Hello, everyone. Good afternoon. Thank you for being here again for another multi-center echo teaching sessions. Today, I have a very special guest. We are going to be discussing about our Tribal Repair. It's a very interesting talk and we have new, we have new informations coming up and you're going to have like a hopefully a pretty good discussion about this topic. We have a very special guest, Dr. Annette Vegas. For those of you who don't know Dr. Vegas, she's Professor of Anesthesiology here at University of Toronto, Staff Cardiovascular Anesthesiology and Critical Care Physician at Toronto General Hospital and also Director of Pedoperative Tee Program also at EGH. Among many other teaching activities, Dr. Vegas has a special interest in echocardiography and has developed web-based educational materials, especially the PI Med Toronto for teaching both TE and also TTE. She has extensive published journal articles and book chapters and out of textbooks and co-edited textbooks related to echocardiography. Dr. Vegas, thank you very much for being here. We are really really happy for having you here and I'm going to hand over to you now and I'm going to mute myself. Thanks Fabio. You should start to see my screen. As I can see your screen. Excellent and I'm hoping you can hear me very well. Thanks very much to Fabio and Rafael for the kind invitation to speak today on the topic of the aortic valve repair decision making. Over the course of today's session, what we hope to do is to use a case-based approach to look at cases involving sparing of the native aortic valve. We're also going to review some classification guidelines for the assessment of the mechanisms of AI, managing AI, or top of the from the American Heart Association, how to assess the bicuspid aortic valve, and how to assess for aortic valve sparing procedures. We're going to use mostly TE images in the context of surgical literature and best practices to explore these topics. I have no disclosures or competing interests and I'd like to share today with one of my colleagues, Dr. Chris Windell. Chris is one of our cardiovascular surgeons who really is a pioneer in the topic of aortic valve sparing procedures. He recently retired and fortunately was gracious enough to accept this invitation. So as we present the cases, I'll elicit his opinion about how a surgeon thinks and what a surgeon would do in this situation. So the first case we're going to present is a typical case that you might see in your operating room. It's an 80-year-old female whose asymptomatic has comorbidities of hypertension on trans thoracic echo was found to have an aortic aneurysm and aortic insufficiency. A CT scan confirmed the presence of the aortic aneurysm. It involved the ascending aorta and the proximal arch. Have a look at these clips and see what you think. One question to answer is what two abnormalities do you see on the 2D image in the midisophageal aortic valve long axis view? Think about what the mechanism of AI is in this patient. So for those of you who are eagle-eyed, you recognize one abnormality right away and that was the dilated ascending aorta here past the STJ. The other abnormality is an aberrant or abnormal coronary artery which may influence how the surgeon chooses to manage this patient. We're going to start with poll question one. The question is how would you quantify in your operating room the grade of AI in this patient? You can choose as many choices as you think. In another 10 seconds and I'm going to end the poll. I'm going to share the results with you, Dr. Vegas. So 24% said vina contracta, 29% said relation between the jet height and LVOG diameter, 10% fresh halftime, 33% aortic reversal, and 5% Augustine volume. I'm going to stop sharing here. Okay, so there really is no right answer here and many people use multiple techniques to grade AI. All right, I'm just trying to advance my slides here. Okay, so in this patient we can look at vina contracta and remember as you're trying to make these measurements, it's important to zoom in and try and get a nice flow acceleration vina contracta and jet area here as shown here and the vina contracta here measures 7 millimeters if you were to do the jet height to LVOG area that comes out to 31%. If you're looking at pressure halftime it's 405 and there is no aortic reversal in this patient. So if we were just to use these simple measurements we would have severe based on vina contracta, moderate based on jet height and pressure halftime and there's no descending aorta reversal. Most of us don't use quantification but you can use quantification in this patient. You can go to the transgastric views as shown here and this is a deep transgastric view showing the AI jet which fortunately lines well with spectral Doppler. So here you can measure the vina contracta sorry the PISA hemisphere and it comes out to 0.6. You can measure the aortic regurgitation and you look at the VTI here and depending on the software on your machine you can actually plug all these values in and you can see on the screen here this was automatically calculated for us. In this case the airway was 0.18 and the regurgitation volume was 46 millimeters all of which suggests this patient has at least moderate AI. So is there literature to support what we should be doing in the operating room? I'm sure you're aware of these 2020 guidelines that came out in JACE published by Nakora et al and if you read the fine print I was one of the authors on this paper but really what it comes down to is what do we need to do interactively to assess for aortic bowel surgery and the reality is that we can look at aortic bowel anatomy and to evaluate aortic bowel function we should use simple tests and the ones that we've done here being a contracted pressure halftime an aortic flow reversal are the ones that are recommended for interoperative assessment. In the post repair period we should evaluate anatomy, evaluate aortic bowel function, lv function and coronary flow and coronary left ventricular wall motion abnormalities. So we'll go into a little bit of detail in some of this as we progress along in the talk. So poll number two based on the echo findings and the Elkuri functional AI classification what is the mechanism of AI? Is it type one A, B, C, D, two or three? Okay another 10 seconds okay I'm gonna end the poll so Dr. Vegas 53 percent said type one A 12 percent type one B 18 percent type one C and 12 percent type two and also six percent type three. Let me stop sharing. Okay so the Elkuri classification let's see if I can advance my slide here. So the Elkuri classification is a classification popularized by one of the Belgian cardiac surgeons. It was really published in 2005 and what they tried to do is look at the mechanisms of AI similar to you would be looking at the mechanisms of mitral regurgitation. So they classified it into three types type one two and three. Type one has normal cusp motion and can be related to a functional aortic dilatation or cusp perforation. Type two is related to cusp prolapse and type three is related to cusp retraction or calcified cusps. Within type one there are four sub types and it really depends on where the root is dilated or where the aorta is dilated. So type one is distilled to the STJ. Type one B is involving the aortic root and type one C involves the aortic annulus. Type one D reflects perforation. So this functional classification was brought into play largely because increasingly people are doing aortic valve or valve sparing procedures and it gave echocardiographers and cardiologists and cardiac surgeons common language to talk about some of the mechanisms involved with AI. It's important to remember that a mechanism is not the etiology and we still have to search for the underlying reason for why a patient has AI. So let's look at the mechanism in case one. We look at the aortic valve long axis. We see up close that the cusps actually look like they're co-opting well and the problem really has to do with the aorta. And if we make our measurements we see a systolic annular measurement of 2.2. Remember the remaining measurements should be measured in diastole and while the recommendations are leading edge to leading edge I think most people use inner edge to inner edge. And you can see the measurements listed here. The STJ and the aortic annulus and the ascending aorta are both dilated. So this is in fact to type one A, L-curry classification. So how do we manage AI and aorta? Well there are guidelines out there and these are the American Heart Guidelines. They came out in 2021 and for patients with AI they consider suggesting surgery if the patient has BR AI, if the patient is symptomatic, if the left ventricular ejection fraction is less than 55% and if the left ventricular and systolic diameter not diastolic but systolic diameter is greater than 50 millimeters. It's a class II indication with moderate AI as our patient has if they're coming for other surgery. But the reality is this patient is in the operating room for another reason. They have an ascending thoracic aorta annulus and this is the most recent 2022 in-press guidelines from the Journal of the American College of Cardiology and again AHA guidelines, ACC guidelines and their current recommendations are of course sporadic and by cuspid aortic valve aneurysms to consider surgery when the ascending aorta is greater than 55 and in more fans when it's greater than 50 millimeters. So poll number three, what operation should this patient have and sure it will have to find the L-way in and what he thinks the operation should be. But we'll poll the audience first. Okay, five seconds, two, one, another five seconds among people as you're voting. Okay, I'm going to end the poll and I'm going to share results. So 20 percent said dental, AVR and ascending aorta, 35 percent replacement of the aorta, 45 percent bogs bearing and yeah that's it, 45, 35 and 20. Okay Chris, how about it? You've got an eight-year-old who's asymptomatic has a dilated ascending aorta greater than six centimeters, moderate central AI and a tricuspid aortic valve. What would you recommend the patient have done? Thanks Annette. Can you hear me all right? Yeah, yours sound great. Good. Eight years old and first of all just let me comment a valve sparing route is certainly an option. It is a more technically challenging operation. It takes a longer time and of course time on the heart lung machine as you well know as you get older is harder on the individual. So I would be low to expose her to a valve sparing operation and of course the whole idea of that is you have a valve that's going to last many years without anti-coagulation but at 80 years old I think that the risk benefit is not worth it. When you said replacement of the aorta, I assume you meant replacement of the ascending aorta. It wasn't quite clear. Yes. So let's just pass back to A which is the bental which is an AVR and aortic root, the whole aortic root replacement with the ascending aortic replacement. That's not as challenging and as tough as a valve sparing route but it's still a big operation and I think the main reason that this patient's here is because of her ascending aorta which puts her at a significant risk of death from rupture. I think it's a judgment call as to how bad the AI is. I would suspect that you will not make the AI better if you just correct the sinotubular junction but I highly suspect you will make it significantly less and at 80 years old you can tolerate that AI. She's also already asymptomatic so she's not having symptoms from her AI and I would push for a fairly straightforward and fairly quick operation which would be replacement of the ascending aorta from the inominent artery down to the sinotubular junction which will correct some of the AI probably not all of it. You just don't have enough leaflet or leaflet material to do a valve sparing route I don't think. A RAS procedure that would be a fantasy and she's not there for her aorta valve she's there for her aneurysm so I would vote for B. Okay so let's see what our intrapet surgeon did. So our intrapet surgeon replaced the ascending aorta and just the ascending aorta leaving the native valve intact. So again the patient ends up with probably the same amount of AI as they did before. So Chris any comments about the amount of AI and worrying about this amount of AI in an 80 year old? Not particularly I think her heart size is yes her heart size is normal. I think this is probably likely she's had this for a long time and she could tolerate this. Okay any questions or comments from the audience? Yes I do have a question. Dr. Fendle in regards to this patient what would be the limit in terms of age for you to consider try to do a valve repair a valve sparing procedure for this patient? That's a good question. I think it really depends on the patient's overall physiology so a healthy individual you know 65 or less you would certainly consider a valve sparing. Again not in this patient I'm not sure a valve sparing would be successful in this patient but to your point I would say 65. I mean age thresholds are shifting as you know as we all get older we keep shifting the threshold so a healthy 70 year old I think it's worthwhile if you're comfortable doing a valve sparing operation it's not going to end up being a prolonged pump run and the heart they don't have coronary disease and heart function is good when you start adding other things such as coroner disease or reduced heart function which is I think that's it becomes quite a different situation. Okay I mean valve sparing is it's an ideal operation but it's you know not necessarily the right thing for everyone but I would say a good 65 to 70 year old is worth it's worthwhile. Okay thank you. Okay let's go on to case two. So this is a 19 year old male so substantially younger with Marfan syndrome. He's asymptomatic and has been followed serially through the air top of the clinic here. He has mild AI and is noted to have an aortic root aneurysm of 55 millimeters on trans thoracic echo which was also confirmed to be 58 millimeters on CT scan and these are is a aortic valve long axis use here so have a look at these views and this is a short axis use. All right so let's go to the mechanism of AI here so very similar to our first patient when we do our measurements we get an annular measurement of 25 and measurements in diastole of a sinus of 4.7 and an STJ closer to 5.3. The ascending order which I'm not showing here was actually quite normal at 3.5 centimeters so in this case the L-curry mechanism is type 1b where we have dilatation of the aortic root which needs to be addressed. So pole number four and you knew this was coming what operation should this patient have and you have a chance to weigh in. Again Annette replacement of the aorta I'm assuming you mean replacement of the ascending. Yes thank you. Okay another 10 seconds okay I'm going to stop. So Chris what do you think? So let me just Annette show the answers. Yes yes so 74 percent pulse bearing, 17 percent, 17 percent bento, 4 percent replacement of ascending aorta and 4 percent ros. All right Chris 19 years old asymptomatic these are fairly common patients in our practice here at the general thanks to you and Dr. David so any thoughts about this type of patient? Well again the this patient is here because he has a Marfan syndrome and he's got a dilated aortic root and he's at a high risk of dissection down the road and being at age 19 you really don't want to have to give him an artificial valve in particular a mechanical valve which will commit him to lifelong comadine and the other thing I think is a little bit misunderstood when people say a mechanical valve will last your lifetime that's not necessarily true and I know the anesthesiologists here have seen us having to re-operate on mechanical valves that get into trouble because of a panacea so it's not a totally benign situation so definitely in this case a aortic valve sparing route would be the ideal approach to helping this young man the valve leaflets although they're thinned out and they likely will be stretched out they appear to be normal there may be some fenestrations in them which you would likely accept depending on what they're like but I think he would be ideal for a aortic root sparing operation I would not do a ROS operation because all you're going to do is replace part of the aortic route be better to replace the aorta right up to the even to the inominate problem open right so we've all already sort of delved into this a little bit so and Chris can sort of respond a little bit here so what are some of the indications to do a valve sparing procedure and these are a list that that I came up with and it's sort of symptomatic patients with congestive heart failure asymptomatic patients who've dilated left ventricles and really it reflects more of been the problem with the aorta so they either have type A dissections they have aneurysms or a or top of these depending on the origin of the a or top we talked about you know the age limits and and the moving shifting stand part of the age limits ages less than 60 might consider an aortic valve and and ascending aorta and patients who have severe AI and root enlargements contraindications obviously lack of surgical expertise abnormal cusps poor left ventricular function coronary disease which may prolong the surgery and by cusp aortic valves in the older age group patients any comments Chris what you think and when you think aortic valve should be spared I think these are very reasonable the if the valve can be salvaged then I think it and you have the surgical expertise then it should should be spared if if you don't have the surgical expertise I think it's a it behooves you to refer to a surgeon or a center that has the expertise but that expertise is increasing slowly across the country um the the first of all that it was thought for many years that if you have a bicuspid aortic valve you should have the threshold to address an ascending aortic aneurysm of around 50 that guideline is really changed it was simply a guideline there was not really a ton of evidence to support that so we now use 55 millimeters as the cutoff again you know these measurements are somewhat arbitrary uh and I we sometimes some of us rely very much on what the aorta looks like so if I saw an aorta that was gradually dilating in an older person and then gradually come down to a normal size that's quite different I at least in my opinion than a very eccentrically dilated aorta with a bulge out one side which just empirically I think is more at risk of a dissection so I do think the morphology of the ascending aorta is certainly helpful in surgeons from a surgical perspective and there's there's more and more studies looking at the actual morphology rather than these somewhat artificial measurements but that's what we've had in use in the past so Chris can you comment here because this is one of the again experts in in valve sparing procedures and and he says the key question is not if the valve can be spared that will the preserved aortic valve function well for 10 years or longer sorry if they well so I can't see that it's covering sorry it says the key question is not if the valve can be spared but will the preserved aortic valve function well for 10 years or longer so it's it's more about durability right so a tricuspid valve that's uh spared should last longer than 10 years we know what it does a bicuspid valve you're at some you're at really the mercy of what happens to that bicuspid valve so a true bicuspid valve as he was zero would is likely got the best chance of of lasting a long time bicuspid valves with you know distortion in the leaflets have a much less chance of surviving a long time and then you're of course exposing the patient to another operation down the road and often these are young people and or even middle-aged people if you have a discussion with the patient they're often they may not be that interested in you know the risk of a future operation nobody would be I think that's what you're asking me Annette I wasn't quite clear on that question well no I think it you know many times surgeons in the operating room will feel pleased that they you know accomplished a repair and sometimes it's like oh good we've done the operation the patient's leaving with what we think is a good result but in fact it turns out to be a less than durable result for perhaps anatomical reasons and or functional reasons and we have a case later on that we can we can explore this a little bit with all right so from an echocardiographic perspective though are there measurements are there things the surgeon needs to know beforehand and this is really an evolving literature that's come out the last few years and really what the French group has identified are measurements that we can take that will help our surgeon during vows bearing procedures and perhaps not the more experienced surgeon but perhaps the lesser experienced surgeon and what they're recommending is to measure things like the annulus which we can measure insistently and three other measurements that we don't normally make sorry sorry we make the annular measurements we make the stj measurements and three measurements that we don't usually make and these are things like the geometric height the geometric height is really from the cusp insertion point to the tip of the the cusp measured during diastole we can measure coaptation height or coaptation length again measured in diastole and we can measure something called effective height which is the distance between the annulus and remember this is sort of not a true annulus where the leaflets or the cusp insert to the end of the coaptation point and measurements such as those shown here indicate that it's more likely the valve can be spared the German group have gone further and suggested not only should you make these 2d measurements but you should make them really using a 3d data set and the 3d data set looks at nine to 12 measurements that you make all those four measurements I suggested before using different permutations and combinations and you should be able to look at the coaptation length between the non and the left and the left and the right and the non and the right you can look at effective heights and you can look at geometric heights for each of the valve cusps so Chris I know you and I had a hallway conversation about this but what do you think about these measurements that are now being presented in the literature for co-cardiographers to use interoperatively I think they are to your point I think they are very valuable as people learn more and more about valve sparing root surgery and especially for newer you know people learning the procedure at this time we of course didn't really have any of this when we we started off doing these operations but I think it is very worthwhile to to do the measurements because it allows us to share common language when we're looking at different cases across even around the world when people are getting sort of consults on cases I must say I've never actually done that use the caliper to measure leaflets and I know Tyrone hasn't either but I know Dr. Azunian and Dr. Chung do and I think they feel very comfortable with that so it's perhaps a bit of a generational thing I guess okay great so I will say again at our institution we're not necessarily always going to measure all of these or take all these measurements we certainly don't use 3D data sense but I think that's an evolving technology and I think as we get better with 3D imaging and be able to produce these measurements quickly we probably could and should be be doing them so let's look at case two again and try and figure out how repairable this valve is and if we do the measurements as we've done here we we look at the annulus which is 25 the effective height which is 17 and again 9 should be the lowest number that you see commissure height which is 9 and that should be a minimum of 5 and the geometric height for the right and non which you measure in the long axis view and that's well over 20 in both both cosps so this looks like a fairly favorable valve to repair so Chris I've put this video in because I think a lot of people don't really have the chance to see aortic valve sparing procedures and I think the video will go a little quickly but maybe you can highlight some of the key points about valve sparing procedures well first of all you're looking at this from the surgeon's perspective so anesthesiology be looking at the left side of this and this is it this is done very quickly so already the disease deorta has been removed the Dachron graft has been placed down and the spared aortic the native aortic valve the commissures were were set up to this is really moving fast and uh and we're done so you you could probably see the the the this is the old fashioned sailing test you saw the the sailing being injected and we're going to run it again great you could probably do it you do you can do a lot of surgery in one day if you do it this fast so there's the leaflets we're looking at the leaflets they're nice and symmetric all three of them and now we've taken out the disease deorta and the three commissures are placed inside the Dachron graft this is where the art of this operation occurs it's a quite challenging to get this right and then the aortic layer is sewn up this is the hemostatic layer the coronary buttons are re implanted this is our sailing this was our early poor man's echo we didn't really have good echo in the OR years ago but it's a pretty effective test and the surgeon's early star surgeon still uses today and get very anxious if it's uh if it shows that the valve's leaking that's great and that we could do 10 of these a day I know it's it's sort of moving at the speed of light so you mentioned some of the technical challenges and and you know this is sort of some illustrations that perhaps show this that if you put the post too high versus too low or you twist the post a little bit that it's not surprising you can get AI and one of the challenges we have in the post pop is to determine the mechanism of the AI so and that just a comment on that this is uh I think I you know with with the younger surgeons taking over this uh and learning about this procedure now doing quite well with it this is clearly the most challenging part of this surgery is how to position the commissures to get them on the both the horizontal and the vertical plane because both of those will affect impact on leaflet coaptation and you show quite rightly there on the right there's a floppy cusp because if the commissures are not correctly positioned you can end up with distortion I think that if there's any particular artistic part of this operation this is it and this is also a time for a surgeon to back out if you feel that this is not going to work don't go ahead and do all the coronary implantations and everything else only to find out the operation has failed and now you have to add a lot more cross clamp time to change it to a bento so again the post assessment is as important and you'll often see this thickened root and there's an element of cusp coaptation that implies durability so you want to see the cusp co-app above the annular plane you want to see a co-optation height of at least five millimeters and an effective height of at least nine millimeters all of which should be measured you want to make sure there's no more than mild AI speaking to durability and that ventricular function does not have specifically regional wall motion abnormalities which would imply there's a problem with one of the coronary buttons and Annette to your point I think the right coronary artery typically seems to be it can be more problematic than the left they're often quite small and very easy it's very easy to unintentionally kink it or do something that will compromise the blood flow so that is in coronary flow is very important and you see it very you see it instantly if there's a problem obviously so the surgeon did this operation was a VEL sparing procedure here they had a very very good result so the effective height measured here is 1.5 the co-optation height is 1.09 the co-optation is well below the annular plane and there's really very very little AI maybe a little commercial AI there between the non and the right I will say seldom do our images look so crisp this happens to be one of our better photogenic patients shall we say usually they're filled with bubbles and all sorts of other things and the surgeon is desperately trying to ask us how well things are going this is the transgaster for use and remember you don't actually have to always be at zero degrees sometimes you can be a little off-axis that's 70 degrees but you see a really crisp picture of the aortic valve here again confirming everything Chris would you worry about this mild degree of central AI in this patient I wouldn't overly be overly worried I think this is acceptable because I think everything else geometrically the leaflet co-optation looks very good it'd be very difficult to imagine how one could improve on this in other words if you re-cross-clamp opened up the e-order and started doing something that would placate leaflets or adjust leaflets chances are you're going to make it worse so I would accept this great okay we're going to move ahead to case three case three is a 33 year old female who's completely asymptomatic she has however severe aortic insufficiency and a dilated left ventricle and remember those were indications to appear in the operating room so have a look at these images and see if you can figure out what the mechanism of the AI is here so in the minnesophageal aortic valve short-axis view there's a bicuspid aortic valve with fusion of the right and left cusps this creates asymmetric cusps whoops I spelled cusps wrong sorry about that and sinuses and a raffae is present as well where the cusps are conjoined in the long axis view you see prolapse of the fused cusp and with color you can see that there's an eccentric posteriorly directed AI jet now you can wonder whether that's a bit central but it looks a lot more like it's eccentric and posteriorly directed there so poll number five based on the echo blindings in the l-curry classification what is the mechanism of AI in this patient okay another 10 seconds okay we're going to end the poll and we're going to share results okay seven six percent of all people said type two 12 percent said type one b eight percent said type one c and four percent said type one g i'm going to stop sharing okay so clearly this patient as we suggested had some prolapse and there is prolapse of the fused cusp here and it's important to recognize that unlike same mitral regurgitation where you sorry where you have a very obvious prolapse a ortic valve prolapse is sometimes very subtle and this is in fact what you see with 2d imaging for prolapse it's only a partial prolapse it's not a complete prolapse so everybody recognized the bicuspid aortic valve and if i was asking you to classify the bicuspid every aortic valve everybody would use the siever classification and that's based on the number of raffae and of which there are three types type zero with no raffae type one with one raffae in type two with two raffae which often can be confused as a unicuspid aortic valve by far and away the most common is type one of which 89 percent of bicuspid valves are and within that there are subtypes so there's the right left which is the commonest the non-right which is middle and the non-left which is the least commonest the sievers classification is useful but it doesn't really help surgeons repair valves so more recently last year there was an international consensus statement on the nomenclature and classification of the congenital bicuspid aortic valve and and its a or top of the for clinical surgical interventional and research purposes and what they did was they reclassified the aortic valve into three types the three types are fused two sinus partial fusion or form frost and within those they have phenotypes so in the next slide we're going to look at the different types of aortic valve based on this new consensus classification so the first is the most common which is the fused bicuspid aortic valve which we think of maybe as a type one uh sievers classification and in within that there's two cusp that are joined that are often create asymmetry there's three phenotypes previously similar to the sievers classification three sinuses and often a rabbi is present the next most common is the two sinus bicuspid aortic valve here you have two symmetric cusps two phenotypes the lateral lateral and the anterior posterior commissures at 180 degrees two aortic sinuses and no rabbi and finally something called the form frost and this really has three symmetric cusps it has a systolic triangular opening there's a partially fused rabbi of less than 50 percent sometimes referred to as a mini rabbi and the commissures appear at 123 20 degrees there are three aortic sinuses so this looks very similar to a tricuspid aortic valve but in fact there's a little bit of fusion if one of the cusps two of the cusps associated with this classification is also a bicuspid valve a or top of the classification and dilation of the aortic valve occurs 20 to 30 percent of patients and occurs in 0.4 to 0.6 millimeters per year this classification includes three aortic phenotypes the ascending which is the commonest the root 20 percent and that which is extended into the arch which could include either the root or the ascending aorta in the diameters mild dilation less than 45 moderate 46 to 50 to 54 and severe greater than 55 severe and those with greater than 50 millimeters and risk factors deserve surgery so management of aortic insufficiency and bicuspid aortic valve is no different than management and tricuspid aortic valve the indications are the same in terms of a or top of the and we've heard this a little bit the numbers have changed slightly so patients who have now a or top of the in a aorta greater than 55 centimeters deserve 5.5 centimeters deserve surgery those that have dilated sinuses and ascending aorta in the 50 to 5 to 5.5 centimeter range or other indications for aortic valve surgery deserve attention to the aorta and patients with less or greater than 4.5 can also be considered for surgery and these are the risk factors that would accelerate whether a patient gets their aorta addressed or not so the bicuspid valve assessment by TE this is an excellent paper by McElena et al they're at the Mayo Clinic and they were also first author on the bicuspid aortic valve consensus document and they suggest looking at cusp phenotype as previously mentioned this paper actually came out later than the previous paper so i've kind of taken some of the information from both papers and put it together so you basically want to look at the cusp phenotype in terms of fused two sinuses or formed for us you want to see whether they're two or three sinuses asymmetry of the cusp and sinuses in the presence of a rabbi with or without calcium as shown here you want to look at the cusp condition to see if they're amenable to be repaired so mobility fenestrations calcification and prolapse you want to look at root geometry and measure geometric height and effective height and for the bicuspid aortic valve you want to look at something called a non-fused cusp commissural angle and this becomes important this is important just because it impacts how difficult it is for the surgeon to repair the valve so if the commissures are closer to 180 it's easier to repair the valve so if you measure this angle and it's 160 to 180 degrees chances are greater the surgeon can repair the valve if it's between 140 and 159 it becomes moderately difficult to repair the valve and if it's 120 to 140 degrees it's increasingly more difficult to repair and spare the valve so you measure this angle in diastole by drawing a line through the center of the valve and then you draw a line from the commissures each of the commissures to the center point of that line and you measure the angle as shown here and this angle is 170 degrees so Chris you're on again bicuspid aortic valve sparing procedures are they more difficult than tricuspid i've just listed some of the things from an anesthesia perspective that we would understand but from a surgeon's perspective is it easier to repair a bicuspid aortic valve or spare a bicuspid aortic valve than a tricuspid aortic valve no that's definitely not as easy and here you see a repair taking place it's a little slower than the previous video but i think the ideal situation is where you've got the commissures 180 degrees apart which is is not all that common as you as you just indicated if you have enough leaflet tissue you can attempt to repair it the longevity of these valves is clearly not going to be the same as the tricuspid valve just because we know from experience that bicuspid valves themselves don't necessarily last the patient's life but in a younger patient we will you know definitely try to repair these valves as long as and making sure that the patient's fully aware that this may not be long long lasting i think the threshold for repairing these valves certainly in my understanding varies quite considerably from center to center so you have a group in Germany that's very aggressive and preserving these valves taking calcium off and all this sort of stuff with you know claims that the the longevity is very good we learned years ago uh by simply we used to decalcify patients who might be undergoing coronary bypass and had noted to have mild aortic stenosis and if we decalcified those as a almost like a cosmetic procedure in the operating room those patients seem to come back fairly early within a few years with severe aortic stenosis so uh very concerned about any calcification present on these leaflets so they're definitely much tougher to repair there's less leaflet overlap to work with this particular case i think is a good one because there's a fair amount of leaflet tissue to work with all right so if we apply our science to repairability here we would get a fused right left cast they're asymmetric there's three sinuses the raffae is complete but it has minimal calcium on it and the commissure angle however is measured at 155 degrees there is that fused cast prolapse there's some eccentric posteriori and if you do the measurements the annulus is quite dilated at 38 millimeters the effective height is 7.5 millimeters which is a little bit smaller than what you want uh the commissure height is 5.5 which is fine and the geometric height you measure the geometric height i should say in a bicuspid aortic valve of the non fused cast so that's fortunately usually the upper or posterior looking cusp in the aortic valve long axis view so overall this should be a repairable valve let's see what our intrepid surgeon did oh wait now um so this patient did undergo an aortic valve i'm going to skip bowl number six here did have a valve sparing procedure and this is what the results were so the surgeon excised the raffae put in a 34 millimeter daugran graph did a sub aortic annular capacity to address the annular dilatation position the commissures at 175 to 180 degrees um flicated the fused cusp and reinforce the cusp margin so the post op echo showed co-optation at the annulus the co-optation length was nine millimeters the effective cusp height was nine millimeters there was trivial ai and the commissure angle was 175 if christ do you think this is a good valve outcome uh yes it looks pretty good i a little bit concerned about the leaf that's dropping below the lvot into the lvot from a long term perspective but i think it looks pretty good so yeah i mean there's this controversy and you know we were recently at our meeting we had shape or come and speak and virtually at least and um there was some concern about this concept of billowing or the cusp bellies um below the annular plane but the co-optation point seems to be at or like you know at or above the annular plane here um do you have any sort of thoughts about durability in these types of patients well it's it's been said that the durability isn't as long it's actually challenging to get that data uh because i don't think a lot of this early on was was measured i suspect with a bicuspid valve in this particular case you'll have more trouble with actual degenerate ongoing degeneration of the bicuspid valve possibly all right so we'll accept this as an adequate repair yes okay case number four this is a 40 year old male and you can see the theme is those are relatively young patients they're asymptomatic severe AI and a dilated dilated left ventricle and again look at these images to see if you can sort out what the mechanism of the ai is and it's very similar to our previous patient so there's a fuse bicuspid aortic valve right left they're asymmetric customs line it says you really don't see a raffae in this patient um so it's almost like a type two but not quite um there's definite prolapse of the fused cusp and you can see that quite evident with the red arrow um as well as an eccentric posteriorly directed ai and if we look at repairability it's very similar to the previous one there's fusion of cusp asymmetric cusp three sinuses we don't see a raffae and commissural angle is closer to 180 which is more favorable the annulus is not as violated 27 millimeters the effect of height here because there is prolapse is um point point five and we take it with a bicuspid valve of the non-fused cusp so it's whatever is not collapsing there there is no commissural height because there is no co-optation um and the geometric height is a bit short only at 14 millimeters and you'll notice for a bicuspid aortic valve the geometric height is actually longer than for a tricuspid valve so the surgeon went ahead and did a valve sparing procedure uh they found no raffae was present they put in a 32 millimeter dachron graft flicated the fused cusps and equalized both cusp heights and this is the post op echo any thoughts about this chris um well i would would have been interesting to see what it looked like interoperably but i'm concerned about this jet it may be a lot you know it's a little hard to judge it because it's hitting the wall um hitting the septum there so i it's a 40 year old i don't know whether you'd go back in and see if you can repair that i suspect you cannot um but then your face with you accept this or convert this young person to a mechanical mechanical valve okay so the interop assessment was this was deemed to be moderate eccentric ai now this is very hard to quantify because it's such an eccentric jet um i think the question really becomes do we think it's more than mild and i think the vote in the or was yes it's more than one mild because it's eccentric and seems to be wrapping around um the mechanism was challenging and you know when you have an eccentric jet for this type of procedure it's either retraction of one cusp or or collapse of the other and it was felt to be restriction of the fused cusp so in this case the surgeon chose to go back on and re-repair the valve so sorry there's just an overhead announcement now um so in this case there was co-optation above the annular plane which we wanted the length uh co-optation length and effective height we're good at 7.3 millimeters now there's what we think is just mild ai and the commissure angle was 175 so it seems that going back on was the right answer and there seems to be a slightly better outcome in this situation but again as you say chris it's it's very difficult in the operating room to make these assessments sometimes and we're often asked to think about what the mechanism is in these situations and that did in this situation uh did you get maybe i missed that did you get feedback from the surgeon what the issue was yeah they thought they put the post a bit too high so there was a bit of retraction there and they took out a stitch and it seemed to resolve and make the the cusp co-opt better so in this situation the patient benefited from going back on so it does go back to my initial comment about getting the posts correct and that's again always a challenging part of valve sparing surgery all right we're going to close with this last case and it's kind of a fun case um it's a 37 year old male who's short of breath with severe ai and a dilated left ventricle what's the diagnosis you can put it in the chat because i don't know that i put a poll question on for this one necessarily but just think of what you think the mechanism is for the ai here you're probably thinking modified by cable what's happening all right we'll let you think on that a few seconds here all right so you look in the long axis view and the aortic valve in 2d looks pretty good but when you put the color on my gosh there's a lot of ai you're sort of thinking hmm i wonder what the mechanism of ai is in this patient doesn't look like there's dilatation doesn't look like there's prolapse doesn't look like there's restriction what the hell's happening so then you go to the short axis view and the answer becomes very apparent so this is a patient with a sinus of alzalfa aneurysm with the non-coronary sinus you can see using biplane why if you cut the valve in a certain angle you would see just normal looking long axis views and the only way to make the diagnosis really is in short axis as shown here i don't know if this is hopefully this will play okay so this was one of our first applications of 3d echo in the operating room and we were able to show this wind sock deformity that's described in these non-coronary or any sinus of alzalfa aneurysms and you can see how it looks like the wind sock you would see at an airport with this triangular shape and this is put in the surgical orientation and you can rotate that 3d data set and actually show the orifice of the wind sock as shown here um so really kind of a nice application of 3d echo so our last poll given the echo findings patient age and current guidelines what operation should the patient have another 10 seconds okay i'm going to hand the poll and share the results 56% said valve sparing root replacement 17% said replacement of the ascending aorta 11% bento and 11% avr and 6% frost okay so in fact i think one of the answers was was going to be root repair so just a repair of the root not necessarily the ascending aorta chris um 37 year old male symptomatic tricuspid aortic valve slantus of alzalfa non-coronary aneurysm severe ai and a dilated lb what would you do for your patient chris well i think your patient i know i'm just going to say this is looking very familiar so i i think uh i would i think the approach here would be to repair that uh area where the the aneurysm is and leave it at that without re-implanting coronary arteries and hopefully that took care of any leaking of the valve so basically repairing that sinus and addressing the aneurysm so root repair i guess that would right so um this was actually dr findell's case and i happen to be the echo cardiographer on the case and we thought we closed with this case so really um again it's not all a big valve sparing roots all the time it's not a little bit fixing the aorta or the ascending aorta sometimes it's just fixing the problem and in this case chris managed to reconstruct the non-coronary slantus with bovine pericardium reconstruct the right atrial wall do a tricuspid valve septal leaflet repair in a relatively short period of time and you can see how the 3d echo image just compared to the interop lining of that windsoft deformity do you remember this case chris i do yes did it go as well as you thought it would go yes we had to just do a little thinking on our feet and plug the holes and plug the holes yes yeah okay all right so this was the outcome at this case so i'll just show you the short axis view because that was the one that had the pathology to begin with and you can see this is an actual very very good result in this patient we got a young patient preserved as native aortic valve without doing a valve sparing root so that comes to the end of our session here thank you very much and chris and i would be happy to take any questions okay and just stop


It's time for the Lawn Jean Chronoscope, a television journal of the important issues of the out, a presentation of the Lawn Jean Wittner Watch Company, maker of Lawn Jean, the world's most honored watch, and Wittner, distinguished companion to the world-honored Lawn Jean. Good evening, this is Frank Knight. May I introduce our co-editors for this evening, Mr. Hardy Bird, author and correspondent, and Mr. William H. Kearns Jr., military editor of Business Week magazine. Our distinguished guest for this evening is General Louis B. Hershey, director of Selective Service. General Hershey, what you say and what you do these days, sir, is very important to quite a lot of people, to say the least. Now, with President Eisenhower's recent action on promotion, there are quite a few authorities who believe that there will be a quickening of action in promotion, a more aggressive policy. I know that you can't give away any plans to the enemy, but could you answer this question? Will there be any stepping up of draft requirements in the forthcoming year? Will more men be needed? Well, yes, there are going to be more men needed. However, we knew it long before General Eisenhower, President Eisenhower, stepped up the present situation because men went in soon after Korea started. Those men are now coming out and they have to be replaced. That's going to take more people than we put in last year. So the answer is yes, but the reason I either don't know or think is no. Well, the Communists aren't going to learn anything from your own prototype, if I can see that. Now, there will be 53,000, I understand, inducted in February. Is that right, sir? That's right. Now, is this very higher than the usual average for inductees? Well, it's 25,000 or so higher than July, but it's only 6,000 higher than December and January. So, by and large, it's not far from the average of 50,000, about what we figured we'd have to induct this year. Do you see about 53,000 a month being inducted for the rest of the year? At least that many, and if it changed, I would think it would go higher rather than lower. Do you expect that it will go up to the 80,000 a month level? No, I don't. I think 60,000 would be high. What is the reason for this need and crease need for draftees? Well, when we started out after Korea, our first job, of course, was to build and also maintain, but maintenance was a very small factor at first, but now maintenance is a whole factor because with a two-year term, men are going out very rapidly because they went in very rapidly two years ago. How many men do you figure you will lose over the coming year? Well, I've heard different estimates and nobody can guess because there's many factors involved, but I'd say 1,100,000. Well, has this increased the stepping up of the number of inductees coming in? Is that going to affect people who have either been deferred? Oh, yes, inevitably because one of the reasons that people have been deferred, of course, there's more than one reason, but one reason has been that we haven't been able to take only about so many, and of course, you defer some people, though you won't have to have too many in 1A, and our potential has fallen from about 3 million 6 to about 1 million 2, and hence by the very mathematics of it, we're going to have to search in the deferred classifications for additional men. Well, I see, sir. Now, let me ask you this. If I were sitting out here and watching this program on television, and I were deferred in the draft, I would ask a very important question, and I don't know whether you can answer this or not, but can you tell us which of those now deferred are most likely to be brought in? No, I don't believe it can. This is true, however, that in the first place, if I were over 26 and became over 26 before June 1951, I wouldn't worry because the law makes me not liable. If I were a veteran, I shouldn't worry. Now, if I am, however, a deferred man, or one who has been rejected in 4F, or one who is in 1A, I would worry about the inverse order in which I've named them. Well, in other words, General, we mentioned earlier that they were a considerable number of men who have been deferred. Now, they are liable up to age 35, is that correct? Yes. Anyone that's deferred before he gets to be 26 gains nine years of additional liability. That is regardless of the reason for their deferment. That's right. General, there might be one solution to this problem. I can't advocate it, but you did. And the Universal Military Training Program, I think you appeared before Congress and wanted that program last year. Is that correct? Well, yes, last year and several years before I've been since about 1908. One of the things complicates it now is that we have other things to do and it isn't quite as easy to institute, although it is possible to institute it. Are you still for it? Absolutely. Now, what is your interpretation of a Universal Military Program? You've got one now in effect. That's right. We have it now and it's just a question of in another year or two, practically everybody will have been inducted and therefore we will have had Universal Training. Unfortunately, at present time, we're only inducting for a couple of years service. And when the man comes back and goes into the reserve, he doesn't obviously want to be remobilized. Whereas if he had a shorter term of training, he could be held to a longer period of, well, it like the farm and being in the firehouse ready to go. Well, I know there are quite a lot of people, particularly mothers, who are very much opposed to Universal Military Training. And as a matter of fact, in his Baltimore speech, President Eisenhower said that he wasn't in favor of it. But I wonder if you would like to give the arguments for it, as you see them. Well, I don't remember. I didn't hear the Baltimore speech, but as I remembered, the question was whether or not you could have selected a service in Universal Military Training simultaneously. Oh, I see. I'm not assured President Eisenhower said he wasn't for UMT. I think it was a question of time rather than effort. Now, I'm been for Universal Training because I think that we in war time or in emergency, all require our young men to serve. And I've always thought it's only fair that they have a chance to be ready to do the things the government required of them. And one of the things about it, if you have something that's a little harder than other things, I think it's in a democratic state, it's better to pass it around and not try by mercenary means to hire somebody to do the unpleasant things. Well, do you see any chance at all of the Congress passing a Universal Military Training program this year? Well, I think there's all of the chance. I don't know how good it is. And I think there's two ways to institute it. One is to institute by additional legislation. The other is to use the legislation which you already have. Well, your present authority to draft expires in 1955. That isn't the liability, it extends, but the right to call anybody expires in 1955. I don't want to be too technical about it, but that is true. Well, then any kind of a Universal Military Training Act would have to take effect after that date. No, I don't have that. There's difference of opinion there, but I happen to believe that we could start now to putting some of our people into a reserve with a seven and a half year liability after six months of training. I see. Well, going back for a minute to the deferment question, how about occupational deferment? Do you see any decrease in deferring men for work, apprentice work, farm work or anything of that order? Well, I think inevitably, if we're going to follow out the legislation, the Congress passed a Universal, I want to repeat, Universal Military Training and Service Act. Now the Congress did not defer anyone except the ministers and divinity students and exempted those. I think the Congress gave the president power to defer with the idea that they could have a fluid, a flexible method by which each in their turn might serve without too much disturbing the public interest. And I'm not so sure that anyone is going to be deferred throughout their entire period of liability. Now, General, of course it's logical. I want to ask a question about this deferment, too. It's logical that an engineer will be deferred before, say, an art student, a student of engineering. Now would a poor, a bad student of engineering be more likely to be deferred than a very good student of art? Well, I think you're being a little unfair at the engineering because in the first place, I was a liberal art student and not an engineer. I don't happen to be a specialist and therefore I probably have a little feeling of frustration. You mean my question is prejudiced so far. Well, no, I'm prejudiced. And I think that we need, one thing we need now are a lot of people to know how to govern ourselves because I think there's a greater need for that than there is things in the physical sciences, but I'm not joined in that belief by the majority of people. Now, this word prejudice, here's another subject, General. It has happened as human nature, I suppose, but I've heard it more than once complaints from parents and from boys who did not want to go into the service right now. And they said that the members of their draft board were prejudiced and that just because this fellow parted his hair that way, they didn't take him and because their son's hair was parted the other way, they took him. Now, what about this prejudice on draft boards? I haven't heard anything about corruption, but what about prejudice? Well, of course, in the first place, the board is administering a law. The board didn't place the liability on the lab. The Congress did. The Congress said he'd serve. They did say that the President might issue some orders about when he would serve. And the fellow who serves on the Selective Service Board has the rather hard responsibility of carrying out a law which did not defer people. And I think, after all, that we probably have prejudice. But on the other hand, I think that the local draft board, through the last 13 years, has done one of the most remarkable services in trying to do without pay and without anything except the knowledge of having well done a very difficult service, namely to keep the armed forces during the war, the 12 million or so, and now the 3 million 6. Well, quite frankly, have you seen any evidence at all of corruption among these boards? I mean, a board member accepting money to defer somewhat. No, we've had, I think, a half a dozen or more people tried in 13 years. I see. Well, now, sir, about this corruption business, about this favoritism business, each board doesn't operate according to the same set of rules, does it? Oh, that's a set of argument, a question of what is rules, what's policy, and what's the implementation of policy. I never have believed in uniformity because there isn't any such thing as uniformity among human beings. But as far as having the same general policy and following the same philosophy, I don't think there's any question. There are a few exceptions. And when there are exceptions, we have the right of appeal very freely given. No one has to take the local draft board. You can appeal to the appeal board without a reason. I see. And that gives you two shots. Just one final question and very quickly, General, we hear a lot about the disadvantages of being drafted and why people hate to be drafted. How about some of the good things about being drafted? Well, I think the man participates in the most significant think of his time. I think he goes out feeling he did his share and he didn't try to push somebody else in his way. And if you want to get into material things, he's got practically three years of education coming to him on Uncle Sam. I see, sir. Well, our time is up now. We want to thank you very much, General Hershey, for being with us. The opinions that you've heard our speakers express tonight have been entirely their own. The editorial board for this edition of the launching chronoscope was Mr. Hardy Burt and Mr. William H. Kearns Jr. Our distinguished guest was the Honorable General Lewis B. Hershey, Director of Selector Service. Now, how would you go about hiring a man for an important job? Well, in a man or in a watch, the record of past performance is the only yardstick of value. That's why so many sensible people own Lawn Jean watches. Now, the honors which Lawn Jean watches have won are a record of past performance. These world's fair grand prizes and gold medals, each a highest award, were bestowed by many men in many lands at many times. Observatory accuracy awards, won just yesterday, so to speak, are also part of the Lawn Jean record. And from the record, there could be no doubt that Lawn Jean watches are above and beyond the ordinary. For almost 100 years, Lawn Jean has been shown to be just about the finest watch in all the world. By every standard, beauty, integrity of manufacture, accuracy, and reliability of performance, Lawn Jean is the world's most honored watch, the world's most honored gift. Premier product of the Lawn Jean with Norwatch Company since 1866, maker of watches of the highest character. We invite you to join us for the Lawn Jean Chronoscope, the television journal of the important issues of the hour, broadcast on behalf of Lawn Jean, the world's most honored watch, and Wittnor, distinguished companion to the world honored Lawn Jean. This is Frank Knott, reminding you that Lawn Jean and Wittnor watches are sold and service from coast to coast by more than 4,000 leading jurors who proudly display this emblem. Agency for Lawn Jean with Norwatch.


Their ideas is a two-day conference in Rio on the 16th and 17th of June. It's being hosted by the Catholic University in Rio and organised by IIED, the International Institute for Environment and Development. The reason we decided to do this was twofold. Firstly, we think that IIED and the organisations that we work with around the world have a huge amount of experience and interesting reflections from our research and our practice that we want to share with a global audience and we think an event next to the summit that takes place just before the heads of government summit in Rio is exactly the right place in which to share that kind of reflection. And secondly, we want to create a space in which people can come and contribute their ideas, their learning, their reflections. So we're not just organising sessions in which people listen to speeches, we're organising sessions in which people engage in a wide range of organisations and individuals have an opportunity to get their thoughts across. What distinguishes this event from other ones is that this tries to focus on specific contexts and practical examples. We've emphasised solutions in the material that we've put together about the event and in the agenda that we've created and that's very much the focus here. We're not talking about abstract concepts, we're not talking about what others should do that's different, so much as saying what's already happening that can be learnt from, replicated, amplified, adapted. This is focusing on practical things that can be done that added up make a huge difference around the world. What we've organised in the agenda for the event is a stream of simultaneous meetings. We're extremely lucky that the university has an extensive range of different spaces for sessions. They're organising a large auditorium which will hold 6 to 700 people in which we'll have eminent speakers from government, from civil society, from a range of organisations giving their views and engaging with specific issues. Simultaneously around the campus we'll have smaller sessions for audiences of between 90 and 400 in different sized venues looking at more specific issues. These might include sessions on payments for ecosystem services in Costa Rica and Amazonas as an example on sanitation challenges in Brazil and lessons from elsewhere in the world. They're getting to groups with more concrete issues and we want to give people the chance to have both the overview from senior people from relevant organisations but also the specifics and a chance to engage with people who work on particular issues and hear the interchange between them and contribute their own views and ideas to those. In terms of the programme for the event we're also very keen that it's relevant for students and there'll be a strong presence from the Catholic University and from other universities in Rio of students and young people interested in these issues so it's not just for professionals from outside Brazil it's also very much relevant for a Brazilian audience. It's a free event so people will be able to turn up without paying any fee we do ask that they register in advance so that we're aware that they're coming but we're not able to give prior seats, places in sessions to people who register in advance because we don't have the capacity to distinguish between people who've given us their details beforehand and those who turn up late in the day. The advantage from registering in advance is that we're in touch with you and we can share detail on the event with you beforehand and we can be in touch with you afterwards as well. So this is very much an opportunity for us to link with a wider audience of people around the world and keep in touch with you before, during and after the event.


Income tax 2023-2024. Why and how to learn tax law. Get ready and some coffee because we're going to stop the tax man in his tracks with income tax preparation 2023-2024. Whenever learning a new topic, the first question that comes to mind is why? Why learn tax preparation? Why learn tax law? And the response which gushes out of every American heart every American soul is to save money from the dumpster fire that is government spending pulling her into the promised land of the private sector where she can grow, where she can flourish rather than being burnt as a sacrificial offering to the gods of big government boondoggles. Alright I might have got a little bit dramatic there but that's probably the first thing that comes to mind saving some money. Our next objective to be in compliance with the law. When we're talking about tax law that of course means paying the taxes that were legally required to pay and being in compliance with filing requirements were legally required to do. You might think that these first two objectives are contradictory to each other but they're not really because our objective in tax preparation will often be to pay the least amount of taxes that we are legally required to pay. Because of the complexity of the income tax system it's quite easy to accidentally pay more taxes than you're legally required to pay which means that you've sacrificed more of that money to the dumpster fire of government spending and government boondoggles and is it likely that you're going to be getting that money back? Probably not. So our objective is to get it right the first time. Now you might argue about whether or not you agree with particular tax laws and we'll talk a little bit more about this in a second. But if you know the tax system and you know the tax law and tax preparation you'll be better informed to have discussions with people about what the best kind of tax system would be and the rationale for it and you can make those types of arguments once again within the compliance of the law. You might also be learning taxes because you want to be in business doing tax preparation in some way shape or form. If that is the case then I would think that you would want to narrow down your focus to think about what that exactly looks like. Oftentimes I find that when we think about goals we have a very broad type of idea of the goal which we really need to narrow down into particular steps so that we can go onto an objective that we can actually achieve. So for example are we thinking about doing tax preparation at another firm or are we thinking about having our own business where we can do tax preparation. Is there an area that we can specialize in? Taxation itself is huge so generally you're going to want some kind of specialization. You might specialize for example in lower income tax returns in which case the business model will typically be you're going to be charging less for the preparation but you're going to be doing a lot more of them so you're going to make less money per return but you're going to have to do more returns in that case or you do tax preparation for larger or more wealthy individuals in that instance then they have more complex returns generally. You're going to make more per return and possibly do more work in planning and tax preparation as well as tax planning type of services in that instance. You can also specialize in certain areas. Do you want to specialize in for example one location where you don't have a bunch of different state tax returns or possibly you want to specialize where you have multiple state tax returns and possibly income in different areas for an income are different types of areas you can specialize. You also might be more interested on the business side of things versus the personal side of things. Doing business tax returns, tax returns that have a schedule C for sole proprietorship or an S corporation flow through entities like an LLC or corporate type return partnership type of returns. Oftentimes people with accounting backgrounds like myself tend to enjoy that side of things because you get to use more of the double entry accounting system. So in any case highly recommend that if you're looking to start working in some area of taxation that you start breaking down the goals to particular steps and I think that'll make it easier to move forward. Now some other questions that come up with relation to tax law that might not be as obvious are what is the purpose of government? Who should pay for government services? So what is just? What is fair? What are these terms even mean? Oftentimes people think of these kind of questions as possibly more interesting than tax law, than tax preparation, than tax code. What is the government for? What's the best kind of system? Should we be more capitalistic or should we be more communistic or socialistic type of business? Should the government be running more of the private sector? Should the government be distributing money in some type way, shape or form? Those are kind of interesting questions that come up all the time, but again they seem to come up in some kind of an abstract type of format. When you get down to the nitty gritty of it, when you get down to what does that actually work, taxes are going to play a crucial role in that as we've seen all the way through the founding of the United States for example, which was primarily based on tax arguments was one of the big topics as a colony. So when we get into the questions of how is a government taxing, it's going to touch in on a lot of these questions that people seem to think of as more interesting than taxation. So for example, in politics you will often hear people using words such as just or fair to describe many different things and oftentimes to describe the tax system. They will say things like we need to have a just tax system. We need to have a fair tax system and learning more about tax law I think will get us better at basically being able to pick out those key words and trying to hone down on them and ask critical questions rather than having these broad blanket statements that are in essence meaningless. In other words, no one argues that you should not have a just tax system. No one argues that you should not have a fair tax system.