competitor that I can go to. It has the potential for global reach, but I'm wondering the best approach to sizing the market. Is it to take a competitor like another software that's kind of tangential and abstracting from there by by looking at that or am I over baking it and you can explain like from your perspective, what is reasonable. So the way that I would do it is figure out who like how many customers potential customers around the world or in the market that you'd be going after. How many of them are there potential like 100%. If you had a magic wand and you could capture 100% market share of the people who you're solving the problem for so hopefully you have like, what is the problem. What's your solution. And for all the people that are experiencing that problem whether it's companies or, you know, consumers. And then what do you think you're going to charge. If you're going to charge 100, and you've got 40 million people who might fit this category you would just basically say 40 million times 100. That's generally my market size. So that's a really simple way if there's like no market that currently exists for this product. So that's what I would recommend. And then, you know, I said there was a rule of thumb of just $1 billion. Now if it's 700 million, I think you'll still get some interest from investors. But if it's 7 million, you're not going to get any investors so that's sort of where the market size rule of thumb comes in of how to figure that out. Is that helpful. Yeah, no that's really helpful. And I think I'm at the stage where like the pricing specifically isn't something that is sorted just yet, you know, if it's like SAS based pricing or a few like how to layer it. Is it kind of just finger in the air. Whenever you're considering right now, I mean because sometimes people like oh I only need to charge $1 and there's a million customers out there. Well, okay, now you have a million dollar business. It might make sense now to charge $100 because now that's $100 million business. You know, it should be within the realm of what people would actually be willing to pay. That's how you might want to think about it. And particularly a lot of people say oh I'm going after a billion dollar market, but the price of my product now is only, you know, it's 90% lower. It also impacts your market size now that you're going after. And last question on that is how much validation do you like. I'm sure you guys are kind of scratching at the surface to go like is this valid. So what kind of validation would you be looking for it for like an angel investment stage. So it's a really good question. And Bailey, I would say if we look at the different stages of investment, the precede stage is really when you've got an idea. So you don't have to validate it other than then share what you think the global opportunity is for your business. Okay, when you go for the seed stage, you generally have to have about a million dollars worth of revenue. Under your belt to raise that next round of capital. So you're, you know, and there might be things in between. But the point is, is that you've got a minimum viable product. You've proven it with customers. You're out there and you're looking to raise more capital to build scale towards what would be a series A, B or C further down the track. Okay. So it's just really sort of understanding those terminologies and where what kind of investor you are looking for. The other thing to keep in mind is in New Zealand, we've got a very small market. So the players in New Zealand tend to be generalists as opposed to specialist investors. Whereas as soon as you go into an offshore market, you'll have venture capital companies that will specialize in tech. Or specialize in deep tech. Or software as a service. Or in agri tech. Or in food and beverage. So then you can specify and look for organizations that are relevant to what it is that you're trying to do. And so I just kind of want to share that with you because that's a fundamental difference between the New Zealand market and say the American market, which is, you know, more advanced and a much bigger market. So therefore they can achieve that level of specialization. I hope that's helpful. And that was great. Thanks both. Yeah. I just wanted to add to do a Google search as best you can for market size. There's lots of like research things that you can just grab the headline to get an idea of what, you know, it might not be Bailey for your specific, but you'd be shocked at how many times angel investors talk to entrepreneurs and they haven't done a Google search on what, how big their market size is. So Google can be your friend and try and dig that out. Or talk to a local librarian who might be able to help you as well. Or an investor too. They might be able to help you figure that out as well. Anyone else have any questions. Feel free to put up your hand and or meet yourself. In the meantime, I've got a question, actually. You talked about finding those allies in your network and especially with male investors. Do you see a rise in interest about like understanding how to be allies for women founders and women entrepreneurs and how, how to best actually find them and I guess educate and, you know, and support that journey of becoming an ally.  I feel like golden seeds about 20% of the members were men and archangels here it was a smaller percentage of the last meeting I went to. It's a great question. I don't know how to cultivate cultivate it. I do know that sometimes men might not feel as comfortable ending entering a sort of a women's only space. I think that's probably more issues that men need to work through than anything else. But I don't care. So do you have any thoughts on that? Right. Look, I think that there are male allies. There are a lot of men that, you know, they have daughters and they have mothers. They have sisters. And so it's really one being conscious of the communication style. So when you are communicating with that person, is that person exhibiting inclusive kind of dialogue in their questioning or in their communication. And so those people are the ones that you really want to start to build relationships with and look to develop networks from as well. So I, yeah, I've, Sean's a great ally.  But you start to have that sense of those that are and that are going to kind of provide you with the leg up and those that are not. And so in terms of educating people, I think as Sean and I have pointed out, there is a willingness. To to grow this, you know, to develop the network and the to be more inclusive. What we are sorry is distracted. Yeah, lost my train of thought. Sorry.  So if nothing else, you know, pure greed should drive some men to invest in women led businesses. It's just a better investment. You know, if you're trying to choose to put your money behind this company or that company. And they're both sort of the same on every other aspect of business led by a woman is likely to perform better. So, you know, pointing that out to men could sway them. And that comes back to those prevention questions and promotion questions. Actually, there is a male lead businesses that should have a few more prevention questions asked to ensure that the money that investors are putting in is actually, you know, going into the right places. So let's not look at prevention questions as being all completely negative. It's about risk mitigation. And so what we were trying to share there was about how you can turn it around towards a promotion answer, which gives you the ability to to raise capital and answer it in the in the positive. The other aspect is what we've really wanted to bring your attention to is this problem is not going to be solved by just getting more women investing in women led businesses. We need a the market to be working constructively together. Men and women to to solve this problem together. So that's why we wanted to share some of this information today with you and encourage you to network more widely and to find those male allies that can help you open up your funding resources. I feel like that's another another session to delve even. I've got a question from Kelly. Are these slides being shared? Are you happy for us to share the slides with the participants today? Yes. Yep. Cool. I will make sure to email out these slides to you all. So we can continue to explore and and yeah, let's let's continue this corridor and and do another session. If that happens. So I don't see any other specific questions. But the comments. Thank you, Kirsty and Sean. Great. Let's wrap it up and we'll give some time back to your day. So thank you again for this amazing corridor and Kirsty and Sean. And thank you everyone here that has tuned in live. We have all of our past EHF live sessions on our website or just drop you a link so you can also look at the last session that Kirsty and Sean did a couple of months ago. If you have an idea for a live session, please let me know. Here is my details. Please feel free to email me. We'd love to make these sessions relevant to you and the communities that you belong to and associate with. So let's close with the karekia. Tuia i runga. Tuia i raro. Tuia i roto. Tuia i waho. Tuia i teheretangata. Ha rungo te po. Ka rungo te au. Ti hei. Mauriora. Ngamahinui. Ka kite ano. Thank you. Thanks everybody.


Hello again. Thank you once again for having me here and giving me the opportunity to talk about mitrovabric repair and I'd like to sort of put in practice some of the stuff that we discussed in the previous talk with with the clinical case and the disclosure are the same as I had before and the case is a young lady who came from the road as a private patient to our clinic about a month ago. She was 34 years old, tall girl with three children. She was also a physician. She had exertional dyspnea, Asimoto tyroiditis, and paroxysmal atrial fibrillation. On preoperative echo, she knew she had a mitral regurgitation since she was a child, and she was followed by sort of follow-up echoes for many, many years. And the last echo showed that severe mitral regurgitation with an ejection fraction of 60%, she was actually scheduled for a mitrovabric pair with minimally invasive approach. How did we do the echo? And how do we do the echo for mitrovabric pair with minimally invasive approach? We do it just like we do it for all other procedures. Here in Leipzig, we have this protocol with a sequence of views that needs to be acquired as a comprehensive examination. And for each view, it's specified what measurements have to be done and what for each view, what modality needs to be used in terms of 2D color, 3D and Doppler. And so we follow the same protocol. And as we start, we start from the transgustric. Now it's short axis. I'm not only going to show you the views that are relevant to our case. This is a short axis view. It's very important to document that there is no wall motion abnormality. In this patient, we go to a four chamber view. You can appreciate there's a prolapsing mitral valve with bi-different prolapse both anterior and posterior are prolapsing. There's a normal preserved ejection fraction, although there's a high grade mitral regurgitation. And you can see that we can already see a regurgitan jet there. That's sort of a complex jet in the X-plane view. We look at the right ventricle. The right ventricle is normal size, normal annulus, no tricuspid valve regurgitation whatsoever. So absolutely no indication to do anything to the tricuspid valve. And now we go to mitral commissural view, which is sort of the golden view for assessment of mitral regurgitation, mitral commissural view to the left, perpendicular plane, cutting through the middle of the valve on the right. Then we have A2 and P2. And now what we do is what I was showing you before, you start from the image in the middle, and then we take our secondary plane and we tilt it right and left to scan through the entire valve. And we can appreciate where the jet are coming from. So in the middle, we see a jet, but we don't really see the origin of the jet. To the right, which is the more lateral aspect of the valve, there is a small jet that comes that you can start to appreciate with sort of a funny-looking posterior mitral valve leaflet here. And as we move medially, then there's a bigger jet.  Now we go to 3D, you can see this is a valve that where everything, but not really everything is prolapsing. We definitely have anterior leaflet prolapse that's more pronounced in the A2 area. There's P2 prolapse, A1 is also prolapsing. But you see here to the right side so medially in the valve, there's a P3 is not prolapsing, it's actually restrictive. And if you look at the 3D color, the jet comes exactly from this sort of posterior-media commissure of the valve. I did the offline analysis of this valve here and you can see at the bottom starting with NPR, starting from more medially, you can appreciate the features of this valve with a sort of restrictive short P3 prolapsing P2 and a prolapsing P1. I also did then offline a mitral valve model just to confirm my findings. As I said in my other talk, we don't use this on a clinical base in the operating room, if there's time I do it, I show it to the surgeon at school, but we don't use this measurement for decision making. So looking at the mechanism, what is the case here? The case is the excessive leaflet motion that is affecting the valve in an asymmetric way. We look at the circumflex to tell the surgeon how far away is from the annulus. I did it with NPR here and I always got five millimeters, so it's more or less five millimeters from the annulus. Does it make a big difference? I mean, certainly when the surgeons hear that it's more than five millimeters, they feel sort of more relaxed in putting the stitches. But when it's like less, they may be more cautious, but I'm not sure if they really change their practice, but it's sort of a measurement that we always give them. Assessing the risk of SAM in this case, the only significant value is the angle between the mitral valve and the aortic valve that in this case is one or seven. And as you see from this sketch from the previous talk is less than 120. So we went on and look for the circumflex. You can see here I started from a long axis. I turn to the left and I follow the left main and you can see the bifurcation and you can see the flow in the circumflex as it starts. And I didn't see any more flow as the circumflex goes along the annulus. Canulation is a key component of this procedure. We look for the wire in the arterial line. We look for the wire in the superior vena cava, and then we advance the cannula, follow it in the superior vena cava. What I see very often is that we see the wire in the superior vena cava and then the surgeons dilate. And once they've dilated with the here that we use three dilator of progressive size, so bigger size. So after the second or the third dilator, often the wire comes out of the superior vena cava. So this is, it's very important to detect that because now the wire railroads, the cannula, if we advance the cannula and the wire is in the left atrap and the joint or in the left ventricle, then we can really perforate the left atrap and the joint of the left ventricle. Before the surgeon advance the cannula, make sure the wire is in the superior vena cava. And this is everywhere in the world. The surgeons have no patience. They need to wait. They cannot advance the venous cannula from the groin until we've seen the wire in the superior vena cava. So the surgery went well. Our surgeon in this case was Michael Barger. He found the A2P2 prolapse with a restriction of P3. He decided to put neocords on the lateral portion of P2 and then he did secondary cordal transfer to pull down the A2 segment. And then he put a physioflex ring that was 36 millimeter and the anterior mitral valve leaflet, we actually measured it was 34, I think, and we did cryoblation for atrial fibrillation. So now we just release the cross clamp and you can see here on the left with color flow, I can follow the circumflex and I can see flow in the circumflex. All the way and under the new, so the new ring that was put in. So I've demonstrated yet right away that there's flow in the circumflex. And then the heart just started to beat and the valve, the heart is empty. It's not pumping. I can check the aortic valve for regurgitation and there's no regurgitation.  So we just cross clamp, we haven't reperfused yet. We still need time to warm up the patient but we come off pumping quickly look at the valve. So in four chamber, two chamber, we look at flow, color and morphology. The valve is, since there's no more prolapse that can be detected and there's no flow. We look closely in the long axis view and we can identify a very small regurgiton jet. We get a better look at the valve now with full load of the left ventricle with X plane. I do the same trick. So I start from the center of the valve in this Mitra commissure of you and then I go right and left.  Now with 3D we look on fast. You can see the ring to the left and on the right, you can see these two small jet one is a little bit bigger on the right side that's more media. That's where this P3 segment was tethered down into the ventricle. Now we look at the short axis view to confirm there's no one motion abnormality, despite we've already seen that there's flow in the circumflex we need to confirm it with a normal short axis view. And remember that for these procedures, we have to guide the weaning from cutting pulmonary bypass. The surgeons don't see the right ventricle because the chest is closed and they don't see it at all. So what we need with echo then to look at both ventricles and have a look at the right ventricle as we come off. So this was sort of accepted as a good result because the patient was young. She had a very complex pathology and a small regurgitan jet that was left on the medial aspect of the valve was thought to be acceptable. She, the matricle agitation also in physiological awake condition before discharge was still trace. And the patient was discharged home seven days post op, given our policies. The patient stayed longer than she would have stayed in the hospital probably in Toronto but this is sort of a very normal post operative course, and the patient send me an email two weeks ago. From home to tell me that she was very appreciative of our care and she's very happy and she's doing great recovery from her surgery. Thank you very much and I hope and I think there's going to be a nice discussion and I'll be waiting for your questions and I hope we'll be able to answer them all. If not, then please email me and anytime. Once again, I invite you to come and visit us in life. Thank you very much. Thank you very much to our speakers for a fun, fantastic session. There's lots of questions that came through in the chat so I'm going to start off here the first one is. Yeah, I think it's directed at previous do you prefer lung isolation, or only pushing the lung away with abdominal back. And what is the impact on per surgical ventilation. This one that goes with this is why do you prefer not prefer one lung ventilation in to repair one single human tubes. Well, that's a good question. Somehow we had, we had a few cases in Leipzig where using double lumen tube finally resulted in, I don't know whether it really resulted but we saw that we had unilateral pulmonary edema. And to the tune that some of the patients had to go on ECMO. The reason I was told that they completely abandoned double lumen ventilation for mitrowab surgery. So, by when I joined they were already doing single, using a single lumen endotracheal tube and basically we go on pump right away. So, you generally do not need, you do not miss the single double lumen endotracheal tube because once you're on pump the lungs are down. And when we come off we close the pericardium even before we come off. So, pretty much everything is done on pump.  You hear me. Yes. Yeah, so hi. Thank you for having me that's awesome to see you all I'd like to be there in person but it's still sort of a challenge. So, so please do organize this symposium next year and invite me I'll come. So the, so to, to, to Piroce's point, we did a study, I think so obviously if you use a single lumen tube you commit to a slightly longer by past time, but in comparison to double lumen tube but you obviously don't have the relative challenges of a double lumen tube. Well we actually what's been reported by most of the other centers will use the double lumen tube after micro valve repair with minimal invasive approach. There's a significant eye incidence of reperfusion pulmonary edema. So unilateral pulmonary edema, and we actually did a study and we quantify with the radiology the pulmonary edema in our patients and there was a sort of doctor by the master thesis for one of my colleagues and the incidence of unilateral pulmonary edema after my micro valve repair or mixed cabbage or meat caps in our patients population using a double lumen tube was way way lower than what's been reported in the literature elsewhere. So for us the choice of of a double lumen tube is for simplicity so whatever so we try to keep things simple and and whatever makes it faster we we go for it and also to decrease the incidence of post operative unilateral pulmonary edema. So just to add to that max that we've used double lumen tubes for many areas, but somehow we have never touched up until now I've never experienced this problem. When we do a minimally invasive area. Yeah, but I mean, I don't know what we. Yeah. So something which probably we need to study that more in detail probably. I mean to get the answer you should do a randomized trial but I think for us is because for us is sort of using a single lumen tube is is sort of become the standard of care. So then that's, that's basically what we go for. On the other hand, I don't know when you were here in life, maybe you were doing more of this minimally invasive. So we write anterior lateral to the economy. But like right now we don't do that many so because there's only really one surgeon who does them. And on the other hand, we do, we do a lot of mid caps and mitral valves with the top economy. Yeah. Yeah, I mean we do. I mean there's also here it's the, it's the smallest number that we do have a very good as it is a very difficult to come by nowadays with tabby. Exactly. But the cases which are on the borderline between tabby and surgery then they agree to undergo surgery if you're offering minimally invasive so right anterior to me we are so. Okay, thank you very much that was a very interesting discussion I have another question here. Can you elaborate a bit on any differences or specific challenges in P3 disease in terms of surgical technique and other factors that influence durability of a repair. Is it simply that P3 problems are corrected, correlated with basal aneurysms and medial papillary dysfunction or informed. So the P3 I'm not usually it is ischemic it is only isolated P3 and as Max has shown the, you know, the different factors that go against repairing the valve. You have to be observed and it's particularly the tending height is greater than one centimeter and your angle is more than like almost 40, then you would avoid doing a repair. If you want to do a repair in such situations then there are different techniques which you have to apply at the level of the papillary muscle. And so you can either approximate the lateral and the medial papillary muscles with a tube graph, which is placed within the ventricle, or another technique is to pass a pleasure to suture through the papillary muscle, the posterior papillary muscle and bring this suture through the annulus of the posterior at the level of the P2 P3. And then once you put in the ring, you inflate the ventricle, you know, with your water test, and then gradually tug on the suture. And you will see as you dug on the suture, the P3 and that part of the mitral valve, the medial part will start coming up, you actually see it coming up.  So that's something which you can use. So these are different or then of course you have to can put in a patch and extend the P3 and the P2 P3 area to compensate for the tethering. So these are all different techniques which you can use. We do not know really the long term outcomes of all these techniques. But with the trial comparing P3, you know, I mean the ischemic functional MR versus repair versus replacement for functional MR, it was quite humbling to see the number of recurrent mitral regurgitation 30% at two years, which is a hell of a lot. And I think surgeons have changed them more towards replacement than repair for such cases. Perfect. Max, did you want to comment? Yeah, so I mean the only thing that I mean this is what Piroz described is unfortunately techniques, there's very few surgeon who can do it, but there's not many people around the world who can do it. So my point was and the older I get, the more I try to keep things simple. So what we have here, so what we do are practicing like it is if we have so unique when you have a secondary matter of regurgitation in the OR and you're doing surgery. When you're clipping it's a different story, but if you're doing surgery, then what we do is we look at the tethering height. If the tethering height is more than one centimeter, we don't repair the valve. If the tethering height is less than one centimeter, then we may repair that you have a central jet and the whole valve is equally pulled down into the ventricles. Then you put a ring is going to be fine. What you need to know though is that if you look at the valve and you have an eccentric jet, then you need to think about this second situation where just putting a ring is not going to be enough. And even if you may get away in the OR, it's not going to last as a repair. So that's to me was sort of the point of presenting these two phenotypes that I think it's important that we identify and we tell the surgeon, okay, yeah, you'd be fine or this is going to be something complicated. And you're measuring the tethering height specifically at each scallop. Not just one tenting height in the middle. You're doing sort of, no, we just, no, no, no, we, we measure just the tenting height in four chamber view. And that's it. I've got another question here regarding circumflex distance assessment. Do you measure in lastly or in systolic. And sometimes it's difficult to differentiate between the circumflex and the sinus usually it's feasible in 3d but do you have any useful tips. The useful tips is is if you don't want to do MPRs. So there's two cases, either you don't want to do MPR just because you hate it or you don't like it or you don't have time for it, or because you don't have a good enough 3d data set because that's also happens that you just don't have a good enough quality data set you have a block of the micro valve you import it into MPR and you just cannot recognize the circumflex and then if you cannot recognize this you cannot recognize you can make it up but if you don't see it you don't see it. In that case, what what my suggestion is and that's what we do when when we saw if you if you don't have time, you look at the mitra commissural view in the mitra commissural view on the right side of the valve. You, you start to see the left at the end of just right under it, you always almost always see and record can recognize the circumflex and then there you can measure the distance from the annuals, you just have one point but you're very close to where the highest chance of actually catching the circum, circumflex, circumflexes, and I mean and I'm very glad I, I hope I had this discussion when it was still in Leipzig but I mean I think people can probably comment, because the surgeon are always asking me no, it's very important tell me how far away is the circumflex, I mean, is it like does it really change your technique heroes or or is just knowing that the circumflex is not so close just makes you feel better. I think the latter is true. But no, so it's very important that when you take your annual plastic sutures in the area of the circumflex that's probably from the commissure, the lateral commissure going across to the P1 P2 area that your needle angle is extremely important. So if you take the stitch this way, you tend to use your stitch tends to go into the left atrium more than the annuals, and everyone should know at least a surgeon should know that the circumflex does not run in the ventricle it runs in the atrium. And that's how you need it. So the important thing is when you take the stitch it has to be this way so you take a forehand which goes towards the ventricle muscle and towards the ventricular lumen. So if you do that, I think 99.9 times out of 100 you won't nail the circumflex. And that's particularly important in minimally invasive, because in minimally invasive if you if the natural angle of taking the shot in that area can easily nail the circumflex you don't have the luxury sometimes of holding the plane of the annulus in a way that you can actually take it that way. So you have to be very careful and see that your needle is always perpendicular to the plane of the mitral annulus and goes towards the lumen more than going away from the lumen. And I think you can pretty much avoid it every time. However close it is. So the other thing that I wanted to tell about the circumflex is I must admit that so this is a it's a it's a life. It's a little bit of a life thing because like I never looked the circumflex in Toronto then I come to life again, like, and I had to learn how to look at it. So, and I can say my experience is you need to, I think it makes sense to look for it before the surgery you don't always see it. So if you see it, you see it. If you don't see it, it doesn't really mean that it's not there. And the same time is when you unclamp when you unclamp my experience now in Leipzig and we do a lot of these procedures and we look at it almost all the time so definitely for my travel but I also look for other procedures. When you see flowing the circumflex in about 70% of the cases when you see flow, it means that there is flow. If you don't see flow, there's two possibility either there is an occlusion, or that you just don't see it because of the anatomy of this patient so the fact that you don't see flow doesn't always necessarily mean that there is an occlusion. One thing. Second, especially for my for trackers after mitral valve repair. If you have a circumflex occlusion, you will also have one motion abnormalities. So it's important to get a good short axis you before you won't pump to document that there isn't any one motion abnormality when you come off pump. You look at the, you look at the, on the other hand, look at the ECG. So the ECG, if you have an occlusion of the circumflex is not going to be normal. And then, finally, so it's three things flowing the circumflex almost an abnormality ECG. And if, if you have any doubt, then you have you cannot take the patient to the intensive care unit or the recovery room. It has to go directly to the cut lab. We have many times, and when we have a very even a smaller, the smaller suspicion, we call the cut lab we activate so what is a sort of the equivalent of a semi cold semi they make a room available for us, we go from you are straight to the cut lab and do a cast and before you take the patient to the to the ICU you cannot take a chance of a patient who has no coronary disease to actually have occluded circumflex. I think it does help in at least identifying patients who might be a problem. I mean, they may not be a problem. I agree with you. But at least you won't miss the ones who have the problem. And you will be able to address or at least investigate further and prevent a long sort of drawn ischemia or in fact right. Absolutely. If you guys have another question if you can, when do you decide to use a complete ring versus a band. Most of the time I use a complete ring. But sometimes there is a discrepancy between the size of the ring you want to use and the intra trigonal distance. Now if you feel that you need a larger ring for an anterior posterior diameter. But when you use that size and you see that the anterior posterior is fine but it's overshooting the trigons. Then you cannot use that ring because you cannot overshoot the trigons because that's going to deform the valve in that situation and I go to a band because I'm not restricted because the band will take the shape of the of the annulus itself and so that will prevent deformation of the annulus. The second thing is also when you have calcification in the posterior annulus like a short segment of calcification where which you don't really need to excise sometimes in that situation again I would take a band because stitching a band to that calcified area is okay but if you're going to suture rigid to rigid, there's a chance of dehesions whereas a band will not dehes.  In that situation again it would preferable, it would be preferable to use a band, otherwise you will get a dehesance. If you crunch a rigid structure, use a rigid structure to crunch the annulus too much, you are bound to get a dehesance. So these are the situations but the most common one is the first one where there's a discrepancy between the anterior posterior diameter and the intra trigonal distance that I would use a band. And one more point when I feel that there is a high risk of sand. In that situation again I would use the band more often than a rigid ring. So that the anterior annulus is free and it does reduce the risk of sand later on. That's a great answer, thank you very much. So then I've got a question here, regarding seeing the guide wire in the SVC, what do you do regarding central venous axes to avoid misidentification of your CVC and the guide wire? I think explain helps a lot with my feeling. So what we do, I must say that what we do in Leipzig we use endovascular ECG when we place a central line for all of our cases. So you basically connect the ECG lead to your wire for the central line and we position it so we leave it at the depth where the P wave is two thirds of the R wave. And I never see my CVP line in the superior vena cava where the wire is. So I never have the problem. The problem you have sometimes when you, if the patient has a pacemaker wire, so then sometimes you have a pacemaker wire then you don't know which wire it is. So and explain helps. And the other, and this is also we see it for for for clips and for transceptile puncture. It's you basically need to, to maybe you ask the surgeon to wait or we drew them withdraw the wire, and then have a good view of the superior vena cava before the wire comes in so then you know which one it is, which one is which which one is your wire and which one is your, your, your pacemaker wire. I must say that, yeah, as I said with the with the central with the central ECG, sorry with the endo luminar or endovascular ECG on the wire for the central line insertion. We are usually have the central line that's high enough. Actually not to see it in the by cable view. Yeah, the other option would be that then when you place your central line, you, you put a tea probe before you put the central line you can confirm the presence of the wire as it comes from the internal jugular vein. And then second you can actually position your, your, your catheter. So then it's in the vein and you don't see that it's not far enough. It's not too deep into them up to the junction of the superior vena cava to the right. I think the other issue is also if you have a PA lining then it becomes also then you also have another thing that's, that's in, in that area I also find it useful if you ask the surgeon to go back to the IVC. And if they turn the guide wire and you actually follow them, if you go very slowly. I think it's, I mean, because it's very, very well educated but in general, it's, it's a matter of like educating the surgeon and now, I must say, unfortunately, I need to admit we had a few complications of for Venus. For a line for, for category by past. And also the surgeons who were a bit more aggressive and less patients have realized that the others, there's, there's, that's not really that's not worth it. So because if you if you have a complication for from Venus cannulation then it's a really bad one. Yeah. I have another question here. It's for you. What's the philosophy of thinking between leaflet resection and cordyceuture for MR. How do you select the technique. Well, I usually use the respect technique that I avoid. So let's put it this way I use the resection technique only in maybe Barlow's or severe mix of matters disease where you have like extremely large amounts of leaflet. And if the prolapsing segment is like three centimeters in height. In that situation I would use a resection plus. So I won't use a formal resection which they used used to used before like most surgeons used but I just use a limited resection. And then I again put cordy to that because the idea is to have the largest or if it's possible. And secondly also as I mentioned before in my talk that I prefer to have the posterior leaflet a bit mobile, rather than just using it as a platform for the anterior leaflet to smack into. So for all these reasons, you have to use a respect technique because the moment you start respecting too much, it's going to become stiff. There is no way your leaflet is going to be mobile. And it does give a longer line of co-optation which has been proven we have papers from Leipzig which have proven that with the loop technique we have a larger orifice area, a longer line of co-optation, which would both go in favor of a better long term outcome. I think I'm going to do one last question here and Max this one is for you. Do you think that there are any advantages to choosing between 2D, 3D or BSA indexed martel valve tinting area measurements. So differences, I mean there are studies that like, so with 3D you can measure the tinting volume, but the majority of the guidelines and the majority of the studies are actually based on 2D measurements. And to measure the tinting volume you need to use a 3D reconstruction of the mitral valve using whatever 3D, for the MV from Tomtec or the MVN from Philips or the old sort of MVN because now Philips has taken over Tomtec or with the cement system you use the other 3D measurements software. But clinically, honestly I don't see an advantage and at least in our center we rely on what's suggested in the guidelines which is the tinting height from what I would add is that a lot of these 3D measurements are not standardized. So depending on which software package you're using, you may get very different measurements from the same 3D data sets. Especially when you're doing volume measurements where they have to measure the volume from the some kind of angular plane and how they're developing that angular plane will make a big difference in terms of what you get for the volume value. Very good point. Thank you so much to Piroz and Masi for joining us and I really hope next year we can have you in person. Thank you for having us. It was amazing. I was so happy. It was really good. It was so nice to see a surgical, you know, to see the surgical perspective with the echo. I think that was perfect. Thank you very, very much for your time. Thank you very much. Thank you very much. Great session. Thank you. Nice to see you, Max. Bye bye. Nice to see you to Piroz. Bye bye.